Introduction
Mass-gathering event planners and designers intend for their events to be positive experiences and to have meaning for those who attend. Mass-gathering events are important as the shared experience of attendance can lead to “communitas.” GetzReference Getz 1 defines communitas as the shared experience of the audience, including a sense of belonging and kinship. Motivations tell the event organizer about the types of behaviors they should expect from the audience, which may lead to patient presentations. Through these understandings, health promotion and event safety messages can be developed for a particular type of event based on the likely composition of the audience in attendance.
There are three goals to this report: firstly, to discuss motivations of the audience attending outdoor music festivals, sporting events, and religious events; secondly, to discuss how these motivations can be harnessed by event organizers and on-site medical teams; and thirdly, what types of interventions can be used to promote harm reduction and maximize safety while tailoring these to each specific crowd. The long-term aim is to make long-lasting public health interventions in a particular “cohort” or discrete event type population.
Report
Background
Health promotion and providing public health information should be at the core of any event to minimize public health risk and to provide opportunities for the promotion of healthy behaviors in the local population.Reference Isla, Endricks and Barbeschi 2 A key part of this process is to identify and agree upon what public health information is needed for the mass-gathering audience; also, how this information should be communicated, and any other health messages or strategies that need to take place. A more developed understanding of audience behavior may provide critical information for mass-gathering event planners, event risk managers, and Emergency Medical Service personnel to better predict and plan to minimize risk of injury or illness. In turn, this may reduce patient presentations at events and reduce health service usage. For the event designer, understanding audience motivation and subsequent behavior enables the design of the event to be modified and to adapt settings and programs as a response to observable audience behavior in real time.Reference Brown and Hutton 3
According to Hutton, Brown, and Verdonk,Reference Hutton, Brown and Verdonk 4 it is important to remember that audiences do not arrive at an event as a “blank slate,” but bring with them a range of motivations. These motivations include four main elements: (1) the demographic and sociographic of the individual; (2) the expectations of the audience based on how the event is marketed; (3) the audience members’ previous experience at events; and (4) the beliefs of the family or friends that accompany the audience member to the event. Motivations in the mass-gathering context can also include pre-event drug and alcohol consumption. These motivations do not solely dictate or indicate audience behavior, but are one of a wide range of factors that influence, and that can perhaps modify, audience behavior at an event.Reference Hutton, Brown and Verdonk 4
Escaping Everyday Life
Too often, there is an expectation that audiences will comply with set rules and not act outside societal boundaries at events. This belief is flawed, as with freedom of choice comes freedom of action, and staying healthy or being safe is not always at the forefront of people’s minds at mass-gathering events. It is well documented that music festival goers attend outdoor music festivals to escape everyday life, and part of this escapism may include the use of alcohol and other drugs.Reference Hutton, Ranse, Verdonk, Ullah and Arbon 5 , Reference Van Germert, Dietze and Gold 6 Outdoor music festivals are often reported to have a high rate of incidents and presentations to on-site care due to the presence of alcohol and other drugs.Reference Allen, O’Toole, McDonnell and Harris 7 , Reference Chan and Quinn 8 Rule breaking, which includes high levels of intoxication, is not new in the mass-gathering space. Researchers who reported on both the 2004 Oxegen Festival in Ireland and the 1999 Sweetwaters Festival in New Zealand reported high levels of intoxicationReference Nix, Khan, Hoban, Little, Keye and O’Connor 9 , Reference Yates, Hazell and Schweder 10 and a significant increase in presentations at the emergency departments of local hospitals.Reference Nix, Khan, Hoban, Little, Keye and O’Connor 9 Social and physical environments can heavily influence the safety of people at outdoor music festivals. Social factors include individual motivations, behaviors, and knowledge of people at an event.Reference Hutton, Savage, Ranse, Finnell and Kub 11 Whereas physical environments include mosh pits and activities such as crowd surfing where audience members purposively crush together in a tight group in front of the stage.Reference Yates, Hazell and Schweder 10 , Reference Earl, Parker and Capra 12 , Reference Lim, Hellard, Aitken and Hocking 13 Escaping everyday life may not only be isolated to outdoor music festivals, and this concept could be applied to other mass-gathering events. Knowing risk taking activities are likely to take place can assist in event design, planning of health care services, and associated health promotion activities at these events to enhance spectator experience and services (Table 1).
Table 1 Motivations, Health Promotion, and Strategies – Outdoor Music Festivals/Electronic Dance Festivals
An Act of Faith
Religious events especially can see over-zealous behavior. For example, religious events like the Hajj may be a pilgrimage that participants make only once in their life. Rituals that demonstrate a display of faith often dominate religious events.Reference Hawkins and Brice 14 Religious followers that attend these events are focused on the ritual itself, with little consideration of their health needs.Reference Rashid, Gatrad and Sheikh 15 The commitment of the audience member to these religious mass gatherings should not be under-estimated. These persons may display behavior that might range from the passively devout to the aggressively fanatical, and everything in between.Reference Khan, Memish and Chabbra 16 Understanding the cultural elements of what already exists within the event and what is brought to the event by the audience are important for predicting likely behaviors and assessing risk.
During many religious festivals in India, fireworks are used to celebrate the occasion; the Chaharshanbe is one such event. Fire is integral to the celebration, as it is used to scare away evil spirits and is an essential part of the event.Reference Saadat, Naserpour and Smith 17 , Reference Tavakoli, Khashayar and Ahmadi Amoli 18 Therefore, the risk of burns is high, especially for young males who seek blessings for their families. Burn injuries are common and accepted as part of the event and are considered good luck. Most common injuries occur to the hands and eyes.Reference Hawkins and Brice 14 , Reference Saadat, Naserpour and Smith 17 , Reference Tavakoli, Khashayar and Ahmadi Amoli 18 In the excitement and chaos of this event, it is not always possible to prevent people from getting burned, yet it is possible to plan to treat this type of injury if it is known to be common for this event. For example, having first aid equipment specifically for burns (ie, appropriate salves and ointments) is important, as well as ensuring running water is available.
Perhaps the most famous religious event is the Hajj, followed by World Youth Day and the Catholic Jubilee, where devotees travel great distances.Reference Rashid, Gatrad and Sheikh 15 , Reference Faustini, Marinacci and Fabrizi 19 , Reference Hutton, Roderick and Munt 20 An important aspect of these events is the requirement of the audience to undertake a pilgrimage over long distances. In addition, the final ritual/rituals are performed no matter what age or general health problems participants may have prior to commencing. Pilgrimage is quite taxing on the body as people may be required to walk long distances. At the Hajj, participants are required to wear open sandals, therefore foot injuries are common, as are burns to the soles of the feet and minor cuts and bruises from falls.Reference Rashid, Gatrad and Sheikh 15 , Reference Hutton, Roderick and Munt 20 , Reference Currie 21
Physical and heat exhaustion, sunburn, and sunstroke are all conditions common at these events.Reference Rashid, Gatrad and Sheikh 15 , Reference Hutton, Roderick and Munt 20 , Reference Currie 21 However, these injuries are minor compared to those that can occur with a large influx of people; these being the increased risk of communicable diseases.Reference Noweir, Bafal and Jomoah 22 When pilgrims of religious mass gatherings arrive at an event, they may have crossed borders, caught infectious diseases, and now be carriers of illness.Reference Rashid, Gatrad and Sheikh 15 , Reference Hutton, Roderick and Munt 20 , Reference Noweir, Bafal and Jomoah 22 For example, pilgrims at the last Catholic Jubilee event suffered from a gastro-intestinal disease due to Giardia contamination.Reference Faustini, Marinacci and Fabrizi 19
At World Youth Day, the risk of influenza and its transmission are high. Within the prevailing culture of the event of sun, prayer, and friendship, health is not foremost in the minds of young people as they are focused on “in the moment” aspects of being at the event.Reference Hutton, Roderick and Munt 20 Even with evidence of influenza at these events, hospital admissions are often low, and this may be attributable to the young audience feeling healthy enough to overcome the infection and not attend hospital for treatment. Additionally, low admissions may be a result of the audience being so engaged in the event and the sense of community there that they are loathe to leave the event site until such time as their illness disables their ability to continue to enjoy or participate in the event.Reference Hutton, Roderick and Munt 20 In these mass events, exposure to disease can be tempered through hand washing and universal precautions.Reference Rashid, Gatrad and Sheikh 15 , Reference Currie 21 , Reference Noweir, Bafal and Jomoah 22 Further safety measures including vaccination, hydration, and knowledge of the conditions awaiting the pilgrim are vital for the event manager so that planned on-site care can be set up around these issues.
Other religious festivals, such as the Ram Janki in India, report many deaths from human stampedes.Reference Burkle and Hsu 23 Stampedes are often due to zealous followers trying to get through narrow gates to take part in the celebration, and lack of egress and access can lead to many deaths. Despite these risks to health, Yeolekar and BavdekarReference Yeolekar and Bavdekar 24 claim that religious festivals are important in helping to further develop community bonds, keeping indigenous culture alive and vibrant, and bringing cheer and happiness to families and societies.Reference Yeolekar and Bavdekar 24 As these rituals and attendance at these events are part of their faith, audiences risk their health by performing these rituals regardless of their age, gender, and general health, leading to further complications. Additionally, pilgrims from lower socioeconomic groups may have limited access to medical care and can suffer long term from injuries sustained at events. For example, most of the people who travel to Mecca are from resource poor countries that do not provide vaccines against infectious diseases, increasing the risk health of others around them due to crowded circumstancesReference Khan, Memish and Chabbra 16 (Table 2).
Table 2 Motivations, Health Promotion, and Strategies – Religious Festivals
Being Part of a Tribe
Like religious festivals, sporting events are important as they reinforce community cohesion and the enhancement of an individual’s sense of well-being. Sporting events also enhance national pride and a sense of belonging through supporting a team or club.Reference Fredline, Jago and Deery 25 , Reference Lewis and Wolfson 26 Many of these events become a space where people seek to enjoy large amounts of food and alcohol, leading to over-consumption.Reference Lang and Frost 27 Understanding that this type of activity is part of the attendance at many sporting events is necessary for appropriate event risk management and the mitigation of the immediate and dire health effects this behavior can lead to. Even though the event is only a trigger, many spectators suffer heart attacks due to smoking, fatty foods, over-eating, excess salt, alcohol, illicit drugs, and physical exertion.Reference Lang and Frost 27 , Reference Hutton and Cusack 28
Clearly, audience members bring the state of their health with them to the event, but fans continue to consume fizzy drinks, burgers, and hot dogs which may exacerbate any underlying health issues.Reference Allen, O’Toole, McDonnell and Harris 7 , Reference Lang and Frost 27 This behavior, coupled with the stressors related to their physical and emotional engagement with the sporting contest as a spectator (ie, yelling, cheering, shouting, jumping up and down, and getting angry or upset), is a potent combination that involves a range of risks for the audience member.Reference Yeolekar and Bavdekar 24 In this type of scenario, on-site care staff need to prepare for conditions such as heart attacks, indigestion, and the effects of alcohol.
“Mega” events like the Football World Cup have a culture all of their own that attracts large-scale attendance and interest.Reference Blumberg, De Frey, Frean and Mendelson 29 This interest, when translated into very large numbers of people travelling from all over the world, brings with it an increased risk of communicable disease infection. As well as the travel risks, there is also evidence of unhealthy and antisocial behavior at these events, for example, binge drinking, unsafe sex, and violence.Reference Hills and Tall 30 People who travel to these types of mega events are often very passionate sports fans. The level of excitement generated gives an indication of the emotional and physical investment people make when attending such an event. For example, Kelly, Windsor, Delaney, and MaguireReference Kelly, Windsor, Delaney and Maguire 31 reported that at the 2002 World Cup in South Korea/Japan, high rates for depression and anxiety were found amongst spectators. They also reported high psychiatric referral rates related to alcohol misuse. This type of finding tells event planners that spectators may need access to counselling services. Event volunteers can provide such information, and websites and contact numbers can be displayed on screens during the event so that spectators can access services at their discretion.
As well the effects of depression, passionate sports fans can undergo “spectator stress” that can trigger cardiovascular events. In these environments, defibrillators are a must. However, if the event planner considers that people are going to misuse alcohol, get “over excited,” and ride the emotional highs of wins and losses, they can build in infrastructure at the event to support them. Strategies such as crowd care were implemented at the Polish World Cup to good effect. In addition to chill out zones, with no alcohol allowed, qualified counsellors and warm beverages provide a supportive environment for the audience. Roshchin and colleaguesReference Roshchin, Mazurenko, Blyznyuk and Smiley 32 reported that strategies such as these were effective in supporting spectators. In addition, these venues can provide pamphlets and brochures with QR codes with links to support services in that town or region that audience members can seek on their own. These types of strategies can lead to the overall public health of the event.
Other health issues commonly associated with the World Cup and the Olympic Games are a segment of the audience attracted to the event who utilize the services of sex workers.Reference Hills and Tall 30 The cultural predisposition of an audience that drinks (often to excess) and that travels from outside the region where the event is hosted creates a public health risk related to Haemophillus influenza A and HIV transmission (audience member to sex worker and vice versa). Here, condom use and hand washing are important, along with screening of sex workers to ensure they are clean prior to major events. Recently in Brazil, the culture nuances of underage prostitution came to light with the expected influx of thousands of people during the World Cup.Reference Smith 33 Even though Brazil does have a large underage sex trade, it is not legal, so as well as the health care aspects of unprotected sex, it was also important to inform people coming into the community that engaging in some activities can be against the law.
Alcohol consumption is closely associated with many sporting events and American football is no exception.Reference Merlo, Ahmedani, Barondess, Bohnert and Gold 34 Merlo has found that a “no drinking” policy or dry zone can lead to the practice of “tailgating” (where you drink from the trunk/boot of your car) prior to the event.Reference Merlo, Ahmedani, Barondess, Bohnert and Gold 34 Studies on Celtic football in the United Kingdom have also found that the ingestion of excessive alcohol leads to the majority of presentations at medical facilities at those events (Table 3).
Table 3 Motivations, Health Promotion, and Strategies – Sporting Events
Discussion
Event organizers intend their events to be positive experiences and to have meaning for those who attend. Therefore, continual vigilance to improve public health effectiveness and efficiency must become best practice at mass-gathering events. Primary interventions such as immunizations, running water, soap, and shade are important aspects of pre-event planning. However, public health planners need to go one step further and acknowledge the motivations of attendees at events to craft health messages and interventions that will reduce the number of injuries and illnesses obtained at mass-gathering events. Surveillance at large mass-gathering events has focused on communicable diseases with little understanding of what motivates the audience to attend the event. Systems must be sensitive enough to detect potential behaviors of the audience, for example, the use of fireworks or a clash between two tribes during a sporting match. Relying on the audience or event goers to act safely and responsibly at all times is short sighted when event goers can be supported to stay safe and healthy at an event.
Hutton’s work at Schoolies Festivals, where young people celebrate the completion of high school, shows that when young people go to an event with the intent to drink with their friends, that is exactly what they do.Reference Hutton and Cusack 28 This type of insight into motivations has been used to put in place strategies to support audience members attending these events. For example, free water, chill out areas that are alcohol free, and peer-led support can help to reduce the rate of intoxication and increase the safety of participants at these events.Reference Hutton, Cusack and Zannettino 35 , Reference Hutton, Munt, Zeitz, Cusack, Kako and Arbon 36
In all three of these mass-gathering modalities, it is seen that in all events, the ability to wash hands and have running water is a must. As with outdoor events, shade and free sunscreen are also important. What audience motivations do is bridge the link between medical practices, such as on-site care, and public health interventions, such as crowd carers, free water, and chill out zones. Once particular harm minimization strategies are put in place, these can be standardized to be included in the basic infrastructure of each event
Conclusion
The aim of this opinion piece is to begin a conversation acknowledging that audiences come to mass-gathering events with an expectation of how they will behave at an event (motivations).
The paper has argued that by understanding the motivations, and potential behaviors of the audience at an event, event planning can be enhanced to improve the well-being of the audience. Too often, there is an expectation that audiences will comply with set rules and not act outside societal boundaries at events. This belief can be a mistaken one, as with freedom of choice comes freedom of action, and staying healthy or being safe is not always at the forefront of people’s minds. Through understanding the motivations of the audience, event organizers and on-site medical teams can plan and prepare interventions to promote harm reduction and maximize safety at each event. The ultimate aim of developing this understanding is to better inform the health promotion and public health messages that can be developed for a particular type of event, based on the likely composition of the audience in attendance.
