The Event Environment

Outdoor music festivals are now starting to produce their own codes of conduct to influence crowd behaviour.^10–12 Guidelines such as these provide an expectation of behavior for the attendees/participants, outlining expected norms and a series of consequences for behavior outside of the stated norms. Examples such as these may indicate a shift from a purely occupational health and safety perspective on safety to the use of a social/behavioral lens.

Event planners and designers intend their events to be positive and provide meaning for those who attend.^{Reference Getz13} Events can be celebratory, providing the audience with a unique way of seeing, thinking, and knowing that leads to a positive experience, a shared meaning, and to a shared experience or “communitas” (that is, a shared belonging that removes the individual from the everyday).^{Reference Hutton, Brown and Verdonk14} Yet the space, design, and environment of the event can impact on the health of those attending or participating. Guidelines such as these provide an expectation of behavior to the participants, outlining expected norms and a series of consequences during the event. The inference being that poor behavior will not be tolerated; however, there is no framework for how this poor behavior will be managed. Examples such as this indicate a move from an occupational health and safety perspective on safety to a more behavioral lens. Even so, the physical environment can be easily controlled through legislation, safety guidelines, and event design; however, human behavior is more complex^{Reference Hutton, Savage, Ranse, Finnell and Kub15} and further work needs to be done in this space to mitigate risk and reduce presentations to on-site medical care.

Command, Control, and Communication

Mass-gathering events do not happen in isolation, they often occur in public spaces such as stadiums, ovals, and park lands. These events can be considered soft targets for acts of deliberate harm, such as vehicles being used for terrorist-related activities.^{Reference Marty and Health Organization16} Therefore, MGE health needs to be seen as a whole event, and security is an important part of a safe MGE. The World Health Organization’s (Geneva, Switzerland) Key Considerations state that planning and response to public health risks are achieved through C3: command, through the efficient use of resources; control refers to organizing resources to respond to event demands in a timely manner; and communication, whereby there is a coordinated dissemination of information before, during, and after the event.^{Reference Marty and Health Organization16} These three tenets require cross-disciplinary cooperation to rapidly recognize and manage incidents as they occur at an MGE. The key issue for MGEs is the scalability of C3 as they relate to the event. Additionally, there is a need for each stakeholder to be aware of their key responsibilities. For example, security is an important part of crowd control, which if not managed effectively has the ability to lead to poor health outcomes at an MGE.

Public Health

Public health aspects of MGEs have been a consideration for event planning for decades.^{Reference Endericks and Health Organization17} Of particular importance to public health at MGEs is surveillance of communicable disease and other illnesses. Such surveillance can assist in the identification of illness sources, such as food outlets with contaminated food resulting in gastroenteritis-like symptoms, and therefore action to prevent public health emergencies from an MGE. They can also be used to identify the incidence of influenza-like illnesses and subsequent impact upon the greater community.^{Reference Rainey, Phelps and Shi18} This is of new importance in the context of COVID-19. Public health research and evaluation of MGEs are often reported related to specific events, such as the Commonwealth Games or Olympics,^{Reference Severi, Heinsbroek and Watson19,Reference Qiu, Crilly and Zimmerman20} or related to specific communicable diseases such as Dengue.^{Reference Lowe, Barcellos and Coelho21,Reference Qiu, Crilly and Zimmerman22} However, the integration of public health principles for research and evaluation are seldom reported in the literature alongside the biomedical, environmental, and psychosocial domains. An integration of public health research and evaluation, such as surveillance systems used, reporting governance, and governance of local public health units with in-event health services and the broader health service, is important for a comprehensive understanding of the nature of MGEs. This would also serve to inform decision making on how MGE organizers should respond to communicable disease outbreaks or public health emergencies of international concern.

Health Promotion

Public health and health promotion as overarching concepts are missing from the mass-gathering literature, with researchers focusing on medical care and response, valuing a reactive rather than proactive approach to health care at these events.^{Reference Hutton, Brown and Health Organization23} Hutton, Ranse, and Munn^{Reference Hutton, Ranse and Munn7} assert that health promotion and the provision of public health information should be at the core of each MGE, which works alongside and compliments the medical response. Understanding the audience and how health messages can be communicated is an important part of health promotion^{Reference Hutton, Ranse and Munn7,Reference Hutton, Brown and Verdonk14} and can add to the civic responsibility of an event through community engagement mechanisms.^{Reference Roberston, Hutton and Brown8} Currently during music festivals around the globe, health messaging is used to reach audience members, ranging from crowd control to avoid crushes to messages about looking after friends and drinking responsibly when alcohol is being served.^{Reference Hutton24} Health promotion not only reinforces healthy behaviors, but also promotes social cohesion and can improve health outcomes both in and out of the event.^{Reference Hutton, Ranse and Munn7,Reference Roberston, Hutton and Brown8,Reference Harrison and Health Organization25}

Legacy

Despite limited evidence, it is generally viewed that hosting an MGE can influence improvements in health processes brought upon by shared conversations and agreed upon objectives.^{Reference Endericks and Health Organization17} Agreed upon objectives allow for measurable outcomes, which ultimately lead to the improvement of an MGE. Many times, improvements are made anecdotally and become part of the day-to-day quality improvement processes of an MGE. However, these improvements are the legacy of the event, and once documented in the literature, can contribute to the argument that MGEs are an important part of developing and honing knowledge in this space.^{Reference Endericks and Health Organization17,Reference Witt, Kotlhar and Mesquita26}

An important outcome of knowledge development in this space is having a clear plan at the beginning of the next event to allow for consistency in the provision of written reports and associated intelligence. This information leads to the collection of evidence-based data that support management strategies of future events. Consistency of reports assist in the assessment of harm minimization approaches at outdoor music festivals, thus providing a more reliable picture of the effectiveness of policies on the health and safety of audience members at these events. Record keeping of this type is important in modifying and enhancing strategies that are currently in place. This type of activity also assists in maintaining good collaborative practice amongst all participating organisations.^{Reference Hutton24} Finally, the main role of legacy is to produce better patient outcomes at each event and decreased patient presentation rates following the event – in the local community or in the following year if the event is held again.