Introduction
Mass gatherings are organized or unexplained events if the number of people is sufficient to strain the planning and response resources of the community, state or nation hosting the event.1 Planned events are “inherent in all societies” and are important in terms of “public policy, industry and corporate strategy” and are “fundamental to the experience economy.” Planned events are, in fact, a field of research interest and investigation, collectively named “event studies.”Reference Getz2
In 2004 ArbonReference Arbon3 proposed a mass-gathering conceptual framework that included three domains to understand how mass gatherings worked. These three domains are the environment, the biomedical and the psychosocial. Both the environmental and biomedical domains are well understood, whereas little has been developed on the psychosocial domain.Reference Hutton, Zietz, Brown and Arbon4 Understanding the predispositions of the audience generally, and the cultural predispositions of the audience in particular, are an important part of the psychosocial domain of a mass-gathering event as these, in turn, help to develop an understanding of the likely behaviors of those attending. Within the psychosocial domain, preventive strategies can be developed aimed at encouraging sensible consumption of alcohol. These types of interventions should consider these audience predispositions within the psychosocial domain so that any interventions are appropriate and targeted at the specific psychosocial profile.Reference Getz2
The authors argue that a predisposition is a predetermined set of values, influencers and behaviors that the audience member brings to the event. The literature often refers to the “culture” of an audience member when what a person brings with them to an event is described. This limits the discussion solely to the cultural background of a particular audience cohort or the individual attending the event. When audiences arrive at an event, they may well bring a set of values that might influence behavior because of their cultural background, but they do not arrive at an event as “blank slates” and are more likely to bring a broader range of predispositions. These predispositions may include: the demographics and sociographics of the individual or mix or ratio of the group; the expectations of the audience (based on how the event is marketed and/or on the audience member's previous experience at this or other events); motivations; and, to some extent, the predispositions of the family or friends that accompany the audience member to the event. Predispositions in this context can also include pre-event drug and alcohol consumption. Each of these predispositions (and any combination of one or more of them) will have some influence on audience behavior.Reference Eriksson5 These predispositions do not solely dictate or indicate audience behavior, of course, but are one of a wide range of factors that influence and may, perhaps, determine audience behavior at an event (for example, pre-event drug and alcohol consumption). A more developed understanding of the predispositions that might influence audience behavior will provide critical information for event planners, event risk managers and emergency services personnel to better predict and better plan to minimize risk and reduce patient presentations at events. For the event designer, a more developed understanding of audience behavior consequently enables the design of the event to be modified and allows the designer to adapt settings and programs as a response to observable audience behavior in real time. This review, then, investigates one of these predispositions, culture, as a starting point in the research of predispositions more generally.
Background
There is little consensus on a definition of culture. Eriksson states that it provides people with “the tools for interpreting and making sense of their world.”Reference Eriksson5 King, Turner, and Jago state that culture is a celebration of aesthetic values; and a storehouse and expression of cultures and, as well, a critique of cultures.Reference King, Turner and Jago6 Event planners and designers intend their events to be positive experiences and to have meaning for those who attend.Reference Brown and James7 The cultural component of events may include celebration; symbolic elements; the public performance of a sacrament; and aesthetic elements that may be catalytic or informative and may be intentionally designed and staged in a way that provides 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 Getz8
Culture, in the mass-gathering event context, can be more precisely defined as the shared values, beliefs and experiences of a defined audience cohort. The values and beliefs may be religious in nature or it may simply be that the cohort identifies itself as Gen X or Gen Y. The cohort may be an identified psychographic or sociodemographic segment of the event's or region's population. The key determinant will be that identifiable factors are shared by a group of audience members, not just an individual. It is likely that any event may have more than a single cohort.
While all events might have such a cultural perspective or significance,Reference Getz2 the psychosocial aspects of crowd behavior at cultural events, in particular, may be different from other planned events, as these events may involve a memorable transformative experience for those in attendance. However, as with the nature of the psychosocial dimension of mass-gathering events, the experience and the meaning is, to some extent at least, dependent on the expectations, values and meanings that the audience member brings to the event.1-Reference Arbon3, Reference Turner9
The Hajj is an example of these psychosocial elements and of communitas at a cultural event. Over four million people from different countries travel to Makkah, Saudi Arabia, each year to experience Hajj. Pilgrims enter a realm, moving in a liminal journey from the profane to the sacredReference King, Turner and Jago6, Reference Turner9, Reference Brown10 that recognizes a common human bond that is free of tribalism, color prejudices, provincialism, social hierarchy, and other divisions that might lead to antagonism. Hajj is seen by the audience as an invitation from God to liberate the soul by submission to Him alone.Reference Van Gennep11, Reference Currie12
The importance of culture is also highlighted in a case study on the Aotearoa Traditional Maori Performing Arts Festival held in Auckland, New Zealand. The act of celebration brings people together and reconfirms shared values. This is particularly important for an audience when those values are not those of the dominant norms in a society. For indigenous or native peoples in former colonial countries, festivals have become a means of reinforcing cultural norms and establishing or confirming their “legitimacy.” In these events, when local “grassroots” involvement is strong, events retain a function of reinforcing community cohesion. An individual's sense of well-being is enhanced through attendance at the cultural event that provides a sense of belonging.Reference Getz8
Methods
Publications concerning the cultural aspects of mass gatherings were reviewed to understand audience motivations. A key word search was conducted to locate scholarly peer-reviewed articles published in English from 2001 through 2011 by searching the following online databases: GALE, NLM, Web of Science, Elsevier, Wiley, BMJ Journals, OUP, IngentaConnect, RMIT, DOAJ and JSTOR.The extensive search was undertaken by combining the terms Emergenc* OR Public Health with Mass gathering*, Event*, Crowd*, World Cup, Rall* (rally, rallies, rallying etc), Soccer, Football, Superbowl, Rock, Concert*, Jamboree*, Hajj, Pope, Papal, Lourdes, Fatima, Pilgrim*, Festival*, Cricket, Marathon*, Rugby, Olympi* (Olympics, Olympiad, etc.), Game*, Tennis, Sport*, Demonstration*, Protest*, Summit, Riot*, Flash mob, Arena and Stadi* (stadia, stadium). Wild card entries were utilized to ensure that all variations of a term were included in the search.
To qualify for inclusion, a publication was required to discuss: culture/cultural aspects; and/or audience motivations; and/or any of the predispositions listed above in mass-gatherings context, irrespective of whether the events were studied generally or specifically. Published news articles were omitted. The search resulted in over 3,000 articles which were refined to 721. Through reading the full text articles of the identified studies, their relevance was ascertained and the publications were classified as either relating to religious, sporting or music mass gatherings. The final number of relevant articles was reduced to 229. From this number of articles a further analysis of the word “culture” was used to determine inclusion criteria as part of the review, leaving the authors with 94 articles to review (Figure 1). As the aim of this manuscript was to discuss predisposition in regard to culture and its effect on the psychosocial domain of mass gatherings, in the end only 60 articles were used from the initial 94.
Search Strategy for Culture/Predispositions
Results
Religious Mass Gatherings
Religious events are often dominated by rituals that indicate a display of faith.Reference Hawkins and Brice13 There is often pressure on followers of religion to attend these events with little consideration of their own health needs.Reference Rashid Gatrad and Sheikh14 During the Chaharshanbe Soori, in India, fireworks are used to celebrate the occasion.Reference Tavakoli, Khashayar and Ahmadi Amoli15, Reference Saadat, Naseripour and Smith16 Fire is integral to the celebration, culturally, as it is used to scare away evil spirits and is an integral part of the event. Burn injuries are, therefore, accepted by the audience as just part of the event. Religious festivals that use fire to protect the devout might do so with the risk of injury, but if you are burned it is considered a blessing. Most common injuries occur to the hands and eyes.Reference Hawkins and Brice13, Reference Tavakoli, Khashayar and Ahmadi Amoli15, Reference Saadat, Naseripour and Smith16
Injuries from celebratory riots have also been documented. Mostly injuries are minor and are alcohol-related or musculoskeletal injuries. However, at times when fireworks or bonfires, fire jumping or firewalking are involved, there are often substantial injuries from burns.Reference Hawkins and Brice13
The commitment of the audience member individually (and the audience as a whole) to these religious mass-gathering events should not be underestimated. This cultural predisposition might include behavior that ranges from the passively devout to the aggressively fanatical and everything in between. Understanding the cultural elements both of the event and brought by the audience are important for predicting likely behaviors and assessing risk. Audiences travel great distances to perform the Hajj,Reference Khan, Memish and Chabbra17 and to attend World Youth DayReference Hutton, Roderick and Munt18 and the Catholic Jubilee.Reference Faustini, Marinacci and Fabrizi19 Part of these events is the requirement of the audience to undertake a pilgrimage over long distances, and this ritual will be performed no matter what age or general health problems participants may have prior to commencing.Reference Khan, Memish and Chabbra17, Reference Gautret, Soula, Delmont, Parola and Brouqui20 This large influx of people also leads to an increased risk of communicable diseases at these events.Reference Saadat, Naseripour and Smith16-Reference Rashid, Gatrad, Shafi, Memish and Sheik21
The health issues for religious mass gatherings are well documented. However as these rituals and attendance at these events is a part of their faith, audiences risk their health by performing these rituals regardless of their age, gender, and general health. When pilgrims of religious mass gatherings arrive at an event, they may have crossed borders, caught infectious diseases and now be carriers of illness. For example pilgrims at the Catholic Jubilee event suffered from a gastrointestinal disease due to Giardia contamination.Reference Faustini, Marinacci and Fabrizi19 Additionally those pilgrims from lower socioeconomic groups are unlikely to be vaccinated due to limited access to medical care and vaccines or the money to pay for it. Most of the people who travel to Mecca are from resource poor countries that do not provide vaccines against infectious diseases.Reference Gautret, Soula, Delmont, Parola and Brouqui20-Reference Rashid, Shafi, Haworth, Memish, Bashir, Ali and Booy22
As well as the culture of the religious event, the culture of the crowded circumstances leads to increased health risks; more so when people travel to an event;Reference Gautret, Soula, Delmont, Parola and Brouqui20 continual vigilance to improve public health effectiveness and efficiency should become best practice.Reference Rashid, Gatrad, Shafi, Memish and Sheik21, Reference Rashid, Shafi, Haworth, Memish, Bashir, Ali and Booy22.
Hajj
The Hajj is the one of the most researched planned religious events. Risks include exposure to infectious diseases, including Influenza A (H1N1), tuberculosis and meningococcus.Reference Rashid Gatrad and Sheikh14, Reference Khan, Memish and Chabbra17, Reference Haworth, Rashid and Booy23-Reference Wilder-Smith, Barkham, Ravindran, Earnest and Paton32 In addition, bloodborne viruses such as hepatitis have been recorded.Reference Harunor and Shuja33 Some health promotion measures happen if the pilgrims come from prosperous countries which have established vaccination programs for intending pilgrims.Reference Dixon34 For example, tetanus, diphtheria and poliomyelitis vaccinations are administered in France.Reference Gautret, Soula, Delmont, Parola and Brouqui35 Apart from the exposure to disease, when pilgrims are performing Hajj rituals they also suffer from heat exhaustion and heatstroke, foot burns and sunburn.Reference Currie12-Reference Rashid Gatrad and Sheikh14, Reference Noweir, Bafail and Jomoah36 Safety measures, including vaccination, hydration, and knowledge of the conditions awaiting the pilgrim, are vital.Reference Rashid Gatrad and Sheikh14
Human stampede has been reported at other religious festivals such as the Ram Janki, a religious festival held in India every March.Reference Burkle and Hsu37 This stampede was due to zealous followers trying to get through narrow gates to take part in the Ram Janki celebration. Festivals such as these are important in helping to further develop community bonds, and Yeolekar and BavdekReference Yeolekar and Bavdekar38 state that these types of festivals ensure that the indigenous culture is kept alive and vibrant as well as bringing cheer and happiness to families and societies.Reference Yeolekar and Bavdekar38
Increased infectious transmissions at religious event is also an issue. At World Youth Day, a weeklong pilgrimage of faith,Reference Hutton, Roderick and Munt18 the risks of influenza and its transmission were 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 health.Reference Hutton, Roderick and Munt18 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 hospitals for treatment. The low admissions may, however, be a result of the audience being so engaged in the event and the sense of community found there that they are loath to leave the event site until such time as their illness disables their ability to continue to enjoy or participate in the event.
Sporting Mass Gatherings
In these events, when local grassroots involvement is still strong, events retain functions of reinforcing community cohesion and the enhancement of an individual's sense of well-being through providing a sense of belonging.Reference Getz8
Within the mass-gatherings literature, sporting events are represented in many different ways. Major sporting events such as the football (soccer) World Cup, are often attended by very passionate sports fans. These passionate sports fans can undergo “spectator stress” that can trigger cardiovascular events.Reference Leeka, Schwartz and Kioner39 The level of excitement gives some indication of the emotional (and physical) investment people can make when attending an event such as the World Cup. Even on a much smaller scale the marketing of an event may contribute to the culture that is developed. In local Australian Rules football in South Australia the marketing has used the song Two Tribes (by the band Frankie Goes to Hollywood) as its theme (with the lyric “when two tribes go to war …”) and proudly displays the Tribal Warrior of the Week from one of that week's games.40
Lang and FrostReference Lang and Frost41 state that some events can become a space where people seek to consume large amounts of food and alcohol; they refer to this activity as “conspicuous consumption.”Reference Lang and Frost41 Understanding that this is part of the culture of attendance at many sporting events is necessary for appropriate event risk management and the mitigation of the immediate and dire health effects that overconsumption can lead to. Leeka, Schwartz, and KlonerReference Leeka, Schwartz and Kioner39 reported that many spectators suffer heart attacks at sporting events due to smoking, fatty foods, overeating, excess salt, alcohol, illicit drugs and physical exertion.Reference Leeka, Schwartz and Kioner39 Clearly, audience members bring the state of their health with them to the event, but fans continue to consume fizzy drinks, burgers, and hot dogsReference Lang and Frost41, Reference Allen, O'Toole, McDonnell and Harris42 (and often drugs and alcohol) at the event, which exacerbates any underlying health issues. This, combined with the stressors related to their physical and emotional engagement with the sporting contest as a spectator (eg, yelling, cheering, shouting, jumping up and down, getting angry and upset), is a potent combination that involves a range of risks for the audience member.
World Cup
Similar to travelling for religious reasons, for mega-events (those events that are so large that they affect whole economies and reverberate in the global media),Reference Getz8, Reference Blumberg, De Frey, Frean and Mendelson43 like the World Cup, the event has a culture that attracts large-scale attendance and interest, and this interest, when translated into very large numbers of people travelling from all over the world to attend the event, brings with it an increased risk of communicable disease infection.Reference Blumberg, De Frey, Frean and Mendelson43, Reference Lai, Bottomley and McNerney44 As well as the travel risks, there is also evidence of unhealthy and antisocial behavior at these events (for example, binge drinking and violence). According to Kelly et al,Reference Kelly, Windsor, Delaney and Maguire45 alcohol misuse during the 2002 World Cup was rife. They also stated that psychiatric referral rates for alcohol misuse were 100% greater than the previous year, and rates for depression/anxiety and schizophrenia also increased.Reference Kelly, Windsor, Delaney and Maguire45
The ability of the design of an event to affect the emotional state of the audience member either individually or as a cohort has been well investigated from a number of perspectives (see, for example, Moital et alReference Moital, Jackson and Gouthro46 and Pullman and GrossReference Pullman and Gross47) and a highly charged emotional state in a mass-gathering audience is likely to raise concerns for any event manager, regardless of whether that emotional state is: positive (eg, the 2012 Closing Ceremony of the Olympic Games); negative (eg, the fearful emotional state of those trapped in the tunnel at the 2010 Love Parade event); or rapturous (eg, the Hajj).
Associated with the World Cup is a segment of the audience that utilizes the services of sex workers. 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 Human immunodeficiency virus (HIV) via audience member to sex worker and vice versa, and the possible victimization of the sex workers.Reference Marlise, Richter and Cherisch48
High sound pressure (measured in decibels or dB) levels at matches (as also occurs elsewhere at music concerts and indoor and outdoor events where there is amplified music) create a risk of incurring sound-induced hearing loss. High sound pressure levels at events are also known as stressors creating anxiety and fatigue. Repetitive rhythms and beats per minute tempos can also have adverse effects on an audience from a health perspective.Reference Duncan49
However, there are also positive psychological aspects to attending an event such as the World Cup. The event provides a shared experience and a resultant interesting topic of conversation which may promote cultural unity. Further benefits such as social interaction for the individualReference Gunnervall, Petersen, Svensson and Brown50 and a sense of belonging, pride, an increased cultural awareness, and a range of other factors at the community level, are well documented.Reference Getz8, Reference Fredline, Jago and Deery51-Reference Lewis and Wolfson53
Olympic Games
Mega-events like the Olympic Games bring an international travel culture which requires a range of event safety measures including public health surveillanceReference Larkin54 and bioterrorism prevention.Reference Larkin54, Reference Hills and Tall55 The Olympics has extraordinarily high levels of tourism and media coverageReference Getz8 and it might be argued that the “whole world” is watching. Studies have shown that there is a culture of partying (including illicit drug taking) by audience members during the period of the Games. Indig et alReference Indig, Thackway, Jorm, Salmon and Owen56 assert that health messages and a rapid response to identified unusual patterns of illicit drug-related harm, particularly at known “hot spots” at Games venues and in the host city and surrounds, are critical to the successful minimization of patient presentations.Reference Indig, Thackway, Jorm, Salmon and Owen56
Alongside issues related to bioterrorism and partying, the size of the audience at such mega-events can lead to epidemiological issues such as the transmission and increased occurrence of illnesses such as the common cold, influenza and episodes of gastrointestinal illness.Reference Larkin54, Reference Jorm, Thackway, Churches and Hills57 As well as the more commonly occurring infectious illnesses, the sexual health of athletes competing at the Games needs to be considered as part of the culture of the Games due to the increased sexual activity among athletes.Reference McNulty, Rohrsheim and Donovan58
Marathons
Much of the documented literature pertaining to marathon races (at professional and “fun run” levels) focuses on the health of the athletes who are running in the event. The competitive culture of such events, where the audience's predisposition of pushing one's body to the limit, needs to be accommodated in the event planning and subsequent event risk management plan. While this predisposition is not considered extreme for healthy individualsReference Finn and Coviello59 other researchers have reported the incidence of myocardial infarction and/or sudden death,Reference Sampson60 severe dehydration, hyponatremia, heat stroke, renal failure, acute coronary syndrome, ischemic colitisReference Finn and Coviello59, Reference Sampson60 and thermoregulatory issues.Reference Kenefick, Cheuvront and Sawka61 Clearly, the culture of marathon running and the predisposition of the audience have a significant impact on the health outcomes of the event and the likely levels of patient presentations.
College Football
Alcohol consumption is closely associated with American football.Reference Glassman, Werch, Jobli and Bian62, Reference Merlo, Ahmedani, Barondess, Bohnert and Gold63 When there is a no-drinking policy inside games there is culture of “tailgating” (where you drink from the trunk of your car) before games to consume alcohol.Reference Merlo, Ahmedani, Barondess, Bohnert and Gold63 In addition to this preloading of alcohol at the event (but outside the venue) high levels of alcohol are consumed at pregame festivities. Studies on Celtic football in the United Kingdom have also found that the ingestion of excessive alcohol leads to the majority of presentations at those events.
Music Mass Gatherings
Outdoor music festivals are purported to have the highest rate of patient presentations due to the presence of alcohol.Reference Allen, O'Toole, McDonnell and Harris42, Reference Chan and Quinn64 It is well documented that music festivalgoers engage in drinking and other drugs at these festivals.Reference Van Germert, Dietze and Gold65 Both the 2004 Oxegen festival, touted as Europe's largest music festival held in Ireland, and the 1999 Sweetwaters festival, a festival of music, culture and technology held in New Zealand, reported high levels of intoxicationReference Yates, Hazell and Schweder66, Reference Nix, Khan, Hoban, Little, Keye and O'Connor67 and a significant increase in presentations at the emergency departments of local hospitals.Reference Nix, Khan, Hoban, Little, Keye and O'Connor67 The Glastonbury Music Festival, held in England each year, was first held in 1970. Due to the longevity of the event, audience members have clear expectations of what the event entails, either through their experience of previous events and/or the narratives of those who have attended previously, and from the event's own marketing. The audience arrives at Glastonbury anticipating and expecting fun, celebration, friendship and alcohol, part of their cultural disposition along with adolescent risk taking.Reference Earl, Parker and Capra68
Other identified risks for outdoor music festivals are: the “mosh pit culture” where audience members purposively crush together in a tight group in front of the stage and “crowd surf,”Reference Yates, Hazell and Schweder66, Reference Earl69, Reference Lim, Hellard, Aitken and Hocking70 risk of sexually transmitted infections (STIs)Reference Earl69 and hearing loss due to high sound pressure levels.Reference Naquin Shafer71
Additionally it is well documented that music festival goers engage in drinking at these festivals, and campaigns against binge drinking have been used in an attempt to curtail young people using alcohol and other drugs at these mass gatherings.Reference Yates, Hazell and Schweder66 However, why these substances go hand in hand with these particular types of events is not well understood and requires further investigation.
At Australian school-leavers festivals, otherwise known as schoolies, Hutton et alReference Hutton, Cusack, Zannettino, Shaefer, Verdonk and Arbon72 have found that young people go to schoolies with the intent of drinking alcohol in order to have fun. In addition, this study also found that young people do not actively seek out any type of health messages or information prior to attending this festival. If information is sought, it is through peers and parents, although young people reported that as they already frequent night clubs and drink alcohol prior to going to schoolies, they already have established patterns of behavior around alcohol use prior to attending schoolies.Reference Hutton, Cusack, Zannettino, Shaefer, Verdonk and Arbon72
Conclusion
Event planners and designers intend their events to be positive experiences and to have meaning for those who attend. Events are important to those who attend as the shared experience of attendance can lead to communitas. However, as with the nature of the psychosocial dimension of mass-gathering events, the experience and the meaning is, to some extent at least, dependent on the expectations, values and meanings that the audience member brings to the event.
By understanding the predispositions of the audience, event planners and designers, event risk managers and event safety personnel are able to better understand the motivation of the audience and how this might impact audience behavior at the event. An important first step is the investigation of one of these predispositions, that of “culture.” Further work needs to be done, however, to investigate the broader range of predispositions, with the ultimate aim of developing this understanding to better inform the health promotion and public health messages that can be developed for a particular type of event, based on the composition of the audience and the broader range of predispositions that they are likely to bring with them to the event.
