Challenges faced by the Iranian health system in response process to terrorist explosive attacks: a descriptive phenomenology qualitative study of live experiences

Abstract

Introduction

Mass casualty incidents present significant challenges not only for healthcare providers and emergency service responders at the incident scene, but also for the hospitals that receive those affected. Terrorism related mass casualty incidents can lead to a diverse array of circumstances, necessitating those hospitals and their personnel be adequately prepared to manage more complex and demanding requirements. This study aimed to explore the health system challenges related to the response process to terrorist explosive bombing attacks from the perspective of Iranian health system managers and experts.

Methods

The present qualitative study employs a descriptive phenomenology approach conducted in Iran. Data were gathered through in-depth individual interviews with 16 health managers and experts, using purposive sampling. The Data analysis was conducted utilizing Colaizzi’s 7-step method. To ensure the trustworthiness of the findings, the study adhered to the recommendations set forth by Lincoln and Guba.

Results

After multiple rounds of analyzing and summarizing the data and taking into consideration similarities and differences, 230 initial codes, 18 sub-categories, 5 categories and 2 main themes were created based on the results of data analysis. Theme 1: Intra-organizational challenges including categories of (prehospital and hospital challenges). Theme 2: Inter-organizational challenges including categories of (chain of command, insufficient security and ineffective communication and information).

Conclusion

This study explored healthcare workers and managers experiences with internal and external organizational challenges in responding to terrorist explosive bombing attacks. Findings reveal that such incidents pose unique demands distinct from other emergencies, requiring tailored preparedness strategies, especially in prehospital, hospital, and logistical sectors, despite existing general disaster plans. An effective response needs multisectoral collaboration with security forces and aid organizations. The presentation of real-world insights can inform targeted preparedness programs for high-risk, chaotic terrorist scenarios.

Clinical trial number

Not applicable.

Introduction

A terrorist attack is defined as the intentional application of unlawful force and violence by non-state actors to achieve political, economic, religious, or social objectives through instilling fear or coercion [1]. In recent years, bombings and explosions targeting civilians have emerged as a prevalent tactic of terror, resulting in injuries, fatalities, chaos, and widespread fear [2]. The accessibility of explosives and the dissemination of knowledge regarding their construction and utilization have rendered these devices the most frequently employed weapons in contemporary terrorist activities [3]. In the past five years, a total of 36,200 terrorist attacks were documented globally. These incidents resulted in 81,300 fatalities and 110,300 injuries. Most (40–50%) incidents involved explosive or bombing attacks [4]. Terrorist attacks targeting mass gatherings continue to pose a significant threat globally. Between 2019 and 2023, attacks on public events (concerts, festivals, and rallies) accounted for over 200 incidents, resulting in approximately 1,100 fatalities and 4,500 injuries [5]. Stadiums and sports venues experienced more than 90 attacks, leading to more than300 deaths and more than1,200 injuries [6].

Participants in mass gatherings may be subject to targeted actions during, throughout, or following the event [7]. The increasing incidence of terrorist attacks presents a growing threat to national security, and numerous countries are affected by these assaults, resulting in substantial casualties and injuries [8]. Religious ceremonies have been particularly susceptible to terrorist incidents, as individuals attending such events face an elevated risk of attack. These incidents often transpire at or in proximity to religious sites or places of worship, encompassing entry points and interior areas. Innocent civilians globally frequently serve as targets for terrorist acts, including bombings, shootings, and vehicular assaults. To maximize casualties, terrorists often focus on locations with high concentrations of civilians [9]. Studies reveal a generally low level of preparedness among various countries and communities to effectively respond to terrorist attacks [10]. Similarly, healthcare providers are often inadequately prepared to manage such incidents. Consequently, it is crucial to develop plans that enhance the safety of events and accommodate large numbers of participants [11].

The healthcare system encounters multiple difficulties when addressing terrorist incidents at mass gatherings [12]. Terrorist explosive attacks continue to pose a severe threat to public health, generating mass casualty incidents (MCIs) that test the limits of medical and emergency response systems [13]. These challenges include preparedness and clinical training, limitations in incident command systems, inter-agency coordination, surgical services, communication, and mental health support [14]. To ensure effective command, control, and communication during emergencies, all local hospitals must be prepared to respond to potential incidents and possess surge capacity capabilities [15]. Coordination between hospitals and prehospital emergency services is paramount, especially in managing trauma casualties [15, 16]. The healthcare system must integrate training and drills into its readiness programs to bolster preparedness levels and ensure a proficient response to such incidents. Furthermore, reviewing past incidents and distilling lessons learned and challenges from real events can significantly aid in formulating effective preparedness plans [16, 17].

It is challenging to obtain clear and reliable information about the tasks carried out by special services during the prevention and response to a terrorist attack [18]. Challenges related to command and coordination under time pressure during multi-institutional operations at the scene of an attack have been reported. Different services (police, fire, medical) may have different interpretations of objectives despite the overarching goal of saving lives, highlighting a need for conceptual, legislative, and planning activities regarding the organization of on-scene command at the preparation stage [19]. In addition to the challenges of managing the scene of an incident and the need to be prepared for them, previous studies have pointed out the importance of paying attention to the psychological state of the responders. This area requires a specific program for this type of incident in the recovery phase [20].

Previous studies have demonstrated that phenomenology has been employed to examine experiences related to specific scenarios [21]. Phenomenology emphasizes the lived experiences perceived or interpreted by participants [22]. Exploring the experiences of others can unveil insights previously unavailable, making it a valuable method for this study’s objectives. In addition, the efforts of policymakers and managers have focused on preparing for common incidents and disasters, and less attention has been paid to special incidents such as terrorist attacks with special preparedness needs and a comprehensive search revealed a lack of qualitative research concerning the experiences of disaster experts in the response process to terrorist incidents. Therefore, this study aspires to identify the challenges faced by the Iranian healthcare system during a terrorist bombing incident at a mass gathering.

Description of the terrorist incident

At 2:50 PM and 3:17 PM on January 13, 2023, coinciding with the fourth anniversary of the martyrdom of Martyr, an important person in Kerman city, two terrorist explosions occurred in the area of the Martyrs’ Cemetery. These two tragic and bloody incidents resulted in the martyrdom and injury of a large number of pilgrims at the ceremony. In total, these two incidents left 284 injured, 195 of whom were hospitalized in 12 government, private, and military hospitals in Kerman, and 95 were martyred.

Based on prior planning and population estimates, eight ambulances, four ambulance buses, and two motorcycle ambulances were deployed along the Golzar-e Shohada route for prehospital emergency services. Hospital access routes were established for emergency medical personnel and mapped on mobile devices. The first ambulance technicians confirmed the incident to the university’s operations command center, prompting the Emergency Operation Center (EOC) to issue a red alert for all hospitals to prepare for emergency evacuations and surge capacity to accommodate the injured. Patients were assigned to the nearest treatment centers. All operational prehospital emergency codes in Kerman and teams from Mahaan, Joupaar, Chatroud, Kouhpayeh, and Baqeen were sent to the scene to transport the injured. Within an hour of the first explosion, 21 ambulances and four ambulance buses transported victims to 12 educational and private hospitals in Kerman, coordinated by the dispatch center and the Medical Care Monitoring Center of the university. Due to the high number of casualties, this incident was classified as a Mass Casualty Incident (MCI). Following rescue operations and patient transfers, despite protocols against moving bodies, deceased individuals were transported by ambulances to hospital morgues and forensic facilities to alleviate the tense atmosphere at the site. Media monitoring, rumor control, and effective communication were managed through state television, with updates provided by the university spokesperson. Hospitals provided immediate treatment upon receiving patients from the prehospital emergency services, implementing necessary medical interventions, including surgeries, stabilization, and ICU care.

Method

Study design, setting, and participants

The present research is a qualitative study employing a descriptive phenomenology approach, aimed at understanding the experiences and perspectives of individuals involved in the response process to a terrorist incident. Phenomenological research primarily relies on interviews with individuals possessing direct experience of the phenomenon under investigation [23]. Observational data and personal diaries both past and present can augment interview data. Researchers should conduct unstructured in-depth face-to-face interviews exclusively with subjects who have firsthand experience of the phenomenon [24]. The primary objective is to identify the challenges faced by the healthcare system during a terrorist bombing at a mass gathering in southeastern Iran in 2024. Descriptive phenomenology entails exploring and analyzing a specific phenomenon to elucidate the participants’ subjective experiences [25]. To identify and categorize the challenges within the health system, interviews were conducted with managers and experts from Kerman University of Medical Sciences, who had first-time experience response and directly engaged in the response process to the terrorist incident. Inclusion criteria encompassed direct experience managing terrorist bombing attack incidents, presence at the scene, involvement in providing health services during response operations, and willingness to participate in the study. The sole exclusion criterion was a lack of consent to participate.

Data collection

In this study, participants were selected through purposive sampling and we conducted in-depth face-to-face interviews with participants in locations agreed upon by the theirs to collect data and ensuring their comfort. At the outset of each interview, participants received necessary explanations regarding the research objectives, data collection methods, and confidentiality assurances. Two pilot interviews were conducted with individuals outside the selected participant group to establish validity and ensure the questions’ relevance. Revisions were made based on their feedback and input from colleagues to address any identified deficiencies. The interviews lasted between 18 and 50 min; each commenced with the open-ended question: “Can you describe your experience of responding to a terrorist incident?” This approach allowed participants to articulate their experiences in detail and with ease. The questions focused on critical areas, including challenges encountered, actions taken, and the strengths and weaknesses of the health system in addressing a terrorist bombing at a mass gathering. Exploratory questions, such as “Can you provide an example of this issue or challenge you faced?” or “Could you elaborate further on this topic?” were utilized to gain deeper insights into the challenges and concepts discussed. All interviews were conducted by the first author, a male with a PhD in health in emergencies and disasters, possessing 18 years of clinical training experience and expertise in qualitative research. In this study data collection continued until saturation was reached. While a consensus on the precise definition of data saturation remains elusive, and a systematic approach to its implementation is lacking, it is generally understood as the iterative process of incorporating new participants into the dataset until data redundancy emerges [26]. Saturation is achieved when the addition of further data yields diminishing returns, failing to contribute novel insights to the existing dataset. The objective of data saturation is to ensure replicability within categories; replication serves to validate findings and ensure thorough comprehension and completeness. In essence, qualitative researchers employ progressive case selection, continuing until data saturation is achieved, without predetermining the total number of participants [27]. In this study, data saturation was determined after the 14th interview. To ensure saturation, two additional interviews were conducted, and no new codes were identified.

Data analysis

Data analysis was conducted utilizing Colaizzi’s 7-step method, which comprises: (1) familiarization with the data, (2) extracting significant statements, (3) formulating meanings, (4) organizing themes, (5) providing a comprehensive description of the phenomenon, (6) identifying the fundamental structure of the phenomenon, and (7) returning to the participants [25]. Following informed consent, the interviews were audio-recorded using a mobile phone and subsequently transcribed. The transcripts were analyzed using MAXQDA-20 software. Coding was then conducted on the sentences, with each sentence assigned a code representing its core concept. Specifically, statements related to the phenomenon under investigation were underlined to identify significant sentences. Important phrases were distilled into core concepts. Initially, each sentence was assigned a code representing its meaning. Subsequently, codes with similar meanings were grouped into sub-categories. In the next stage sub-categories with similar meanings were organized into main categories and researcher grouped these concepts into categories based on shared characteristics. Finally, on a general level the main study categories were organized under study themes. Therefore, results were synthesized to form general themes for providing a better comprehensive description of the phenomenon.

Ensuring rigor and trustworthiness of data

To ensure the accuracy and reliability of the data, the criteria for scientific rigor in qualitative research, as proposed by Guba and Lincoln, were employed [28].For credibility was achieved through prolonged engagement, persistent observation, maximum variation in sample selection concerning education and workplace at different levels, peer checking (reviewing codes and categories with research co-workers), and member checking (reviewing codes and categories with study participants).To ensure dependability, we elaborated in detailed the data collection process, research purpose, limitations, analysis methods, and theme extraction procedures, thereby facilitating thorough auditing by external observers. To enhance confirmability, the researcher extracted codes and themes from participant descriptions, and the resulting analysis was reviewed by research colleagues to ensure accuracy. Regarding transferability, the study’s findings along with supporting quotations were presented to three professionals with expert health in emergencies and disasters who had not been involved in the research, and whose experiences aligned with the study’s context.

Ethical consideration

Participants were thoroughly briefed on the study’s objectives, the methodology for reporting results, and the procedures for audio recording during interviews. Following this explanation, written informed consent was secured from all participants before their involvement in the study. Furthermore, participants were made aware of their right to withdraw from the study at any point without facing any repercussions. The scheduling and location of the interviews were determined at the convenience of the participants. Confidentiality of the information provided and the assurance of the right to withdraw were upheld throughout all phases of the research. All procedures complied with the guidelines outlined in the Declaration of Helsinki.

Results

The study participants consisted of 16 individuals involved in response operations to a terrorist bombing incident. Among the participants, 10 were male, and 6 were female. 4 participants held bachelor’s degrees, 3 had master’s degrees, 3 held doctoral degrees, and 6 were emergency medical specialists. Of the 16 participants, 6 were from the prehospital area (4 on-scene operational personnel and 2 managers), 2 were from the emergency operations center managers, 6 were from the hospital area (3 medical staff, 3 managers), and 2 were from the logistics department of the University of Medical Sciences. The demographic characteristics of the participants are presented in Table 1.

Table 1.

Demographic information of participants

Demographic characteristics	Subcategory	Number (Percentage of the sample)
Gender	Male	10 (62.50)
	Female	6(37.50)
Age (Years)	25–35	9(56.25)
	36–45	5(31.25)
	≥ 46	2(31.25)
Work Experience	10≤	4(25)
	11–20	10(62.50)
	21–30	2(12.50)
Organizational positions	Prehospital	6 (37.5)
	Hospital	6 (37.5)
	Logistic	2 (12.5)
	EOC	2 (12.5)
Education Status	Bachelor’s	4(25)
	Master’s	3(18.75)
	Doctoral Degrees	3(18.75)
	Emergency Medical Specialists	6(37.50)

After multiple rounds of analyzing and summarizing the data and taking into consideration similarities and differences, 230 initial codes, 18 sub-categories, 5 categories and 2 main themes were created based on the results of data analysis. Theme 1: Intra-organizational challenges including categories of (prehospital and hospital challenges). Theme 2: Inter-organizational challenges including categories of (chain of command, insufficient security and ineffective communication and information), Also each category consists of several subcategories which are reported separately in Table 2.

Table 2.

Challenges of the health system related to the response process to terrorist explosive attacks

Theme	Categories	Sub-categories	Example code
Intra-organizational Challenges	Prehospital Challenges	Hard access to routes	- Excessive public presence at the incident scene - Lack of a dedicated path for reach the ambulances deployed to victims and exit from incident scene - Heavy vehicle traffic on the surrounding streets of incident location
		Victims’ unsuitable distribution	- Lack of a clear mechanism for choosing a transport destination for victims - Unsuccessful implementation in zoning (triage-treatment-transport) in the incident site - Inability to triage on site by prehospital personnel - Absence of an advance medical post (AMP) and mobile hospital at the incident scene for victims’ distributions - Lack of cooperation from some non-government hospitals with prehospital system for reception victims
	Hospital Challenges	Unexpected and unforeseen presence of important persons and volunteer	- Presence and visits of provincial and national officials in hospital - The presence of healthcare workers from other country medical sciences universities without calling them
		Non-implementation of continuous triage process	- Insufficient physical space in educational hospitals - Lack of trained personnel for triage of mass casualty incident (MCI) caused by bomb explosions - Lack of related facilities
		Logistic limit support	- Lack of specialized equipment in educational hospitals crisis warehouse - Lack of specialized facilities for victims of terrorist incidents (multiple trauma), such as neurosurgeons and related facilities - Insufficient psychological support
		Poor coordination of inter-hospital transfers	- Not accept of trauma cases by private hospitals to avoid medico-legal processes - Disagreement between different medical professionals for interhospital transfer of Injuries - Lack of memorandum between government and non-government hospitals during terrorist attacks
Inter-organizational challenges	Chain of Command	Fragmented authority in multi-agency operations	- Contradictory decisions of organizations in charge of disaster management - Lack of common literature among of organizations in charge of disaster management - Lack of familiarity organizations with each other command structure
		Failure to activate of incident command elements	- Lack of incident command post (ICP) - Failure to activate ICS in some organizations - Lack of unified command post (UCP) - Lack of unified command system (UCS)
		Lack of inter-organizational coordination	- Conflict in priorities - Coordination conflicts with security forces - Lack of a strategic view of organizations in charge - Lack of coordination of necessities and infrastructures - Poor coordination between local police and pre hospital system to route ambulances
		Poor cooperation and control in evacuating and transferring the bodies	- Lack of clear guidelines for managing bodies - Blocked paths - Failure to receive bodies in the hospital - Lack of clarity responsible organization for evacuating bodies
	Insufficient Security	Difficulty in ensuring security space in the hospitals and incident scene for managing the injured	- Possibility of another terrorist attack on the hospitals - Public crowd in educational hospitals emergency departments - Possibility of further explosions at the scene - Interference between the security zone and the treatment area
		Lack of a mechanism to identify rescuers from ordinary people	- Absence of attendance registration system for the time of the incident in hospitals - Inability to quickly confirm specialized documents
		Difficulty in the presence of healthcare workers in hospitals due to security reasons	- Insecurity of streets and passages - Threats on the routes leading to the hospital - Curfew regulations
	Ineffective Communication and Information	Weakness of access to communication equipment’s	- Not access to basic infrastructures such as the Internet, electricity and telephones - Density in the phone network - Reduced communication quality - Inadequate satellite devices - Inadequate radio communication
		Weakness in information and communication technology infrastructure	- Technical limitations of alternative communication devices - Lack of complete communication coverage for all rescue forces - Interruption of the communication system for relief
		Lack of an inter-organization unified contact center	- Scattered decision-making centers - Overlapping responsibilities of some organizations - Confusion in identifying the responsible authority
		Lack of a unit statistical resource for informing	- Multiple statistical references - Unclear public information channels - Lack of a centralized registration process of injured and bodies
		Confusion caused by the lack of reliable sources of information	- Influence of rumors published in cyberspace - Providing scattered and incorrect information from unreliable sources - Contradiction of the media in providing terrorist attack related information

Theme 1: Intra-organizational challenges

The increasing specialization and departmentalization within the health sector has presented challenges to effective intra-organizational collaboration. Often, departments lack awareness of the capabilities, services, and experiences of their counterparts [29]. The interviews with the participants revealed that insufficient management in both prehospital and hospital settings, a neglect of evidence-based management practices, arbitrary decisions made by managers, and unprofessional actions within the university’s administrative sphere were significant intra-organizational challenges encountered during the response to terrorist explosive bombing attacks. These themes including 2 main categories: prehospital and hospital challenges.

Prehospital challenges

Prehospital Emergency Medical Care (EMC) is a critical service in terrorist attacks management and in the event of a terrorist attack, pre-hospital emergency personnel and managers must approach the scene with a focused and deliberate mindset, possessing a clear understanding of their roles, responsibilities, and the established incident management and response plan, however the results of this study showed that the nature of terrorist-type explosive incidents challenges many components of preparedness. This category includes 2 Sub-categories: hard access to routes and victims’ unsuitable distribution.

According to one of the participants:

I noticed that when faced with various situations such as terrorist incidents, the performance of the 115-emergency fleet was affected by crowding and bottlenecks. Factors such as irregularity and abnormality in the pattern and distribution of routes and travel time of the pre-hospital fleet were very evident (Participant 3).

One of the main problems we really experienced was that there was no clear route to reach the injured because there was a lot of crowding and heavy traffic on the surrounding streets leading to the incidents scenes, making it virtually impossible to quickly reach the injured (Participant 1).

I think most public hospitals especially private hospitals don’t have a response plan to terrorist incidents, so we weren’t sure if we should take the injured person to a private hospital because we didn’t know his condition or who would pay for it. In private hospitals, you have to pay before treatment process (Participant 12).

While transporting the injured to the nearest medical center after terrorist attacks seemed ideal, the lack of specialized facilities (e.g., neurosurgeons) for multi-trauma victims delayed timely medical care (Participant 9).

Hospital challenges

Hospitals encounter considerable difficulties in preparing for and responding to terrorist attacks. These challenges can be compounded by factors such as resource constraints, insufficient training, and the distinctive characteristics of injuries resulting from terrorist incidents [30].This category includes 4 Sub-categories: unexpected and unforeseen presence of important persons and volunteer, non-implementation of continuous triage process, logistic support and Poor coordination of inter-hospital transfers.

Some of the participants’ statements in this area included:

One of the neighboring provinces sent 35 volunteer nurses, which was not only not helpful but also created a new problem for us in managing them (Participant 4).

While officials’ presence aids incident assessment and response coordination, it may disrupt operations distract personnel compromise patient privacy attract excessive media attention and create excessive psychological stress (Participant 6).

While triage was conducted upon arrival at their hospital, the lack of a unified protocol and staff unfamiliarity with emergency triage methods led to errors, especially during secondary triage, which followed routine (rather than crisis-adapted) procedures (Participant 2).

While immediate transport of the injured to the closest medical center following terrorist events may appear optimal, the absence of specialized resources for trauma victims, including neurosurgical expertise and related infrastructure, at these locations can impede timely access to appropriate medical care (Participant 9).

Existing memorandums of understanding between the university and responsible organizations have not ensured acceptable performance from many private hospitals, which have proven unable to provide adequate services during the acute phase of disaster response (Participant 10).

Theme 2: Inter-organizational challenges

Responding to disasters in the health system is impossible without cooperation with other cooperating and supporting organizations. The importance of this cooperation becomes clearer in terrorist incidents. The results of the present study showed that in this particular incident, incoordination and lack of cooperation can severely affect the response operation and expose predetermined preparedness plans to unpredictable and new conditions. This theme includes 3 categories related to chain of command, insufficient security and Ineffective communication and information.

Chain of command

One of the categories of this section was the challenges of chain of command. The presence of this challenge in this particular incident, which required cooperation in high-level security conditions, greatly complicated the operational response. This category was a continuation of the lack of a unified command challenge. Implementing incident command elements like incident management system (IMS), incident command system (ICS) and unified command system (UCS) would not only solve the command problem but also the coordination problem. The results of this study showed that in the highly stressful conditions of terrorist incidents, coordination with other cooperating organizations becomes more difficult.

This category includes 4 Sub-categories: fragmented authority in multi-agency operations, failure to activate of incident command elements, lack of inter-organizational coordination, poor cooperation and control in evacuating and transferring the bodies.

One participant said:

We had many supervisors and authorities at Hospital B who were unrelated to health. This indicated that the EOC of the governor’s office either was not established or had not implemented a unified command system (Participant 16).

The position of some responders from other organizations at the scene of the incident and even in the hospital was unclear. It seemed that the incident command system was not activated in some organizations (Participant 16).

Some of the participants’ statements on this subject include:

This incident showed a need for a memorandum of understanding between the health system and other responding organizations, such as police and security forces, to improve coordination, and conduct training exercises (Participant 13).

At the scene of the incident, the health sector and other organizations for triage and initial medical interventions did not coordinate. They insisted that the victims be transferred immediately (Participant 11).

Unclear jurisdiction over martyrs’ body transfers posed a key challenge. Beyond prehospital emergency services’ legal mandate, situational tensions forced their provisional involvement, sometimes compromising injured patients’ transfers (Participant 15).

Insufficient security

One of the most specific categories of this study was a lack of security. Given the nature of this incident, the golden hours of incident response and casualty management were spent under high security conditions. These conditions were unique compared to other natural disasters because they were accompanied by anxiety for all response personnel. Also, the implementation of response operations, both in the incident field and in hospitals, required close cooperation with security forces. This category includes 3 sub-categories: difficulty in ensuring security space in the hospitals and incident scene for managing the injured, lack of a mechanism to identify rescuers from ordinary people and difficulty in the presence of healthcare workers in hospitals due to security reasons.

Some quotes from study participants included:

In the initial moments of the incident, there were not enough military forces to provide security in the hospitals, and if the terrorists had planned in advance, they could have easily created new incidents in these places (Participant 16).

At Hospital B, part of the hospital’s fencing had been damaged due to city construction work, which allowed relatives of the victims and unauthorized individuals to enter and compromised the hospital’s security (Participant 7).

This incident demonstrated the need for healthcare staff and volunteer forces to have identification cards approved by security forces. This requires the establishment of a memorandum of understanding with security personnel and the police (Participant 11).

Ineffective communication and information

Effective communication and information management are paramount for successful disaster response efforts. In times of response to terrorist attack transparent, timely and precise information enables informed decision-making by individuals, improves coordination between response teams, and strengthens community resilience. This necessitates clear communication with the public regarding risks, warnings, evacuation protocols, and available resources, alongside ensuring seamless information exchange between response organizations [31, 32].

This category includes 5 Sub-categories: weakness of access to communication equipment’s, weakness in information and communication technology infrastructure, lack of an inter-organization unified contact center, lack of a unit statistical resource for informing and confusion caused by the lack of reliable sources of information.

Some statements of study participants included:

Early misinformation (e.g., false reports of hospital bombings or closures) increased staff psychological distress and disrupted volunteer coordination (Participant 8).

There is a need to deploy mobile telecommunications towers for large-scale events like this, so mobile communications do not get easily disrupted (Participant 6).

Healthcare personnel require training to directly contact workplaces and report on-site during media-involved incidents, regardless of other communication failures (Participant 1).

The absence of unified public communications from the central disaster authority caused confusion, prompting unreliable media outlets to disseminate inaccurate statistics during critical initial hours (Participant 5).

It has been 12 hours since the terrorist attack, and we lack a reliable news source to follow developments. Numerous rumors are circulating online, making it difficult to discern truth from falsehood. We have received no official explanations, and on occasion, information initially dismissed as rumor has proven accurate and even beneficial (Participant 14).

Discussion

The outcomes of this study analyzed the difficulties experienced by the health system in addressing a terrorist incident. According to the findings, the results have been organized into 2 themes, 5 categories and 18 subcategories identified that represent the challenges faced by the health system during the response to terrorist explosive bombing attacks, as elaborated below:

Theme 1: Intra-organizational challenges (prehospital and hospital)

The inherent complexities of the incident suggest that applying disaster management principles in such scenarios is often challenging and, sometimes, impractical. Although there has been a closer alignment of prehospital services with disaster and emergency response, the unique nature of terrorist incidents introduces new and unpredictable challenges. Research examining emergency technicians’ willingness to respond to terrorist events has indicated a notable reluctance, with technicians demonstrating a significantly higher propensity to respond to natural disasters. This hesitance is associated with their prior training and preparedness, highlighting that prehospital emergency technicians remain inadequately equipped to confront such incidents [33]. A study conducted by Mirki et al. on prehospital care during terrorist events identified four critical components: preparedness, training and practice, effective communication, and appropriate triage and patient transfer [34].

In the present analysis, one of the significant challenges encountered was the distribution of casualties following the incident. The specific characteristics of such events, coupled with security conditions at the scene and crowd congestion, rendered the triage of victims exceedingly difficult. Additionally, the chaos resulting from the explosion rendered several pre-designated access routes unusable [35, 36].

One important subcategory identified in the present study was non-implementation of continuous triage process. Triage in the context of terrorist events faces distinct challenges, including the absence of clear protocols and designated medical personnel, and there have been documented instances of “over-triage” [37]. Triage in terrorist incidents necessitates specialized training during the preparedness phase. Beyond acquiring standardized protocols tailored to specific events, extensive practical drills are essential for comprehending the unique conditions associated with these incidents. The distinct circumstances of such events, coupled with the inherent insecurity of the scene, render the establishment of Triage, Treatment, Transport Zone (TTTZ) and the execution of standard triage particularly challenging, therefore effective collaboration and support from law enforcement and security personnel are paramount for implementing these standards.

Additionally, the study identified challenges faced by hospitals in addressing these incidents. Although hospitals typically possess general disaster response plans, they confront novel difficulties when responding to terrorist incidents. Under these circumstances, effective resource management within hospitals mandates prior planning and augmenting available resources [38–40]. A study conducted in France emphasized that hospitals require a diverse array of resources, comprehensive planning, and specialized training to effectively respond to trauma resulting from terrorist incidents, recognizing that the diversity of injuries may present unforeseen challenges [41]. Another investigation highlighted three critical dimensions of hospital responses to victims of terrorist attacks: varied injury patterns, infrastructural capabilities, and human resources. Hospitals must train, conduct drills, and maintain resource reserves to navigate these challenges adeptly [42].

The study highlights the challenge of transferring critically injured victims to better-equipped hospitals, especially in unstable areas with poor inter-hospital communication. Communication breakdowns due to disrupted systems and a lack of protocols further complicate emergencies. Research emphasizes the importance of alternative channels, like radio, and multi-layered communication to reduce risks during crises [43, 44]. The study also found that rumors spread quickly during crises, on-site, and in hospitals. When official information is lacking, people turn to unreliable sources or social media, fueling misinformation. To reduce uncertainty, individuals often rely on easily accessible but unverified information [45].

One important subcategory identified in the present study was the challenge of unexpected and unforeseen presence of important persons in the response phase to terrorist attacks in the incident scene and the hospital’s emergency departments. During emergency responses, the focus should be resource management and facilitating processes for effective and timely care of the injured. Prioritizing the management of stress and anxiety in individuals who have suffered accidents is essential [46–49]. However, the presence of officials and government representatives in the early hours of the incident response can create significant challenges for the response process, including the rapid assessment of hospital victims.

Theme 2: Inter-organizational challenges including categories of (chain of command, insufficient security and ineffective communication and information)

The study highlights the difficulty of establishing a unified command during chaotic incidents like terrorist attacks. A pre-defined hierarchy with clear roles and centralized control improves coordination, reduces confusion, and ensures efficient resource distribution [36, 50, 51].

The study underscores the challenges of securing incident scenes and hospitals during terrorist attacks. Uncontrolled access and rumor spread further disrupt victim care. Studies have emphasized that effective security requires controlled entry, traffic management, and strong law enforcement coordination [52–54]. The study showed the importance of defining roles for responders and volunteers to improve coordination and security. Hospitals should also collaborate with security forces in training drills to establish protocols for lockdowns and access control, as they cannot manage security alone [55].

The study highlights persistent disaster communication challenges, echoing previous research showing recurring failures even after past incidents. Governments must invest in reliable (and backup) communication systems for hospitals and emergency services, along with thorough staff training [32, 56]. The study found that risk communication often fails during crises, similar to past incidents. Health officials should prioritize detailed drill planning and ensure reliable communication tools are available to improve terrorist attack responses.

Another important category identified in the present study was a coordination-related challenge. Similar studies have also reported this challenge as an obstacle to achieving immediate goals in disasters [52, 57]. Extreme events demand coordinated, multi-jurisdictional responses under intense pressure and tight deadlines. This socio-technical challenge hinges on both technical infrastructure and organizational coordination. The dynamic interplay between human decision-makers, digital systems, and institutions remains poorly understood, making crisis response an exceptionally complex for public and nonprofit leaders. In medical universities, meticulous attention must be directed towards managing the risk of accidents and incidents, adhering to national and international guidelines, with particular emphasis on the preparedness phase, to ensure a correct, timely, and standardized response to terrorist incidents.

A recurring subcategory in participant interviews was the “confusion caused by the lack of reliable sources of information”. Terrorist attack-related rumors circulated online, negatively impacting the population by increasing anxiety and worry. Solhi et al. highlight the prolonged and uncensored broadcasting of natural disaster news, rumors, and distressing images on television and social media [58]. While the primary cause of trauma is the direct experience of the incidents, continuous exposure to such media and conflicting opinions regarding incidents can extend the duration of trauma [59, 60]. However, the researchers of the current study suggest that strategic management and control of rumors could positively impact safety culture and enhance the preparedness of relief organizations in the face of future terrorist incidents.

Limitation

The present study offers valuable insights into the distinct experiences of health system managers and experts in Southeast Iran. Acknowledging that all findings may not be applicable across all cultural and contextual settings is essential. The experience of disaster risk management, particularly in the context of response processes during terrorist attacks, is shaped by preparedness level and various cultural, economic, social, and additional factors. Meanwhile, in reporting the findings, emphasis was placed on identifying tangible and operational challenges with potential generalizability to broader health systems, thereby enhancing the utility and applicability of the results. It is advisable to embark on similar research initiatives in different communities to achieve a more comprehensive understanding of responses to terrorist attacks during mass gatherings.

Implication for health managers and policymakers

The following represent key accomplishments for health managers and policymakers in disaster risk management of terrorist incidents involving bomb explosive: (1) Prior to conducting religious ceremonies involving large gatherings, annual discussion-based and operational exercises should be implemented across various incident levels, especially (Level E1), to simulate potential terrorist scenarios. (2) The activation of the IMS, including the ICS at the incident site, along with its established protocols and instructions, warrants specific attention to facilitate an appropriate response to terrorist incidents. (3) Increased emphasis should be placed on national guidelines, such as the National Response Framework (NRF), to prevent the uncoordinated deployment of healthcare personnel from other universities to the affected institution, and to ensure needs assessments for the response process are conducted in accordance with the aforementioned national framework. (4) To effectively execute the hospital’s response plan to terrorist incidents, strategies should be developed to manage the absence of frequent visits from national and provincial authorities, thereby mitigating additional pressure on staff, particularly during the acute response phase (0–2 h). (5) Adequate human resources should be allocated to provide specialized training for terrorist incident response. Additionally, a comprehensive review and provision for any shortages in supplies and equipment within teaching hospitals’ crisis warehouses is essential to effectively respond to incidents within the critical timeframes of 0–2 h, 2–12 h, and beyond 12 h. (6) Memoranda of understanding with private hospitals should be established, reinforced, and regularly exercised to leverage their healthcare and medical capabilities during response operations to emergencies and disasters. (7) The university’s IMS should prioritize public relations, ensuring timely and accurate dissemination of incident-related statistics and information to the public and media. This proactive communication strategy is crucial for mitigating public anxiety and safeguarding community mental health, particularly during the initial response phase to terrorist incidents.

Conclusion

The present study critically analyzed the challenges related to response process to terrorist explosive bombing attacks from the health managers and experts’ perspective. The findings were categorized into two main domains: internal and external organizational challenges. The challenges elucidated in this analysis demonstrate that many issues faced during responses to terrorist incidents are distinct and not readily applicable to other categories of emergencies. This underscores the importance of general preparedness within the health system for both natural and artificial disasters; however, it also reveals that numerous pre-established plans encounter situational obstacles in scenarios characterized by high-security risks and disorder. Consequently, it is imperative for the health system, particularly the prehospital and hospital sectors, and logistical support, to develop and refine specific preparedness strategies tailored to terrorist incidents. Effective health response operations necessitate collaboration with various aid organizations and security forces. Therefore, preparedness plans must be formulated with all relevant responding entities. The insights from this study, grounded in a real incident, can provide a valuable foundation for the development of preparedness programs. To prepare for terrorist threats at mass gatherings, managers should: conduct risk assessments and scenario drills, develop an Incident Action Plan, secure necessary resources, establish emergency routes, and coordinate pre-event briefings. Partial EOC activation and clear communication with response teams ensure readiness, while detailed operational planning optimizes emergency deployment.

Further investigations are essential to thoroughly examine the experiences of healthcare professionals in order to gain a comprehensive understanding of the health system’s responses to terrorist incidents. It is advisable to employ a mixed-methods approach to capture the nuanced and extensive experiences of healthcare providers, as well as to identify the most effective interventions for disaster risk management associated with terrorist attacks.

Author contributions

HF and SS created the study’s concept and design. AT and AA performed the survey, and AT and AK handled data analysis and manuscript writing. HF and AM oversaw the research and provided critical feedback on the manuscript. All of the authors read and reviewed the final manuscript.

Funding

The author(s) received no financial support for this article’s research, authorship, and/or publication.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to restrictions of the Ethics Committee of Kerman University of Medical Sciences. For available data, please contact: kmu_Research@yahoo.com.

Declarations

Ethical approval

The Ethics Committee of Kerman University of Medical Sciences approved this study. A qualitative study was employed in 2024. The code of ethics is IR.KMU.REC.1403.249. All methods were performed following the relevant guidelines and regulations; this article does not contain any studies with animals performed by any of the authors. Informed consent was obtained from all individual participants included in the study. Written informed consent was obtained from individual participants. Confidentiality and anonymity of the participants were ensured by coding of the questionnaires. Study participants were informed clearly about their freedom to opt out of the study at any point in time without justifying doing so.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.