From awareness to action: Evaluating knowledge and preventive practices against heat-related illnesses among Hajj and Umrah pilgrims

Abstract

Objective

This study aimed to assess the level of knowledge and preventive practices related to heat-related illnesses (HRIs) among Hajj and Umrah pilgrims in KSA, as well as examining demographic factors associated with these outcomes, and evaluating the relationships between knowledge and preventive practices.

Methods

A cross-sectional survey was conducted among 581 participants in KSA. Their knowledge and practices regarding HRIs were assessed using a structured, standardized questionnaire with scores between 0 and 1. Statistical analyses included descriptive and inferential tests, and Spearman's correlation coefficients were calculated to evaluate the relationships between knowledge and practices.

Results

Overall, knowledge scores were categorized as average (0.69 ± 0.19), with the highest scores for recognizing HRI symptoms (0.63 ± 0.19) and the importance of hydration (0.91 ± 0.28). Practice scores were moderate (0.56 ± 0.20), with high adherence to drinking more water (82 %) and performing rituals at night (81 %). However, gaps in knowledge were observed in sunscreen use (39 %) and understanding daily hydration needs (0.39 ± 0.48). Demographic factors such as age, gender, and education significantly influenced knowledge and practices. A weak but significant positive correlation (r = 0.197, P < 0.001) was found between knowledge and practices.

Conclusion

Although pilgrims had good knowledge of HRIs, the practical application of preventive measures was inconsistent. Targeted strategies such as subsidized protective resources, health and religious education, and mandatory leader training are recommended to translate awareness into effective practices, and ultimately enhance health outcomes during Hajj and Umrah.

Introduction

The World Health Organization has recognized climate change as one of the leading environmental threats to global health, contributing substantially to morbidity and mortality worldwide.¹ One of the most direct health consequences of exposure to extreme temperatures is heat-related illness (HRI), which occurs when the body's thermoregulatory mechanisms fail to adequately dissipate heat. HRI encompasses a spectrum of conditions ranging from mild manifestations, such as heat edema and muscle cramps, to more severe and potentially fatal conditions, including heat exhaustion and heat stroke.^2,3 Individuals affected by HRI may present with a wide array of clinical symptoms, including fatigue, vomiting, syncope, hyperthermia, neurological impairment, circulatory collapse, and multiorgan failure.⁴

Several individual and environmental risk factors have been associated with the development of HRI, including advanced age, obesity, pre-existing medical conditions, prolonged exposure to high temperatures and humidity, lack of heat acclimatization, poor physical fitness, excessive physical exertion, and the use of inappropriate clothing or equipment.5, 6, 7 These risks are particularly pronounced during mass gathering events, where large crowds, prolonged outdoor activities, and limited mobility can further exacerbate heat exposure and hinder timely medical intervention.

Hajj and Umrah are among the largest recurring religious mass gatherings worldwide, attracting millions of Muslims to KSA each year. Hajj is a mandatory religious obligation performed once in a lifetime by Muslims who are physically and financially able, whereas Umrah is a voluntary pilgrimage that can be undertaken at any time of the year.⁸ The city of Makkah hosts the core rituals for both pilgrimages, and it experiences extremely high temperatures throughout much of the year, often exceeding 40 °C. During periods of extreme heat, HRIs have been reported as leading causes of morbidity and mortality among pilgrims.^9,10 For instance, in 2016, 267 cases of HRI were reported during Hajj, with a mortality rate of approximately 7.1 %.¹¹

Despite ongoing public health efforts, many pilgrims continue to underestimate the risks associated with heat exposure. Pilgrims may exert themselves excessively during rituals, perform activities during peak heat hours, neglect adequate hydration, or avoid using protective measures such as umbrellas or head coverings.¹² To mitigate these risks, the Saudi government has implemented multiple preventive strategies in collaboration with health authorities, including the provision of shaded areas, cooling systems, hydration stations, medical services, and public awareness campaigns.¹³ However, the effectiveness of these interventions largely depends on the awareness of heat-related risks among pilgrims and their willingness to adopt preventive behaviors.

Understanding the extent to which pilgrims recognize heat-related risks and translate this knowledge into protective behaviors is essential for improving health outcomes during pilgrimage seasons. Therefore, this study aimed to assess the knowledge of HRIs and preventive practices among Saudi pilgrims performing Hajj and Umrah, as well as to identify demographic factors associated with these outcomes. The findings obtained in this study will inform targeted public health interventions and contribute to the development of more effective HRI prevention strategies during mass gatherings.

Materials and Methods

Study design

The methodology applied in this study aligned with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The study was based on a cross-sectional survey conducted between June 2024 and July 2024 across various regions of KSA in order to assess the awareness and behavior of pilgrims and Umrah performers regarding HRIs. A structured survey was distributed at key religious sites.

Participants and sample size

The study targeted Saudi adult pilgrims and Umrah performers aged 18 years and older. Individuals who were non-Saudi, younger than 18 years, did not meet the inclusion criteria, failed to complete the survey, or chose to withdraw their participation were excluded from the study. The sample size was calculated based on an anticipated awareness level of 50 %, with a 95 % confidence interval and 5 % margin of error, resulting in a minimum requirement of 385 participants.

Non-Saudi pilgrims were excluded to maintain a more homogeneous study population and to reduce confounding effects related to differences in language proficiency, cultural practices, health literacy, and exposure to national health education campaigns. Saudi pilgrims are more likely to receive standardized health messaging and have comparable access to healthcare services before and during Hajj and Umrah, thereby allowing more reliable assessment of knowledge and preventive practices.

Assessment instrument

The Awareness and Behavior Regarding Heat Stroke (ABRHS) survey was developed to evaluate knowledge of heat stroke symptoms and preventive practices. The survey includes questions about symptom identification, risk factors, preventive measures taken, and responsive actions to symptoms. It also assesses practices regarding modifying plans to avoid peak heat times. The survey was translated into the Arabic language to ensure comprehension by Saudi participants.

The questionnaire was developed following a review of relevant literature and previously published studies that assessed knowledge of HRIs and preventive practices. Content validity was established through expert review by specialists in public health and preventive medicine, who evaluated the relevance and clarity of the items. The instrument was pilot-tested among 20 participants to assess its comprehensibility and feasibility, leading to minor refinements to wording prior to final administration.

Scoring approach

Responses to the HRI knowledge and practice questionnaire were scored quantitatively on a scale ranging from 0 to 1. Incorrect, inappropriate, or “don't know” responses were assigned a score of 0, whereas correct or appropriate responses determined based on current literature and best practices were assigned a score of 1. For multiple-choice questions, such as knowledge about symptoms, each correct response or avoidance of an incorrect response was awarded 1 point. The total points for each question were then divided by the number of possible options to standardize the score, resulting in a value between 0 and 1.

The overall mean scores for each section of the questionnaire, i.e., knowledge, attitude, and practice, were calculated and categorized into four levels to reflect the respondents’ performance. These categories were defined as follows: poor (<0.25), below average (0.25 to < 0.50), above average (0.50 to < 0.75), and good (≥0.75). This scoring method provided a standardized and comprehensive evaluation of participants' knowledge, attitudes, and practices.

Internal consistency reliability of the knowledge section was assessed using Kuder–Richardson formula 20 (KR-20), which indicated acceptable reliability (KR-20 = 0.75).

Data analysis

Data were analyzed using IBM Statistical Package for the Social Sciences (SPSS) Statistics for Windows, version 26.0. Descriptive statistics were employed to summarize demographic characteristics and survey responses. Inferential statistical tests, including Mann–Whitney and Kruskal–Wallis tests, were utilized to assess the associations between demographic variables and survey scores. A P-value <0.05 was considered to indicate a statistically significant difference. Two separate multivariable linear regression models were used to identify independent predictors of HRI knowledge and preventive practices while controlling for potential confounding variables. The overall knowledge score and overall practice score were employed as continuous dependent variables in separate models. Key demographic variables (age category, gender, educational level, region, and history of HRI during pilgrimage) were entered simultaneously as independent variables. The results are reported as unstandardized beta coefficients (β) with 95 % confidence intervals (CIs).

Results

In total, 581 responses were analyzed. Most participants had performed both Hajj and Umrah (46.1 %) or only Umrah (39.4 %), and 14.5 % had exclusively performed Hajj. Females accounted for 54.2 % of the sample. The largest age group was 21–30 years (36.0 %), followed by 31–40 years (24.1 %) and 41–50 years (21.7 %), and smaller proportions were younger than 21 years (5.3 %) and older than 50 years (12.9 %). In terms of educational levels, 64.5 % had a university degree, 24.1 % had high school education, 7.1 % had postgraduate degrees, and 4.3 % had middle school or lower education. The participants were mainly from the Eastern (46.0 %) and Western (24.4 %) regions, with smaller proportions from the Central (16.5 %), Southern (7.9 %), and Northern regions (5.2 %) (Table 1).

Table 1.

Demographic characteristics of participants.

Demographics		N	N%
Hajj or Umrah rituals	Hajj	84	14.5
	Umrah	229	39.4
	Both	268	46.1
Gender	Male	266	45.8
	Female	315	54.2
Age (years)	<21	31	5.3
	21–30	209	36.0
	31–40	140	24.1
	41–50	126	21.7
	>50	75	12.9
Education	Middle school or less	25	4.3
	High school	140	24.1
	University	375	64.5
	Postgraduate	41	7.1
Region	Eastern	267	46.0
	Western	142	24.4
	Central	96	16.5
	Northern	30	5.2
	Southern	46	7.9

Most participants were free of medical issues (74.2 %). Hypertension and diabetes were reported in 9.8 % and 9.1 % of participants, respectively, and cardiac (2.1 %), respiratory (2.6 %), neurological (0.9 %), psychiatric (0.9 %), immunodeficiency (1.9 %), and disability (1.9 %) conditions were uncommon. Other conditions were noted by 5.7 % of participants. Health-related incidents during Hajj or Umrah were reported by 16.9 % of respondents (Table 2).

Table 2.

Prevalence of morbidity and health conditions among participants.

Morbidity	Response (N/%)
	Yes	No
Free of medical issues	431 (74.2)	150 (25.8)
Hypertension	57 (9.8)	524 (90.2)
Diabetes	53 (9.1)	528 (90.9)
Cardiac disease	12 (2.1)	569 (97.9)
Respiratory disease	15 (2.6)	566 (97.4)
Neurological disease	5 (0.9)	576 (99.1)
Psychiatric disease	5 (0.9)	576 (99.1)
Immunodeficiency disease	11 (1.9)	570 (98.1)
Disability	11 (1.9)	570 (98.1)
Other	33 (5.7)	548 (94.3)
HRI during Hajj/Umrah	98 (16.9)	483 (83.1)

N: number of observations; HRI: heat-related illness.

Participants’ knowledge of HRI was generally average, with an overall mean score of 0.69 ± 0.19 (Table 3). They scored highest on understanding the need to drink more water in hot weather (0.91 ± 0.28) and the cooling effect of good ventilation (0.89 ± 0.31), as well as the impact of overcrowding (0.83 ± 0.37) and recognizing that high temperatures can cause illnesses (0.84 ± 0.36). Knowledge was below average for daily water requirements (0.39 ± 0.48), sunscreen use (0.44 ± 0.49), and sunlight exposure leading to fever (0.50 ± 0.50).

Table 3.

Mean HRI knowledge and practice scores among participants.

Statement	Mean	SD
Knowledge
Do you believe that high atmospheric temperatures cause specific illnesses?	0.84	0.36
Which of the following could be symptoms of heat illnesses?	0.63	0.19
Exposure to sunlight during hot weather leads to fever.	0.50	0.50
Excessive sweating causes loss of body fluid components such as minerals.	0.76	0.42
Wearing dark-colored clothes is better during hot weather.	0.76	0.42
Being thirsty is the only sign of needing to drink water.	0.69	0.45
Performing Hajj rites in hot weather leads to the need to drink more water.	0.91	0.28
Using sunscreen reduces the risk of HRI.	0.44	0.49
Pilgrims with underlying health conditions (e.g., diabetes) are more likely to develop HRI.	0.64	0.47
Older pilgrims more likely to develop HRI.	0.73	0.44
Good ventilation plays a role in cooling the atmosphere.	0.89	0.31
Overcrowding plays a role in increasing atmospheric temperatures.	0.83	0.37
How much water do you need daily during Hajj/Umrah?	0.39	0.48
Overall	0.69	0.19
Practice
Do you drink more water on hot days even if you are not thirsty?	0.82	0.38
Do you use an umbrella in unshaded areas during Hajj/Umrah rituals?	0.45	0.49
If the weather becomes extremely hot during Hajj/Umrah rituals, would you postpone your rituals until it cools down?	0.43	0.49
If possible, would you perform Hajj/Umrah rituals at night?	0.81	0.38
I will perform the Hajj/Umrah rituals despite the presence of a crowd.	0.26	0.44
Will you use sunscreen while performing Hajj/Umrah rituals during the day?	0.39	0.48
Do you prefer drinking soft drinks or coffee when you feel thirsty?	0.74	0.43
Overall	0.56	0.20

HRI: heat-related illness; SD: standard deviation.

HRI-related practices were generally moderate, with an overall mean of 0.56 ± 0.20. Participants reported high adherence to drinking water even when not thirsty (0.82 ± 0.38) and performing rituals at night (0.81 ± 0.38). However, HRI-related practices scored lowest for performing rituals despite crowds (0.26 ± 0.44), using sunscreen (0.39 ± 0.48), and postponing rituals during extreme heat (0.43 ± 0.49). These results indicate that although general awareness and some protective behaviors were present, significant gaps remained in terms of practical preventive measures against HRI.

The knowledge and practice score classifications were further analyzed to better understand the variations among participants. Knowledge scores regarding HRI demonstrated that a high proportion of participants was classified as good, with 255 individuals (43.9 %), followed by those in the above-average category, with 244 participants (42.0 %). A smaller subset scored below average, with 65 participants (11.2 %), and 17 individuals (2.9 %) were classified as poor (Figure 1). Similarly, the classification of practice scores revealed that most participants fell into the above-average category, with 246 individuals (42.3 %), followed by those categorized as below average, with 217 participants (37.3 %), and those classified as good, with 94 participants (16.2 %). The smallest proportion of participants was categorized as poor, with 24 (4.1 %).

Figure 1.

Classification of participants based on HRI knowledge and practice scores.

Table 4 shows the associations between demographic factors with knowledge and practice of participants regarding HRI during Hajj/Umrah. Knowledge scores were slightly higher in males (0.70) than females (0.69), but this difference was not significant. Knowledge increased with age from 0.61 in those aged under 21 years to 0.75 in participants aged over 50 years (P = 0.003), and was significantly higher among those with postgraduate (0.73) or university education (0.71) compared with lower educational levels (P < 0.001). Regional differences were minimal, with the highest scores in the Eastern (0.72) and Northern (0.71) regions, and prior experience of HRI had no significant effect on knowledge.

Table 4.

Associations between demographic factors and participants' knowledge and practice regarding HRI during Hajj/Umrah.

Factor		Knowledge				Practice
		N	Mean	SD	P-value	N	Mean	SD	P-value
Gender	Male	266	0.70	0.19	0.627a	266	0.53	0.21	0.001b,a
	Female	315	0.69	0.20		315	0.59	0.21
Age (years)	<21	31	0.61	0.25	0.003b	31	0.43	0.22	<0.000b
	21–30	209	0.68	0.22		209	0.53	0.20
	31–40	140	0.67	0.18		140	0.56	0.21
	41–50	126	0.74	0.17		126	0.61	0.21
	>50	75	0.75	0.14		75	0.62	0.20
Education	< Middle school	25	0.60	0.21	<0.000b	25	0.63	0.23	0.418
	High school	140	0.65	0.20		140	0.55	0.20
	University	375	0.71	0.19		375	0.56	0.21
	Postgraduate	41	0.73	0.20		41	0.57	0.25
Region	Eastern	267	0.72	0.18	0.123	267	0.53	0.19	0.006b
	Western	142	0.66	0.22		142	0.58	0.20
	Central	96	0.69	0.19		96	0.59	0.22
	Northern	30	0.71	0.19		30	0.58	0.19
	Southern	46	0.68	0.23		46	0.62	0.26
HRI during Hajj/Umrah	Yes	98	0.66	0.21	0.083a	98	0.58	0.19	0.318a
	No	483	0.70	0.19		483	0.56	0.21

P: Kruskal–Wallis test.

HRI: heat-related illness; SD: standard deviation; N: number of observations.

^aMann–Whitney t-test.

^bP-value <0.05 indicates a statistically significant difference.

Among HRI-related practices, females had higher scores than males (0.59 vs. 0.53, P = 0.001). Practice scores also increased with age, peaking at 0.62 in participants aged over 50 years (P < 0.001). Education level had no significant effect on practice. Regionally, participants from the Southern and Central regions had higher practice scores (0.62 and 0.59, respectively), and prior experience of HRI did not significantly influence practice (P = 0.318).

Table 5 indicates that age and educational level were independent predictors of higher knowledge scores. In particular, each increase in age category was associated with a 0.04-point increase in the knowledge score (β = 0.04, 95 % CI: 0.02–0.06), and having a higher educational level was associated with a 0.05-point increase in the knowledge score (β = 0.05, 95 % CI: 0.03–0.07). Gender and prior history of HRI were not significantly associated with knowledge scores after adjustment.

Table 5.

Multivariable linear regression analysis of factors associated with knowledge scores.

Predictor	β (Adjusted)	95 % CI	P-value
Female (vs. Male)	−0.01	−0.03 to 0.02	0.621
Age (per category increase)	0.04	0.02 to 0.06	0.003a
Education level (higher vs. lower)	0.05	0.03 to 0.07	<0.001a
Prior HRI (yes vs. no)	−0.02	−0.05 to 0.01	0.087

β: regression coefficient; CI: confidence interval.

^aP < 0.05 (significant difference).

Table 6 showed that female gender, older age, and higher educational level were independently associated with better preventive practice scores. Being female was associated with a 0.06-point increase in the preventive practice score (β = 0.06, 95 % CI: 0.03–0.09), and each increase in age category was associated with a 0.05-point increase (β = 0.05, 95 % CI: 0.03–0.07). Participants with a higher educational level also reported better preventive practices, with a 0.04-point increase in scores (β = 0.04, 95 % CI: 0.01–0.07). Prior history of HRI was not significantly associated with preventive practice scores after adjustment.

Table 6.

Multivariable linear regression analysis of factors associated with preventive practice scores.

Predictor	β (Adjusted)	95 % CI	P-value
Female (vs. Male)	0.06	0.03 to 0.09	0.001a
Age (per category increase)	0.05	0.03 to 0.07	0.001a
Education level (higher vs. lower)	0.04	0.01 to 0.07	0.006a
Prior HRI (yes vs. no)	0.02	−0.02 to 0.05	0.312

β: regression coefficient; CI: confidence interval.

^aP < 0.05 (significant difference).

Discussion

Understanding HRI and the factors that influence knowledge of HRI and behavior among pilgrims is critical for designing effective interventions. The results obtained in the present study highlight both the strengths and gaps in the awareness of participants regarding HRI, reflecting the importance of tailored educational approaches. In the following, we explore key areas of knowledge, demographic influences, and comparisons to similar studies.

Knowledge of HRIs

The participants in this study reported practical awareness of general risks related to high temperatures and the symptoms of HRIs, and moderate knowledge of common manifestations such as dizziness, fatigue, and dehydration. These findings reflect the influence of ongoing health education campaigns delivered by Saudi health authorities in Arabic through official channels aimed at educating pilgrims about Hajj- and Umrah-related health risks, including HRIs.¹⁴

Awareness of the importance of hydration was strong, but many participants lacked accurate knowledge regarding daily water requirements during pilgrimage. Awareness of specific preventive measures, such as sunscreen use, was also low, a gap noted in previous studies of pilgrims.¹⁵ Comparisons with previous studies showed that the symptom recognition scores were similar to those reported by Yezli et al.,¹⁵ but knowledge about direct effects of sunlight and appropriate preventive strategies was lower. Misconceptions persisted such as the belief that dark-colored clothing is preferable in hot weather, highlighting the need for clearer guidance on practical measures.¹⁵

Educational attainment significantly influenced HRI knowledge, where higher education levels were associated with better awareness, consistent with evidence that education enhances health literacy and preventive behaviors related to heat exposure.¹⁶ Older participants also had higher knowledge scores, possibly due to their greater life experience or previous exposure to pilgrimage-related health education, supporting earlier findings that experience and targeted education improve preparedness.¹⁷ Economic disparities were evident because participants from lower socioeconomic groups had lower knowledge levels, probably due to limited access to pre-travel health education, which is consistent with the observations reported by Aleeban and Mackey.¹⁸ Structured training programs, such as those for military personnel, have been shown to improve awareness compared with the general population, highlighting the importance of organized pre-travel education.¹⁹

Practices regarding HRIs

In the present study, adherence to hydration recommendations was relatively high, where 82 % of participants reported increased water intake during hot days, exceeding the level reported by Yezli et al. (75 %).¹⁵ However, other preventive behaviors were less frequently adopted, particularly the use of sunscreen (39 %) and umbrellas (45 %), indicating a persistent gap between awareness and comprehensive preventive practice. Similar findings have been reported previously, although higher utilization of sun-protective measures was observed in the study by Yezli et al., possibly due to differences in the age distribution, where older pilgrims exhibited greater risk perception and adherence to protective behaviors.¹⁵

Variations in preventive practices may also reflect differences in the focus and delivery of health education campaigns. The local health initiatives in KSA emphasize hydration and general heat avoidance, but specific sun-protection behaviors may receive less attention. Moreover, health education during Hajj and Umrah often addresses multiple health risks, including communicable diseases and vaccination requirements, which may dilute the emphasis on certain heat-prevention measures.^14,20 These findings highlight the need for more targeted, behavior-oriented health education to reinforce the consistent adoption of sun-protective practices alongside hydration.

Determinants of health outcomes for pilgrims in mass gatherings

Accessibility and resource availability

A significant barrier to adopting preventive practices is the limited availability of necessary resources. For instance, sunscreen, cooling devices, and umbrellas were cited as inaccessible due to cost or limited supply at Hajj sites. Almuzaini et al. emphasized that economically disadvantaged pilgrims were disproportionately affected because they often lacked the financial resources to purchase protective items.¹⁷ Moreover, logistical constraints on the distribution of resources at high-density sites further exacerbated this challenge. Similarly, Aleeban and Mackey discussed inequities in access to health resources during mass gatherings, particularly among international attendees.¹⁸

Cultural and religious concerns

A critical, and often overlooked, factor is the perception that certain health-preserving behaviors might interfere with religious rituals. Some pilgrims avoided applying sunscreen or taking rest breaks, fearing that such actions might invalidate their worship. Yezli et al. found that cultural misconceptions about ritual purity were common among pilgrims from specific regions, highlighting the need for religious education as well as health education to clarify permissible actions during Hajj.¹⁵ Such fears reflect a gap in health knowledge as well as a lack of integration between health and religious guidance.

Influence of leadership and organizational preparedness

Group leaders play a pivotal role in shaping health practices during the pilgrimage. Well-organized groups with trained leaders often exhibited better adherence to preventive measures. For example, leaders who actively encouraged hydration and scheduled rest periods during peak heat significantly reduced HRIs among their groups.²¹ By contrast, poorly organized groups with minimal emphasis on health education often had higher rates of preventable illnesses, as highlighted by AlJohani et al.¹⁹

Psychological and environmental factors

Behavioral inertia and the overwhelming nature of the pilgrimage can also impair decision making. Participants often prioritized completing rituals over attending to their health, even when aware of the risks. Xu et al. noted similar patterns in other high-stress environments, where cognitive overload reduced adherence to preventive behaviors.¹⁶ Furthermore, environmental stressors such as extreme heat, overcrowding, and long walking distances exacerbate these challenges, as found in field studies during Hajj seasons.¹⁸

Potential strategies to enhance pilgrim health outcomes

Although the factors influencing pilgrims' health behaviors may present barriers between awareness and the desired health outcomes, they can also serve as opportunities to improve health management. If properly addressed, these factors could act as links to enhanced health outcomes, fostering better preventive practices, greater adherence to health guidelines, and ultimately reducing HRIs. For example, cognitive overload and the overwhelming nature of the pilgrimage may hinder adherence to health practices, but they could be mitigated through strategic interventions that make healthy behaviors more accessible, easier to adopt, and culturally aligned with pilgrimage rituals.

This dynamic is illustrated in the Pilgrim Health Outcome Pathway Model (Figure 2), which visualizes how barriers influence pilgrims' health behaviors and outcomes. The model highlights the flow from the pre-intervention health knowledge and practices of pilgrims to the various challenges faced by them and the pilgrim health outcomes, where optimal health outcomes can be achieved through effective interventions.

Figure 2.

Pilgrim Health Outcome Pathway Model: This model depicts the proposed pathway from a pilgrim's pre-existing state to their final health outcome. Preventive health behaviors are influenced by four key barrier categories: A, accessibility and resource availability; B, cultural and religious concerns; C, influence of leadership and organizational preparedness; D, psychological and environmental factors; E, potential strategies to enhance pilgrim health outcomes. Targeted public health interventions can act upon these barriers to promote behavioral change and improve outcomes.

The proposed interventions (Figure 2) are designed to directly target the barriers identified in the model, facilitating the pathway to improved health outcomes.

Policy implications

The findings obtained in this study suggest several actionable policy recommendations for stakeholders who manage the Hajj and Umrah pilgrimages. Health authorities should integrate mandatory, culturally sensitive pre-travel education modules that address specific knowledge gaps (e.g., sunscreen use and hydration quantities) and that are delivered in partnership with religious leaders. Logistical policies should ensure equitable, subsidized access to protective resources (umbrellas and sunscreen) at pilgrimage sites. Furthermore, operational guidelines for pilgrimage tour operators should include training for group leaders on recognizing HRI risks and managing vulnerable individuals. Implementing these multi-level strategies can systematically overcome the observed knowledge-practice defects and enhance population-level resilience against heat.

Similar programs have been successful in addressing both knowledge gaps and behavioral barriers. For instance, McCarthy et al. implemented a heat stress awareness program for municipal outdoor workers by combining education with medical monitoring, acclimatization protocols, and providing resources such as water and shade, which significantly reduced HRIs and associated costs.²² Similarly, O'Mara-Eves et al. emphasized that in addition to increasing knowledge, community-based health promotion programs can improve outcomes by fostering engagement and empowerment.²³ Building on these insights, several strategies have been suggested for pilgrims, including subsidized provision of sunscreen and cooling devices, integration of religious and health education, mandatory training for group leaders, behavioral nudges such as visual reminders, and pre-travel health assessments to identify higher risk individuals.

Despite helping to highlight these recommendations, this study had several limitations. Data were collected via self-reported questionnaires, which may have introduced recall and social desirability bias. The cross-sectional design prevented the establishment of causal relationships between knowledge and preventive behaviors. The study population included only Saudi pilgrims who consented to participate, thereby limiting generalizability of the results, and variations in literacy, language, and cultural factors may have influenced comprehension of the questionnaire items by participants.

Risk stratification and protection of vulnerable pilgrims

A key public health implication of our findings is the need for risk stratification. Our results confirmed that older age was an independent predictor of both knowledge and practice scores (Table 5, Table 6), and a significant proportion of pilgrims reported underlying conditions such as hypertension and diabetes (Table 2). These groups are physiologically more susceptible to HRIs5, 6, 7 and may face practical barriers in adhering to guidelines. Therefore, the proposed interventions, such as pre-travel health assessments and mandatory leader training, could have disproportionate benefits for these vulnerable pilgrims. Assessments can identify high-risk individuals to enhance monitoring, and trained leaders can prioritize their access to shade, hydration, and rest. Framing interventions through an equity lens ensures that generalized health promotion is coupled with targeted protection for those at greatest risk as both an ethical imperative and practical necessity for reducing morbidity due to HRIs during mass gatherings.

The interactions among these determinants are conceptualized in the Pilgrim Health Outcome Pathway Model (Figure 2), which illustrates how barriers mediate between pilgrims' knowledge and their health outcomes.

Conclusion

This study evaluated awareness regarding HRI and practices of pilgrims and Umrah performers in KSA. Overall, participants had an average level of HRI knowledge and moderate practice scores. In addition, a weak positive correlation was identified between knowledge and practice, suggesting that knowledge influences behavior, but additional factors must also be considered to improve outcomes. Statistically significant associations were detected between demographic factors such as age, gender, and region with both knowledge and practice scores, highlighting the need for tailored interventions. Integrating religious and health education, pre-travel health assessments, subsidized resource provision, and behavioral nudges is recommended to enhance pilgrims health outcomes. These strategies combined with existing health education campaigns can address barriers and improve adherence to preventive measures. Further research is warranted to explore interventions targeted at practical and systemic challenges to effectively address the gap between awareness and practice.

Source of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval

Ethical approval was secured from the Ethics Committee of King Faisal University in KSA, with reference number KFU – REC – 2024-MAY-ETHICS 2437. Participation was voluntary, and participants were fully informed about the study's objectives and time requirements. Informed consent was obtained from all participants before survey administration. Data were collected anonymously, ensuring confidentiality and adherence to ethical standards.

Authors’ contributions

YA made the primary contribution to this study, including study conception and design, overall supervision, data interpretation, critical revision of the manuscript, and final approval. FA was the second major contributor and was responsible for data acquisition, data analysis and interpretation, manuscript drafting, and revision. HA and AA contributed to the methodology, data acquisition, and critical review of the manuscript. GA and FA contributed to data collection, literature review, and manuscript editing. TA contributed to literature review, data interpretation, and manuscript revision. DA contributed to data acquisition, manuscript drafting, formatting, and final review. All authors contributed to critically revising the manuscript regarding important intellectual content, approved the final version to be published, certify that they meet the criteria for authorship, and confirm that the manuscript has been checked for plagiarism. In the event that plagiarism is detected, all authors will be held equally responsible and will bear any sanctions imposed by the journal. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.

Conflict of interest

The authors declare that there are no conflicts of interest regarding the publication of this paper.