Factors associated with health service utilization among Iranian pilgrims during the 2023 Arbaeen pilgrimage in Iraq: a cross-sectional study

Abstract

Introduction

The Arbaeen Walking Ceremony (AWC) is one of the largest annual mass gatherings, posing significant challenges to health systems due to increased demand for medical services. Understanding the factors influencing health service utilization (HSU) among pilgrims is crucial for effective health planning. This study aimed to assess the prevalence and predictors of HSU among Iranian pilgrims during the 2023 AWC in Iraq.

Methods

A cross-sectional study was conducted among 461 Iranian pilgrims who participated in the 2023 Arbaeen pilgrimage, using convenience sampling. Data were collected via a structured questionnaire including demographic information, health service utilization (during and after the pilgrimage), the General Health Questionnaire (GHQ-28), and the Perceived Physical Fitness Scale (PPFS). Logistic regression models were used to identify predictors of HSU during the pilgrimage. Data were analyzed using STATA-13.

Results

The mean age of participants was 35.1 years (SD = 14.6), with 50.3% female. Nearly half (49.9%, n = 230) utilized health services during the pilgrimage, including wound dressing (15.6%), outpatient examination (16.5%), and non-prescription medication (21.5%). After returning, 31.5% (n = 145) sought further care. In the journey to Arbaeen, factors significantly associated with higher HSU included older age (aOR = 1.02 per year, 95% CI: 1.00–1.04, p = 0.004) and use of public transportation (aOR = 1.55, 95% CI: 1.02–2.34, p = 0.038). For the return journey, pilgrims returning via Khosravi border had higher utilization (aOR = 1.84, 95% CI: 1.12–3.03, p = 0.016), while those with longer pilgrimage duration (6–10 days) and prior experience (2–4 times) showed increased odds of HSU (aOR = 1.75, 95% CI: 1.05–2.91, p = 0.030). General health and physical fitness scores were not significantly associated with HSU.

Conclusion

Nearly half of Iranian pilgrims used health services during the 2023 Arbaeen pilgrimage. Predictors of utilization varied by travel phase, with age and transportation mode influencing use on the way to Iraq, and return border, duration, and prior experience affecting use on the return journey. These results support the need for tailored health services and pre-travel guidance.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12889-026-28569-6.

Introduction

The Arbaeen Walking Ceremony (AWC) is one of the largest annual religious gatherings, with 20–30 million pilgrims converging in Karbala, Iraq, over 10–14 days [1, 2]. Participants, many walking up to 80 km from Najaf in extreme weather (5 °C to 40 °C), face public health challenges including dehydration, injuries, infections, and chronic disease exacerbation [3–5]. The combination of prolonged physical exertion, limited access to clean water and sanitation, overcrowding, and inadequate shelter creates a high-risk environment for health emergencies, making effective on-site medical planning essential [6–8].

Unlike other types of mass gatherings, such as music festivals or sporting events, where alcohol-related incidents, trauma, and psychiatric emergencies dominate [9–11], the AWC is characterized by a distinct health risk profile centered on physical strain, environmental exposure, and communicable disease transmission [1, 12, 13]. This necessitates tailored health interventions that go beyond general mass gathering guidelines [6, 8, 14]. Despite efforts by WHO and MOH to develop preparedness frameworks, the transnational nature of the AWC poses unique challenges, especially for Iran, which sends over one million pilgrims annually [8, 15, 16].

Health service utilization (HSU) during mass gatherings is a critical indicator for evaluating the effectiveness of medical planning and resource allocation [17, 18]. Studies from Hajj and other religious events have shown that 10–30% of pilgrims require medical assistance, with predictors including age, pre-existing conditions, and travel mode [15, 19, 20]. However, no study has systematically examined HSU among Iranian pilgrims during the Arbaeen pilgrimage, nor has any applied a comprehensive theoretical model to identify key predictors in this context [1, 15, 21]. This gap is significant, as Iranian pilgrims face unique sociocultural and logistical factors, such as transport mode, border crossings, and physical readiness, that may influence health-seeking behavior [1, 7, 15].

To address this gap, we employed the Andersen Behavioral Model of Health Services Use, which conceptualizes HSU as a function of three domains: (a) predisposing factors (e.g., age, gender), (b) enabling factors (e.g., transportation, border points), and (c) need factors (e.g., past medical history, general health status) [22]. This framework has been widely validated in health services research and provides a systematic approach to understanding health-seeking behavior in complex settings. This study aimed to: (1) assess HSU during and after the 2023 AWC; (2) evaluate general health and physical readiness; and (3) identify HSU predictors using the Andersen Model.

Materials and methods

Study design

This online cross-sectional study was conducted among Iranians participating in the AWC in 2023. This research adhered to the guidelines for reporting observational studies as outlined by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

Sample and sampling method

The target population for this study included all Iranian pilgrims who participated in the 2023 Arbaeen Walking Ceremony (AWC). Based on a prior estimate of health service utilization (HSU) rate of 27.8% among pilgrims [21], a 95% confidence level, and a 4.5% margin of error, the minimum required sample size was calculated to be 381. To account for a 15% non-response rate, the target sample size was adjusted to 449 participants. Participants were selected through convenience and snowball sampling methods. While this approach facilitated rapid data collection among a hard-to-reach population, it may introduce selection bias, as participants were likely to share similar socio-demographic or technological characteristics (e.g., younger age, higher digital literacy). To mitigate this, the survey link was disseminated across multiple social messaging platforms (Telegram, WhatsApp, Rubika, and Eitta), and participants were encouraged to forward the invitation to diverse pilgrim networks, including those affiliated with religious associations and travel agencies. Although comprehensive demographic data on the entire population of Iranian pilgrims are not publicly available, our sample’s age (mean = 35.1 years) and gender distribution (50.3% female) are broadly consistent with previous reports on Iranian participants in the AWC [21, 23].

Data collection was conducted online from September 16 to October 30, 2023. Inclusion criteria required participants to be literate and capable of using a mobile phone or computer. There were no exclusion criteria. Despite these efforts, the online nature of the survey may have limited participation among older pilgrims, those from rural areas, or individuals with limited internet access or lower digital literacy. Therefore, the sample may not fully represent the entire population of Iranian pilgrims.

Instruments

The tool had three sections: [1] a 13-item demographic form (age, gender, education, travel mode, border, duration, AWC experience, medical and medication history, and HSU).

The second part of the assessment involved the General Health Questionnaire (GHQ-28). This questionnaire comprises four subscales, each containing 7 items: somatic symptoms (items 1–7), anxiety and insomnia (items 8–14), social dysfunction (items 15–21), and severe depression (items 22–28). Responses use a 4-point Likert scale (0: better than usual; 3: much worse), with total scores (0–84) indicating poorer mental health at higher values.The GHQ-28 was developed by Goldberg and Hillier in 1979 [24], who established a cut-off score of 24 for identifying potential mental health issues. Its validity and reliability have been confirmed in Iran (Cronbach’s α: 0.89–0.92) [25, 26]. The third section of the data collection tool features the Perceived Physical Fitness Scale (PPFS), which includes 12 items divided into four subscales: aerobic endurance, flexibility, muscle strength, and body composition.

Each item is rated on a Likert scale ranging from 1 to 5. The total scores can range from 12 to 60, categorizing physical condition as follows: scores from 12 to 36 indicate poor physical condition, scores from 37 to 48 indicate moderate condition, and scores above 48 indicate good physical condition. The PPFS was introduced by Abadie in 1988 [27]. The convergent validity of this scale was found to be good, and the test-retest reliability was reported as high (r = 0.97) [28]. In an Iranian study [29], construct validity showed significant correlations for endurance (r = 0.453), flexibility (r = 0.480), and strength (r = 0.431); body composition was weaker (r = 0.142). Despite established validity, a pilot test (n = 20) assessed clarity, usability, and cultural appropriateness. Cronbach’s alpha for the GHQ-28 subscales in this sample ranged from 0.78 to 0.89, and for the PPFS, it was 0.84, indicating acceptable internal consistency.

Data collection

The invitation to participate in the study included a link to an online questionnaire hosted at “survey.porcine.ir/s/p9TUSPVX.” Before accessing the questionnaire, participants were provided with a detailed information sheet outlining the study’s objectives, procedures, measures, and the voluntary nature of participation, as well as assurances regarding the confidentiality of their data. Pilgrims were informed that completing and submitting the online questionnaire would serve as their informed consent.

The link was shared via Rubika, Eitta, Telegram, and WhatsApp, with participants encouraged to forward it to fellow pilgrims. Completing the questionnaire took participants between 15 and 20 min. The data collection process took place over two months, from September 16 to October 30, 2023. The questionnaire link was disabled once the desired sample size was reached.

To address the digital divide, we collaborated with religious and travel organizations. Nevertheless, online delivery may have excluded older or rural pilgrims with limited internet access.

Data analysis

Data were analyzed using Stata software, version 13. Descriptive statistics, including mean (standard deviation) and frequency (both simple and relative), were used to summarize the demographic and health-related characteristics of the participants. Multivariate logistic regression models were used to identify predictors of HSU during the outbound and return journeys. Assumptions of the model were checked: the linearity of the logit for continuous variables (e.g., age) was assessed using the Box-Tidwell test, and multicollinearity was evaluated using variance inflation factors (VIF). All VIF values were below 2.5, indicating no significant multicollinearity. All predictor variables were entered simultaneously into the model. Odds ratios (OR) with 95% confidence intervals (CI) and exact p-values are reported for statistically significant predictors. A p-value of less than 0.05 was considered statistically significant. Due to the online survey design, only fully completed responses were submitted and included in the analysis. Therefore, no missing data were present, and no imputation was required.

Ethical considerations

This study received approval from the Ethics Committee of Kermanshah University of Medical Sciences (KUMS) under the code IR.KUMS.REC.1402.318. Participants were assured that their identities and responses would be kept confidential by the research team. Additionally, participants expressed their consent to participate in the study by reading the introductory message and selecting the “Participate in the Study” button.

Results

HSU data were collected retrospectively; participants recalled service use during outbound and return journeys. These data do not represent within-subject longitudinal changes but rather reflect reported patterns of use across two phases of the same event.

Characteristics of the study population

Of ~ 900 page views, 461 completed the survey (response rate: 51.2%). The mean age of the samples in the study was 35.1 years, with a standard deviation of 14.6 years. Half of the samples were female, comprising 50.3% (n = 232). Over half had higher education (51.4%, n = 273); 62.5% (n = 288) used public transportation. Additionally, 44.5% (n = 205) reported a pilgrimage duration of five days or more. About 46% of the samples (n = 212) attended the AWC between 2 and 4 times. The most commonly crossed border was the Khosravi border, with 46.9% (n = 216) of samples using it. Notably, more than half of the samples had no prior medical history, 74.6% (n = 344), and had no medication use 78.3% (n = 361) (Table 1).

Table 1.

Demographic characteristics of the participants (n = 461)

Variables			n(%)**
Age (mean ± SD)*			35.1 ± 14.6
Gender		Male	229 (49.7)
		Female	232(50.3)
Education level		≥Diploma	224(48.6)
		< Diploma	237(51.4)
Mode of transportation		Personal car	173(37.5)
		Public transportation	288(62.5)
Duration of Pilgrimage (day)		≥ 5	205(44.5)
		6–10	193(41.9)
		10<	63(13.7)
Previous experience of Arbaeen (frequency )		1	145(31.5)
		2–4	212(46.0)
		5≤	104(22.6)
Departure board		Mehran	159(34.5)
		Khosravi	216(46.9)
		Shalamcheh and Chazabeh	53(11.5)
		Bashmaq and Tamrchin	5(1.1)
		Airplane travel	28(6.1)
Past Medical History	Yes	Cardiovascular/ Respiratory	21(4.6)
		Gastrointestinal	12(2.6)
		Metabolic and endocrine	42(9.1)
		Neurological/Psychiatric	12(2.6)
		Multisystem	30(6.5)
	No		344(74.6)
Past drug history		Yes	100(21.7)
		No	361(78.3)

*Mean (standard deviation), **Number(Percent)

The scope of HSU

During the pilgrimage, 49.9% (n = 230) of participants reported using at least one health service, while 50.1% (n = 231) used no services. After returning, service use decreased significantly, with only 31.5% (n = 145) reporting any health service use and 68.5% (n = 316) reporting no use. The most common HSU during and after the pilgrimage was non-prescription medication (respectively: 21.5%, n = 99; 16.9%, n = 78) (Table 2).

Table 2.

Health services received during and after Arbaeen Pilgrimage (n = 461)

Variables	Health services received n(%)*
	During		After
	Yes	No	Yes	No
Wound dressing	72 (15.6)	-	23 (5.0)	-
Outpatient clinical examination	76 (16.5)	-	28 (6.1)	-
Serum therapy	31 (6.7)	-	12 (2.6)	-
Dispatch and hospitalization	6 (1.3)	-	4 (0.8)	-
Receiving non-prescription medication	99 (21.5)	-	78 (16.9)	-
Total	230 (49.9)	231 (50.1)	145 (31.5)	316 (68.5)

* Number(Percent)

Mean score of general health and readiness physical activity

The mean General Health score of the samples was 19.7, with a standard deviation of 11.6. This indicates that 70.5% of the samples (n = 325) were classified as healthy. Additionally, the mean score for Physical Activity Readiness was 38.1, with a standard deviation of 6.2, showing that more than half of the samples were in average condition (n = 252, 54.7%) (Table 3).

Table 3.

Mean score of general health and readiness physical activity of Arbaeen pilgrimage

Variables		Mean ± SD*		n(%)**
General Health Condition	Somatic symptoms	4.9 (3.8)		-
	Anxiety and insomnia	4.3 (4.0)
	Social dysfunction	7.7 (3.0)		-
	Severe depression	2.8 (3.9)
	Total	19.7 (11.6)	Healthy	325(70.5)
			Unhealthy	136(29.5)
Readiness Physical Activity	Aerobic endurance	19.7 (3.1)		-
	Flexibility	6.1 (1.9)		-
	Muscle strength	6.4(1.7)		-
	Body composition	5.9 (2.0)		-
	Total	38.1 (6.2)	Good	21(4.6)
			Moderate	252(54.7)
			Week	188(40.8)

*Mean (standard deviation), **Number(Percent)

Factors influencing HSU

The multivariate logistic regression indicated that on the way to the AWC, age significantly increased the chance of HSU (OR = 1.02, 95% CI: 1.00–1.04, p = 0.004). However, on the return journey, increasing age significantly decreased the odds of HSU (OR = 0.97, 95% CI: 0.95–0.99, p = 0.001). Regarding gender, although the rate of HSU was not significantly different between male and female participants (p > 0.05), females showed a slightly lower odds of use (OR = 0.87). Participants with higher education had greater odds of HSU during the outbound journey, though this was not statistically significant (OR = 1.22, p = 0.330). Public transportation significantly increased the odds of HSU during the outbound trip (OR = 1.55, p = 0.038), but significantly reduced it on the return (OR = 0.48, p = 0.001). Pilgrims traveling via airplane on the outbound route had higher odds of HSU, while those returning via Tamarchin and Bashmaq borders showed increased use. The odds of HSU were higher among pilgrims whose pilgrimage lasted 6–10 days on the return journey. Previous experience of the AWC (2–4 times) significantly increased the odds of HSU on return (OR = 1.75, p = 0.030). Pilgrims with a history of cardiovascular, respiratory, gastrointestinal, metabolic, endocrine, or multisystem diseases had higher odds of HSU during the return journey. Additionally, individuals who reported a past drug history during the outbound trip had higher odds of HSU compared to the return trip (Table 4).

Table 4.

Predictors of health service usage among Pligrims on the way to and coming back from Arbaeein

Variables		Health service usage
		On the way to Arbaeen				Coming Back from Arbaeen
		n(%)**		Adjusted OR         (CI)+	P-value	n(%)**		Adjusted OR (CI)+	P-value
		Yes	No			Yes	No
Age				1.02(1.00-1.04)	0.004			0.97(0.95-0.99)	0.001
Gender	Male	115(50.2)	114(49.8)	Ref	-	80(34.9)	149(65.1)	-	-
	Female	115(49.6)	117(50.4)	0.87(0.58-1.32)	0.522	65(28.0)	167(72.0)	0.96(0.61-1.51)	0.857
Education level	≥ Diploma	121(54.0)	103(46.0)	Ref	-	83(37.1)	141(62.9)	Ref	-
	< Diploma	109(46.0)	128(54.0)	1.22(0.82-1.82)	0.330	62(26.2)	175(73.8)	0.70(0.45-1.09)	0.118
Mode of transportation	Personal car	99(55.5)	77(44.5)	Ref	-	72(41.6)	101(58.4)	Ref	-
	Public transportation	134(46.6)	154(53.5)	1.55(1.02-2.34)	0.038	73(25.3)	215(74.7)	0.48(0.31-0.75)	0.001
Departure border	Mehran	78(49.1)	81(50.9)	Ref	-	41(25.8)	118(74.2)	Ref	-
	Khosravi	110(50.9)	106(49.1)	0.72(0.46-1.13)	0.154	80(37.0)	136(63.0)	1.84(1.12-3.03)	0.016
	Shalamcheh& Chazabeh	28(52.8)	25(47.2)	0.90(0.46-1.78)	0.760	14(26.4)	39(73.6)	1.00(0.45-2.22)	0.996
	Tamarchin& Bashmagh	4(80.0)	1(20.0)	0.12(0.01-1.43)	0.094	3(60.0)	2(40.0)	4.48(0.51 -39.13)	0.175
	Airport	10(35.7)	18(64.3)	1.62(0.67-3.91)	0.281	7(25.0)	21(75.0)	1.30(0.47-3.60)	0.616
Duration of Pilgrimage (day)	≥5	85(41.5)	120(58.5)	Ref	-	70(34.1)	135(65.9)	Ref	-
	6-10	113(58.5)	80(41.5)	0.41(0.26-0.64)	0.000	63(32.6)	130(67.4)	1.12(0.70-1.80)	0.630
	10<	32(50.8)	31(49.2)	0.55(0.29-1.04)	0.067	12(19.0)	51(81.0)	0.57(0.26-1.25)	0.161
Previous experience of Arbaeen (frequency )	1	68(46.9)	77(53.1)	Ref	-	41(28.3)	104(71.7)	Ref	-
	2-4	115(54.2)	97(45.8)	0.80(0.50-1.28)	0.354	82(38.7)	130(61.3)	1.75(1.05-2.91)	0.030
	5≤	47(45.2)	57(54.8)	1.03(0.58-1.84)	0.916	22(21.2)	82(78.8)	0.93(0.478-1.82)	0.839
Past Medical History	No	171(49.7)	173(50.3)	Ref	-	105(30.5)	239(69.5)	Ref	-
	Cardiovascular/ Respiratory	10(47.6)	11(52.4)	0.62(0.23-1.71)	0.358	9(42.9)	12(57.1)	2.73(0.95-7.88)	0.063
	Gastrointestinal	7(58.3)	5(41.7)	0.48(0.13-1.73)	0.260	4(33.3)	8(66.7)	1.51(0.39-5.86)	0.550
	Metabolic and endocrine	19(45.2)	23(54.8)	0.62(0.25-1.55)	0.306	14(33.3)	28(66.7)	1.74(0.65-4.67)	0.269
	Neurological/Psychiatric	7(58.3)	5(41.7)	0.83(0.20-3.50)	0.803	4(33.3)	8(66.7)	0.75(0.16-3.57)	0.717
	Multisystem	16(53.3)	14(46.7)	0.41(0.15-1.14)	0.089	9(30.0)	21(70.0)	1.60(0.54-4.72)	0.396
Past drug history	No	46(46.0)	54(54.0)	Ref	-	113(31.3)	248(68.7)	Ref	-
	Yes	184(51.0)	177(49.0)	1.54(0.73-3.26)	0.257	32(32.0)	68(68.0)	0.98(0.44-2.17)	0.952
General Health				0.99(0.97-1.01)	0.264	-	-	1.02(1.00-1.04)	0.097
Readiness Physical Activity				1.01(0.98-1.05)	0.505	-	-	1.01(0.97-1.05)	0.589

*Mean (standard deviation), **Number(Percent), + Confidence interval,

The higher likelihood of HSU among older individuals during the outbound journey may reflect greater health vulnerabilities under travel stress, whereas younger pilgrims may report more issues on return due to fatigue or exposure. The reduced HSU among those using public transportation on the return trip might be due to improved access to personal medications or milder symptoms after rest.

Notably, physical activity readiness was not significantly associated with health service use either during (OR = 1.01, 95% CI: 0.98–1.05, p = 0.505) or after the pilgrimage (OR = 1.01, 95% CI: 0.97–1.05, p = 0.589), suggesting that health service utilization in this population is driven more by medical history and travel conditions than by physical fitness level.

Discussion

While prior studies describe health outcomes, this study uniquely captures dynamic HSU shifts across outbound and return phases, revealing novel phase-specific patterns.

Health service utilization (HSU) during the Arbaeen Walking Ceremony was substantial, with nearly half of Iranian pilgrims accessing some form of medical support. This rate aligns with findings from other large-scale religious mass gatherings, such as the 2018 AWC and the Sabarimala pilgrimage in India, where 40–48% of participants reported health issues requiring intervention [13, 30]. In contrast to our low hospitalization rate, Hajj pilgrimages show higher rates (e.g., 5.6% in Indonesian pilgrims), likely due to greater comorbidity burden [20]. This discrepancy may be attributed to the physically demanding nature of walking 70–80 km under extreme weather conditions, which likely acts as a self-selection mechanism, attracting younger, healthier individuals and excluding those with significant comorbidities. In contrast, Hajj participants represent a broader demographic, including older adults and those with chronic illnesses, many of whom travel by vehicle, reducing pre-journey physical filtering.

A defining characteristic of the AWC, compared to other types of mass gatherings, is the nature of health challenges faced by participants. While events such as music festivals and sporting events are dominated by alcohol intoxication, trauma, and psychiatric emergencies, religious pilgrimages like the AWC are shaped by physical strain, environmental exposure, and infectious diseases—a distinction highlighted in global reviews of mass gathering medicine [2, 9, 10]. This pattern is supported by evidence of diarrheal illness [3], cold exposure [31], and musculoskeletal injuries, common in religious and sporting mass gatherings [11]. These findings are consistent with a recent qualitative study by Kheradmand et al. (2024), which identified logistical and environmental barriers to healthcare access during the Arbaeen pilgrimage, including long distances to medical stations, overcrowding, and limited availability of medications [7]. The high prevalence of non-prescription medication use suggests that pilgrims often self-manage minor ailments, likely due to limited access to formal care, prior experience with self-treatment, or reluctance to interrupt their journey, as evidenced by high rates of antibiotic self-use among mass gathering pilgrims [19].

A key insight is the phase-dependent nature of health risks. For example, older age was associated with increased health service use during the outbound journey, consistent with the known vulnerability of older individuals to physiological stress [32, 33]. However, this association reversed on the return journey, suggesting a “survivor effect”—only the most physically and psychologically resilient older pilgrims complete the full pilgrimage, while those with poorer health drop out or return early.

Observed in endurance events [34], this underscores the need for pre-pilgrimage screening, particularly for older adults with chronic conditions. Similarly, the mode of transportation demonstrated a shifting influence across the journey. Public transportation use was linked to higher HSU during the outbound trip, likely due to crowded and poorly ventilated conditions that facilitate the transmission of respiratory and gastrointestinal infections, as observed in recent mass gathering events during the pandemic era [16]. In contrast, utilization decreased on the return journey, possibly because many individuals had already received care or chose to rest upon return. This highlights the need for time-sensitive interventions at transit hubs, especially during outbound travel [6].

Return via specific border crossings, especially Khosravi, was associated with greater health service use compared to other entry points, potentially due to higher congestion, longer wait times, or weaker medical infrastructure. This finding calls for targeted resource allocation at high-traffic borders to manage the cumulative burden of fatigue, injury, and illness, a recommendation supported by recent scoping evidence highlighting the need for enhanced medical capacity at critical entry points [1]. Pilgrims with moderate experience (2–4 times) used services more on return, possibly due to greater health awareness and willingness to seek care. Unlike first-time pilgrims, who may underreport symptoms due to anxiety or unfamiliarity, or veteran pilgrims, who may rely on self-care strategies developed through repeated exposure, those with intermediate experience might be more attuned to emerging health issues without being overly hesitant or overly confident in managing them. This pattern aligns with observations from other mass gatherings, where repeat but non-veteran attendees exhibit distinct health-seeking behaviors [35]. While this interpretation suggests a positive development in health literacy, it is also possible that cumulative fatigue and prolonged exposure during return travel, particularly through congested border crossings such as Khosravi [1], contribute to higher service use in this group. Thus, both behavioral and contextual factors likely interact to shape care-seeking patterns during the return phase.

Neither general health nor fitness predicted HSU, possibly due to high baseline health or cultural/logistical care-seeking delays. Nevertheless, over half of participants demonstrated only moderate physical readiness, particularly in body composition and endurance, suggesting that many enter the pilgrimage without adequate preparation. As highlighted in prior research, a sedentary lifestyle is a key risk factor for adverse health outcomes during mass gatherings [36], reinforcing the need for pre-travel physical conditioning programs.

The implications of these findings extend beyond description to actionable health planning. Given evolving health risks, medical resources should be strategically deployed by phase, location, and subgroup, a principle supported by operational guidelines for mass gathering medicine [6]. Enhanced medical presence during the outbound journey, especially at transit hubs and crowded routes, could mitigate early exposure risks. At the same time, return points like Khosravi border require reinforced infrastructure, including mobile clinics, real-time surveillance, and crowd management systems, as recommended in assessments of border health preparedness [37]. Pre-pilgrimage screening and education campaigns should target older individuals and those with chronic conditions, providing guidance on medication management, hydration, and physical preparedness, in line with global best practices [2]. Structured readiness programs may reduce injury and exhaustion [36]. Furthermore, the widespread use of non-prescription medications calls for supervised medication stations and hygiene kits to prevent misuse and infection, as demonstrated in recent pandemic-era policies [16]. Public awareness initiatives should also emphasize early care-seeking and environmental protection, particularly in extreme temperatures, a key component of effective health promotion at mass gatherings [35]. These findings should inform national policies, including phased medical response protocols with health and border authorities.

In conclusion, health service utilization during the Arbaeen pilgrimage is not a static outcome but a dynamic process shaped by the interplay of individual characteristics, behavioral patterns, and environmental stressors that shift across the journey. With an estimated 20 million participants annually and occurring in a context marked by fragile health infrastructure, inadequate sanitation, and low risk perception among pilgrims, the Arbaeen pilgrimage presents unique public health challenges that cannot be adequately addressed by generic models designed for secular or less physically demanding events [17]. The Arbaeen pilgrimage cannot be managed through one-size-fits-all models designed for Hajj or secular events; its unique combination of extreme physical exertion, self-selection, and border congestion demands a tailored, adaptive framework.

As emphasized in global guidance on mass gathering medicine, effective planning must therefore adopt a context-sensitive, adaptive, and equity-oriented approach, one that accounts for the distinct sociocultural, logistical, and medical realities of large-scale religious gatherings [2]. By anticipating the changing vulnerabilities of pilgrims, from the initial physical stress of departure to the cumulative fatigue of return, health authorities can design more resilient systems capable of supporting millions of participants in one of the world’s largest annual peaceful gatherings.

Limitations

This study has limitations affecting generalizability. First, the cross-sectional design limits our ability to establish causal relationships or track changes in health status over time. Although health outcomes during and after the pilgrimage were captured, pre-departure health data were not collected. Longitudinal studies are needed to map health trajectories and service timing.

Second, reliance on self-reported data may introduce biases such as social desirability, recall inaccuracy, and underreporting of sensitive behaviors or medication use. While anonymity may reduce some biases, the subjective nature of tools like the GHQ-28 and PPFS warrants cautious interpretation. Future research should use mixed methods to explore cultural beliefs and care-seeking barriers.

Third, the use of convenience and snowball sampling via online platforms (e.g., Telegram, WhatsApp, Rubika, Eitta) may have introduced selection bias, favoring younger, tech-savvy, and urban pilgrims. This could underrepresent older individuals and those with limited internet access or lower digital literacy, potentially limiting the representativeness of findings. To improve generalizability, future studies should employ stratified sampling, in-person data collection at transit points, or collaboration with official pilgrimage organizers to reach a more diverse population. Despite limitations, this study offers one of the first comprehensive assessments of HSU among Iranian AWC pilgrims, with insights for phase-sensitive planning.

Conclusion

This study highlights that HSU during the AWC is a dynamic process, shaped by the physical demands of the pilgrimage, the mode of travel, and the changing vulnerabilities of pilgrims from departure to return. While most participants reported good general health, nearly half accessed some form of medical support, primarily through non-prescription medications. Key factors such as older age, use of public transportation, crossing specific borders, and pilgrimage duration were found to influence service use.

To improve health outcomes for future pilgrims, organizers are encouraged to implement targeted interventions. These include enhancing medical services at high-risk borders like Tamarchin and Bashmaq, particularly during return periods, and establishing supervised medication stations to prevent misuse of over-the-counter drugs. Pre-pilgrimage education and physical readiness programs could help first-time or older participants better prepare for the journey. Additionally, expanding mobile clinics and telemedicine services along the walking routes may improve access to timely care. By anticipating the evolving health needs of pilgrims, from the initial physical stress of departure to the cumulative fatigue of return, health authorities can build more responsive and resilient health systems for one of the world’s largest peaceful gatherings.

Authors’ contributions

VGh, LR, HZ, SR, and MJ were involved in the study design. HZ and MJ collected the data, while SR, and VGh conducted the data analysis. VGh, LR, HZ, SR, and MJ collectively wrote the final report and manuscript. All authors have reviewed and approved the submitted version of the manuscript. It is important to note that authors Vahid Ghanbari and Leili Rostamnia have equal contributions as first authors of this article.

Funding

This study was funded by Kermanshah University of Medical Sciences under code 4020599.

Data availability

The datasets used in this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Kermanshah University of Medical Sciences (IR.KUMS.REC.1402.318). All methods were performed in accordance with relevant guidelines. Informed consent was obtained electronically via a “Participate” button after participants reviewed a detailed information sheet on study aims, procedures, confidentiality, and voluntary participation.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.