Discussion

The main purpose of this study was to assess home confinement and to examine the health anxiety symptoms among home quarantined Iraqi individuals during the onset of COVID-19. The results of this study indicate that most of the Iraqi people practiced home quarantine at the onset of the spread of the virus. The study detected that the common groups compliant with home quarantine were younger adults, females, unmarried individuals, unemployed individuals, individuals with a university degree, and those residing in the northern governorates. More than half of the quarantined individuals exhibited a health anxiety disorder. Among the subscales of health anxiety, reassurance-seeking behavior was recorded to have the highest mean scores. High rates of health anxiety were found among younger individuals, females, the unmarried, lower educational attainment, and southern governorates’ inhabitants. The predictors of health anxiety include gender, the residential governate, the knowledge of the novel virus, and the incidence of chronic respiratory diseases.

During the pandemic, Iraq reported its first confirmed case of COVID-19 on February 22 in Najaf. ^{Reference Al-Malkey and Al-Sammak13} Over the next month, the number of cases exceeded 100 in Baghdad and other Iraqi cities. ^{Reference Mikhael and Al-Jumaili15} At the time of conducting this study, the spread of COVID-19 was in the initial stages and the health authorities had not announced a public emergency. However, some measures were taken by the Iraqi Government. On March 23, 2020, they prohibited travel to Bahrain, China, France, Iran, Italy, Japan, Kuwait, Nigeria, Singapore, South Korea, Spain, Turkey, and Thailand and also prohibited individuals from these countries from visiting Iraq. Iraqi nationals and residents who had visited these countries in the past 14 days were asked to self-quarantine for 14 days on arrival. ^{Reference Al-Malkey and Al-Sammak13} In addition, all those who had traveled from the above countries were required to undertake a medical examination at the border crossing. The public health officials also encouraged home confinement for all arrivals.

At that time, 83% of the study sample practiced home quarantine often or most of the time without the need for force. The high proportion of self-quarantine was observed, despite the collective nature of Iraqi culture and the dependence on socialization. The rest of the population who chose not to quarantine, despite encouragement from the government, was due to a lack of seriousness about the disease and a decision to risk contracting the disease rather than suffer the economic costs associated with a lockdown. ^{Reference DiGiovanni, Conley and Chiu16,Reference Rothstein and Talbott17} This high compliance was in line with other countries. For example, in Canada, during the SARS outbreak in 2003, people also showed high compliance with quarantine, and in a telephone survey, about 97% of them agreed to quarantine if they were exposed to SARS. ^{Reference Reynolds, Garay and Deamond18}

This study indicates that more younger adults quarantined themselves compared to those individuals in the 35–54 and ≥ 50 years age brackets. This group is more skilled in using new technology and Internet services and can enjoy these services in the comfort of their homes. Because most of the females in our sample were housewives and unemployed, they were more easily confined and could cope with being inside their homes. Therefore, they complied more easily to quarantine measures.

Our findings revealed that a better knowledge of COVID-19 is associated with more compliance with the home quarantine procedure and lesser anxiety rates. Transparent and clear public information is mandatory to minimize the panic and increase the adherence to the public health measures, including complying with quarantine restrictions. ^{Reference Dagnino, Anguita, Escobar and Cifuentes19} The respondents holding university or higher degrees were more likely to adhere to the quarantine as they had more awareness and a better knowledge of the novel infection. Compliance was higher when respondents understood the rationale for imposing the quarantine, which can be enhanced through improved knowledge about the relevant disease. ^{Reference Reynolds, Garay and Deamond18}

Isolation and self-quarantine help decrease the spread of the infection, and reduce the spread among friends, relatives, and other social networks. This loneliness contributes to a drop-off in the social support gained, which, in turn, exacerbates the mental health impact of the isolation and quarantine, including an increase in the incidence of anxiety and depression of various types. ^{Reference Hiremath, Suhas Kowshik and Manjunath20} In addition, long-term quarantine may aggravate anxiety, sleep problems, frustration, irritability, and the fear of contracting the virus. ^{Reference Dagnino, Anguita, Escobar and Cifuentes19} Misinformation and the sharing of fake news on social media also induce anxiety, stigma, and a loss of hope. ^{Reference Tang, Zhang and Li21} The loneliness and isolation induced by home quarantine may promote an excessive use of the Internet, including for medical advice that may increase the people’s vulnerability to health anxiety. ^{Reference Tyrer, Cooper and Tyrer22}

It is notable that among the quarantined population in Iraq, more than half were considered to experience health anxiety. This higher rate may be due to the ambiguity and a lack of access to information on COVID-19, in addition to reduced social support and a reduction of collective living impacted by home quarantine. Additionally, during the quarantine, one is mostly undergoing unpleasant feelings as a result of detachment from other people and a doubtfulness about the outbreak status, leading to striking effects. ^{Reference Wilder-Smith and Freedman7} The recorded prevalence of health anxiety was even higher than the prevalence reported in medical clinics (14.9%–19.9%). ^{Reference Tyrer, Cooper and Tyrer22} Furthermore, the figure was higher than the anxiety rate measured on the Beck Anxiety Inventory among Chinese people during the lockdown period (29%). ^{Reference Ahmed, Ahmed and Aibao23} These differences could be explained by the tragic history of Iraq over the last few decades, past exposure to mass traumatic events, and internal and external conflicts that have overburdened the Iraqis and increased their vulnerability to psychological problems.

Among all of the subscales of health anxiety, quarantined respondents showed higher rates of “reassurance-seeking behavior.” This result is in line with the explanation provided by cognitive-behavioral theory, which explains the behavioral responses of health anxious patients. ^{Reference Hadjistavropoulos, Craig and Hadjistavropoulos12} Staying indoors, interacting less with people, might put the person in a bad mood in addition to the concern about contracting the coronavirus can emphasize the reassurance-seeking behavior.

This study indicates that health anxiety was more prevalent among younger individuals who practiced home quarantine to a larger extent than individuals among other age groups. The younger individuals are more vulnerable to stress and emotional instability as they are more inclined to follow up on the news on social media than their older counterparts. ^{Reference Correa, Hinsley and de Zúñiga24} Although a study in China revealed similar findings, ^{Reference Ahmed, Ahmed and Aibao23} a study in the United States found that social isolation puts older people at a higher risk for anxiety. ^{Reference Bell, Singer and Solway25}

The present findings point out that health anxiety among quarantined people was more common among females. This in in line with studies that indicated that being a female is a risk factor for anxiety and, in turn, health anxiety. ^{Reference Dagher, Chen and Thomas26} In comparison to married people, those who were single may have received lesser help and support from a partner, and the lack of relationship interaction, as well as feelings of loneliness may have contributed to the higher rates of health anxiety. ^{Reference Girme, Maniaci and Reis27} In contrast to the study conducted by Chen et al., lower educational levels were associated with higher rates of health anxiety. ^{Reference Chen, Zhang and Zhuang28} However, the fact that the sample taken consisted of purely medical staff may have contributed to the differing results.

This study also showed significant differences in the rate of health anxiety between inhabitants of different Iraqi districts. The residents from southern governorates showed higher rates of health anxiety compared to residents of other parts of Iraq. This may have been because the first cases of COVID-19 appeared in Najaf, which is located in the south of Iraq, in addition to the rapid increase of cases in this geographical area at the time of conducting this study.

The findings of this study confirmed that health anxiety is more prevalent among Iraqi’s quarantined people who have a history of chronic respiratory diseases. This is explained by a reaction to the stress of physical illness and is supported by other studies that indicate that health anxiety is higher among those with physical diseases. ^{Reference Tyrer, Cooper and Crawford29}

This study proved that the Iraqi people responded well to the voluntary home quarantine at the beginning of the pandemic. The public health policy should be better crafted to help prevent the spread of the disease by concentrating on the non-compliant groups. As the adherence to quarantine measures was positively related to the level of knowledge on COVID-19, it is recommended that providing better information on the novel disease can have a positive impact on the compliance with preventive measures. The quarantined individuals exhibited heightened anxiety and worries about their health. This turns to the mental health impact of the novel disease and addresses the needs to the awareness programs and psychological interventions.

This study has some limitations. First, because the study gathered data online rather than during face-to face interviews, the risk of exaggeration was possible. Second, because of the snowball sampling technique, it cannot be considered a representative sample. Third, it is difficult to recognize that the scores of health anxiety existed before the home quarantine. Last, this study examined only some variables to be risk factors of health anxiety and excluded many other possible predictors.