The current study revealed various patterns of viewpoints regarding the COVID-19 outbreak in Iraqi Kurdistan Region. Individuals from different socio-demographic backgrounds participated in this study as they were thought to give representative viewpoints. This explorative study identified three viewpoints reflecting distinctive perspectives of participants around different aspects of the COVID-19 disease.
The first viewpoint reflected the perspective of accepting government measures as an effective strategy to control and overcome the disease. Also, respondents holding this viewpoint believe that the disease is a serious one, and they were adherent to preventive measures. For example, they mostly agreed with the statements of limiting activities outside the home, avoiding crowded areas and people who cough or sneeze and reducing the number of contacts.
Respondents holding this viewpoint share common beliefs and attitudes with people dealing with infectious respiratory diseases . Their educational background could explain one of the reasons that this group of respondents complies with protective measures as all the respondents in this group were graduated from secondary school and above. Several studies identified that those individuals with higher education were more likely to adopt protective measures and behaviors [19, 20].
Additionally, respondents holding viewpoint 1 agree that this disease is serious, and thus their risk perception might be high. Many studies documented the relationship between the perceived risk and engagement in protective measures. For instance, in cases where the higher the risk perception is, people's behavior towards applying protective measures increases [20, 21].
Respondents holding viewpoint 1 showed dissimilarity to those in viewpoint 2 and viewpoint 3, in terms of believing in the effectiveness of government measures since they least agreed with the statement, “emergency services are not well prepared to contain the disease.” The Iraqi KRG implemented restrictive measures in order to contain the outbreak. For example, by the end of February, the government decided to suspend all schools and universities in the region. This was followed by declaring a public holiday for the rest of the government entities except for some sectors such as health and law enforcement departments. Simultaneously, the entire religious and public gatherings were suspended, and lastly, lockdown across the region was declared, which is still ongoing . These measures are seriously taken in order to flatten the epidemic curve as it was documented that the more the number of transmissions is reduced, the flatter and longer the curve will be .
In addition, the KRG follows the strategy of quarantine for those who had a history of travel from outside Iraq, contact tracing and surveillance in order to control and treat the infected individuals with COVID-19. Studies have shown that by using public health measures (isolation, tracing, and quarantine), such contagious outbreaks can be controlled [23–25]. The KRG implementing these measures in the early stage of the disease is quite crucial since the healthcare infrastructure in the region is insufficient and still developing, and without these measures, a catastrophe might have happened.
In addition, the findings indicate that respondents in this group would seek healthcare advice for any illness as they least agreed to the statement, “If I feel ill, I will hesitate to go to the hospital fearing of quarantine of myself and my family.” Also, they thought that by practicing proper and frequent hand washing, they would be able to avoid the infection. The majority of health authorities worldwide recommend that frequent hand washing and social distancing can reduce the chance of getting COVID-19 infection [26–28].
Although respondents holding viewpoint 2 did not consider this infection as a serious one, they were extremely worried about getting the disease and eventually dying from it. In addition, they thought that this disease can not be avoided by frequent and proper hand hygiene. It was interesting to notice how respondents do not take appropriate preventive measures despite being worried about getting the disease. For example, they did reduce the number of contacts, limit activities outside the home, and avoid people who cough or sneeze. Such kind of thinking or behaving among people is quite intimidating in the community as no matter how the government applies restrictive measures if people's thinking and behaviors are not in favor of applying protective behaviors, the situation cannot be controlled [22, 29].
Previous studies suggested that levels of worry or anxiety about previous pandemics such as influenza H1N1 (in 2009) were linked to compliance with government and health recommendations [10, 21]. This is in disagreement with our finding as although respondents holding viewpoint 2 were extremely worried about getting the disease, they were not adhering to protective measures.
In addition, our finding showed that respondents holding viewpoint 2 believed that the emergency services were not well prepared to contain the disease and that closing borders was not an effective strategy to prevent the spread of the infection. However, previous studies indicated that confidence in the ability of the government's measures to control the spread of the disease was related to health recommendation compliance . Previous studies have indicated that those people who have higher trust and confidence in the government's strategy in handling the situation were more likely to comply with their recommendation [21, 31].
Respondents in viewpoint 3 indicated that they follow some protective measures to avoid getting the infection. However, their main concern was that people are unaware of preventive measures and are non-adherent to protective measures. In contrast to respondents’ perspectives in viewpoint 2, they believed that people cannot avoid some behaviors yet. Changing behavior is not straightforward, and it can be an unsteady process .
Similar to respondents in viewpoint 2, this group of people had some concern regarding the government’s ability to take appropriate preventive measures. However, they were not worried about getting the COVID-19 and dying from it. In comparison with other respondents in viewpoint 1 and viewpoint 2, these respondents least agreed that relying on God helps them to avoid the disease. Also, practicing more worship to avoid the disease seemed to be unimportant by these people.
It is remarkable to notice such diverse perspectives and attitudes among this group of respondents, especially regarding people's unawareness and incompliance of public health recommendations. This requires health authorities to apply different means in order to disseminate information and educate people about applying protective measures.
Interestingly, the respondents holding the three viewpoints had a general agreement around a number of aspects of the COVID-19 disease. There was a strong consensus regarding the concept of suspending schools during the outbreak as a wise decision. A review examining the various aspects of school closure as a public health policy identified that school closure is usually suggested for mitigating the pandemics . However, when such decisions have to be made, officials and authorities must plan to alleviate the undesirable features of the closure.
There was also a general consensus regarding the availability of hand sanitizers in all public places freely. In fact, following the emergence of the outbreak in Kurdistan region, most of the public places like supermarkets and hospitals have provided hand sanitizers for their consumers, in order to reduce the spread of the infection.
There was also some agreement among the three groups of respondents about buying enough masks to protect themselves and others from the disease. However, they had a neutral view of the unnecessary use of face masks by the people. The recommendations about when and who to use a face mask are somehow controversial. WHO only recommends the use of face masks in specific cases; for instance, those people who feel unwell having cough, fever, and difficulty breathing should wear a mask. Also, if a healthy person taking care of a suspected person with COVID-19, then s/he should wear a mask . Some provinces of China have imposed a policy of compulsory face masks in public places . Nevertheless, recently, the Centers for Disease Control and Prevention recommends using cloth face masks to assist in reducing the spread of COVID-19 in public areas where it is hard to adhere to social distancing .
This study, through its explorative nature, revealed a range of distinct perspectives of individuals residing in Kurdistan region toward the COVID-19. The variety of perspectives presents here in this study, in fact, reflects the variety of views that exist among people in Iraqi Kurdistan region regarding the COVID-19. By applying Q-methodology, this study helped in understanding people's views and attitudes in relation to different aspects of COVID-19. However, the study findings cannot be generalized as the sample in Q-studies usually includes a small number of respondents . Thus, further research exploring people's views about COVID-19 on a greater scale and in more in-depth ways might be necessary, especially taking those perspectives who are not adherent to the protective measures.