Immediate Psychological Effects of the COVID-19 Quarantine in Youth From Italy and Spain

The COVID-19 quarantine has affected more than 860 million children and adolescents worldwide, but to date, no study has been developed within Western countries to examine the psychological impact on their lives. The present study aims to examine for the first time the emotional impact of the quarantine on children and adolescents from Italy and Spain, two of the countries most affected by COVID-19. Participants were 1,143 parents of Italian and Spanish children aged 3 to 18 years who completed a survey providing information about how the quarantine affects their children and themselves, compared to before the home confinement. Results show that 85.7% of the parents perceived changes in their children’s emotional state and behaviors during the quarantine. The most frequent symptoms were difficulty concentrating (76.6%), boredom (52%), irritability (39%), restlessness (38.8%), nervousness (38%), feelings of loneliness (31.3%), uneasiness (30.4%), and worries (30.1%). Spanish parents reported more symptoms than Italians. As expected, children of both countries used monitors more frequently, spent less time doing physical activity, and slept more hours during the quarantine. Furthermore, when family coexistence during quarantine became more difficult, the situation was more serious, and the level of stress was higher, parents tended to report more emotional problems in their children. The quarantine impacts considerably on Italian and Spanish youth, reinforcing the need to detect children with problems as early as possible to improve their psychological well-being.


INTRODUCTION
The outbreak of the 2019 coronavirus disease  emerged in the city of Wuhan (China) in December 2019. Motivated by its rapid spreading, the World Health Organization (WHO) declared it a pandemic on March 11, 2020 (World Health Organization (WHO), 2020). Italy and Spain are two of the most affected countries worldwide, with, respectively, more than 29,000 and 25,000 reported deaths as of May 1 (European Centre for Disease Prevention and Control, 2020) since its spread. Spain has the world's second-highest number of deaths in relation to the number of inhabitants, with 544 deaths per million inhabitants, followed by Italy, with 481 deaths per million inhabitants, as of May 5 (European Centre for Disease Prevention and Control, 2020). Following the Chinese government's retarding the spread of COVID-19, quarantine was implemented in Italy and Spain, among other countries, starting on March 10 in Italy and 6 days later in Spain. School closure was mandatory, and gathering in public spaces, with certain exceptions, was prohibited. During school closures, children's routines change, and healthy behaviors, such as physical activity, adequate diet, or good sleep habits, could be less probable to happen (Brazendale et al., 2017). Also, as a recent review of studies concludes, the limited social interaction increases loneliness, which is associated with mental health problems in children and adolescents (Loades et al., 2020). However, the effect of closing schools as a measure to decrease virus transmission is inconclusive. According to a systematic review of studies focused on other previous coronavirus outbreaks, school closure did not seem to have a very determining effect compared to other social distancing measures, and following some COVID-19 modeling studies, school closure may only reduce between 2 and 4% of deaths (Viner et al., 2020). Esposito and Principi (2020) highlighted alternative strategies, such as reducing class size or physical distancing, considering the adverse effects of school closure on children and their families (e.g., the economic consequences for parents who remain at home to take care of their children, or problems in implementing distance learning in the poorest areas of some countries). However, a recent study examining parents of Czechia children show that families tend to cope well with education at home during the COVID-19 confinement, although they consider that children would need more time for learning activities (Brom et al., 2020). This is the first time that a quarantine to control a pandemic has been implemented in Italy and Spain, as well as in most countries worldwide. Therefore, there is a lack of conclusive studies providing data on how this measure can affect children and adolescents. Regarding the specific psychological consequences of COVID-19 and the measures to cope with them, few studies have been published. The psychological impact on the Chinese population after 2 weeks of quarantine was rated as moderate or brief by 53.8% of the 1,210 participants in a study with adults from 194 cities in China (Wang C. et al., 2020). Depression symptoms of moderate to severe severity were reported by 16.5% of participants, anxiety by 28.8%, and stress by 8.1%. The results of a study with 4,607 adults aged 17 to 90 years from 31 regions of China, however, reported slight changes in the frequency with which participants experienced negative and positive emotions before and after the COVID-19 imposed quarantine. Rather, some benefits were found, with reports of fewer sleep problems, fewer aggressive behaviors, and less alcohol and tobacco use during the quarantine. As the authors of the study point out, among other reasons, the quarantine was imposed just before the Chinese New Year holidays, when the majority of the population were at home with their families, thus having social support to reduce stress (Li et al., 2020). Concerning the specific stressors affecting the population during the quarantine, a review of 24 studies highlights as main stressors the duration of the quarantine, the fear of infection, frustration and boredom, and not having adequate information or clear guidelines from public authorities; as main stressors after the quarantine, having financial problems and the stigma for people who were infected or exposed to the disease were reported (Brooks et al., 2020).
To date, no studies have examined how the quarantine declared due to COVID-19 may affect children's and adolescents' emotional or behavioral well-being within Western countries. Some previous studies suggest that the effects may be troublesome. In a recently published study, 23% of Chinese school-age children reported depressive symptoms, and 19% reported anxiety symptoms after 34 days of COVID-19 confinement (Xie et al., 2020). A review of 190 studies with an American population concluded that, compared to vacation periods and weekends, by being more structured, class days give children more opportunities to be physically active, spend less time in front of screens, and regulate their sleep schedules (Brazendale et al., 2017). Post-traumatic stress is estimated to be four times higher in children who have been in quarantine compared to those who have not, and their likelihood of presenting acute stress disorder, adjustment disorder, and grief is also higher (Sprang and Silman, 2013). Among the possible consequences of the COVID-19 emergency, a main concern is suicidal ideation, as stressful life events are considered a psychosocial risk factor for suicidality (Carballo et al., 2020). Some authors have reflected on the possible effects of the COVID-19 quarantine on children and adolescents. Wang G. et al. (2020) highlight the need for awareness of the quarantine's potential effects on children's mental health and the importance for governments, non-governmental organizations, the community, schools, and parents to act to reduce the possible effects of this situation. Special attention should be paid to children and adolescents who are separated from their caregivers who are infected or suspected of being infected and those whose caregivers are infected or have died, because they are more vulnerable to psychological problems . It is very important to identify childhood mental health problems as soon as possible, differentiating normal and pathological reactions through the use of screening tools that may indicate the need for intervention Liu et al., 2020).
COVID-19 confinement changed the lives of most children and adolescents. Social relationships and academic routines were changed by virtual friends and distance learning; leisure was restricted to indoors as public spaces were closed. Italy and Spain had one of the most restrictive home confinement rules, not allowing children to go outside until 3 and 6 weeks, respectively, after the start of confinement. Although confinement was necessary to break the pandemic, the interruption of all social contact and the prohibition from going outside home could have had immediate effects in children and adolescents. Controversy in both countries arose over whether confinement would affect children or whether they could adapt to the new situation without being emotionally affected. Knowing if confinement has effects on the well-being of children would help professionals to implement preventive measures and governments, less strict confinement rules. Despite that, so far, we have not found any study that examines the effect in children and adolescents of the quarantine imposed by COVID-19 within Western countries. The available studies have been carried out with adult populations-hence, the results cannot be extrapolated to child populations-and with Chinese populations, whose cultural differences with the West make it difficult to generalize their findings. This study is the first to determine the immediate psychological responses in children and adolescents of the West to the quarantine imposed to put an end to COVID-19. The main objective of the study is to examine the emotional well-being of Italian and Spanish children aged between 3 and 18 who are in quarantine as a measure imposed by governments to prevent the transmission of COVID-19. Specifically, the aim is to know: (a) the immediate psychological responses in children and adolescents during the quarantine perceived by parents, (b) the emotional impact of the quarantine on children's primary caregivers, (c) the relationship between the parents' emotional state and their children's immediate psychological responses, (d) the change in children,s habits, and (e) the relationship between the parents' emotional state and the change in their children's habits. According to the only study carried out to date to examine the immediate effects of COVID-19 in children (Xie et al., 2020), and to findings with adult samples (e.g., Wang C. et al., 2020), it is expected that confinement affects the well-being of Italian and Spanish children, as it affected the Chinese population. Table 1 reports sample characteristics and differences in sociodemographic variables by country. Of the 1,143 participants, 62.3% were recruited from 94 cities in Italy, and the rest, from 87 cities in Spain. The respondents were aged 18 to 66 and were the primary caregiver of children aged 3 to 18 (47.5% were females). Most children were not diagnosed with a physical or psychological problem (89%). The caregivers' educational level was relatively high; more than half of them (61.9%) had attended college to earn an undergraduate degree, a Master's degree, or a Ph.D., and only 6.9% had basic studies. The mothers' and fathers' current employment situations varied. In many cases, the parents had a full-time job or smart-worked. Around 5% reported having lost their job because of the COVID-19 situation. More than half of the participants (69.4%) reported having some at-risk friends or family, but they did not live with them during the quarantine; only 9% belonged to an at-risk group.

Participants
The Italian and Spanish samples were equivalent, except for respondents' educational level, the mothers' or fathers' current employment situation, respondents' situation concerning COVID-19, children's age, and the proportion of children with physical or psychological problems ( Table 1). In the Spanish sample, there was a higher proportion of parents with postgraduate or doctoral studies or with secondary education than in the Italian sample. Compared to Spain, a higher proportion of Italian women were employed (84.3 vs. 94.8%), and they had part-time jobs (8.4 vs. 18.9%). The Italian children were slightly older than the Spanish ones (9.40 vs. 8.55 years), although the effect size was very low.

Procedure
Participants were recruited via social networks (Twitter, Facebook, WhatsApp, Instagram), as face-to-face contact was not allowed. An online survey was created ad hoc using Google Forms and distributed in each country using a snowball sampling strategy. Before participants completed the survey, information about the objectives of the study was provided, and informed consent was requested. Data were collected for 15 days in both countries, with the study starting 15 days after the lockdown. The approval of the Ethics Board of the authors' institution was obtained for the research.

Survey Development
Scientific literature related to the psychological impact of quarantine was reviewed by six experts in clinical psychology, and questionnaires applied in previous studies with adult populations were considered for creating the survey. After a pilot study with a group of parents was conducted, the final version of the questionnaire was structured in four sections, collecting information on: (a) the sociodemographics of parents and children (see Table 1); (b) parental perception on how quarantine emotionally affects children through 31 symptoms, ranging from 1 (much less compared to before quarantine) to 5 (much more compared to before quarantine), reaching a Cronbach's alpha of 0.95; (c) parents' perception of family coexistence during quarantine, severity of the situation caused by coronavirus with regard to the family's well-being, and parents' stress, on a five-point scale; and (d) children's routines: time of screen use, physical activity, and hours of sleep during quarantine compared to before.

Data Analyses
All analyses were performed with SPSS v.26 for Mac. Descriptive statistics were run to analyze participants' sociodemographic variables and other variables of interest for the study. Because the variables were not normally distributed (according to the Kolmogorov-Smirnov test, p < 0.05), non-parametric tests were used. Differences between Italy and Spain in sociodemographic variables, children's psychological responses, emotional impact on the children's primary caregivers, and the children's routines were analyzed using chi-square (χ 2 ) (categorical variables) and the Mann-Whitney U test (continuous variables). Bonferroni corrections applied to p values were used to reduce the risk of type I error. For example, considering α = 0.05 and the comparison of 31 symptoms between both countries, adjusted alpha was set at 0.0016. The odds ratio (OR) was reported for 2 × 2 tables. The effect size of the intergroup differences was calculated using the Rosenthal r statistic, which is interpreted according to the following ranges: 0.1, small; 0.3 medium; and 0.5, large (Rosenthal, 1991). Cramer's V was calculated as a measure of association between multi-categorical variables and interpreted as follows: >0.25, very strong; >0.15, strong; >0.10, moderate; >0.05, weak; and >0, none or very weak (Akoglu, 2018). Multivariate analyses were performed by generalized linear (GENLIN) modeling. For each child psychological reaction, GENLIN modeling was used to examine differences between both countries, adjusting for baseline differences, parents' age, and parental stress. GENLIN models for child routines were used to identify changes during home confinement, compared to before this period and between both countries during home confinement. All models were adjusted for baseline differences between both countries, parents' age, and parental stress (since this variable was the most related to child psychological reactions). All models were adjusted for sociodemographic differences between countries. Because of the ordinal nature of the variables, Spearman correlations were calculated to analyze the relationship between the primary caregivers' emotional effects due to COVID-19 and their children's psychological responses.
The relationship between changes in children's habits (time of screen use, physical activity, and hours of sleep) and parental variables (parents' perception of family coexistence during quarantine, severity of the situation caused by coronavirus with regard to the family's well-being, and parents' stress) was also analyzed using Spearman correlations. A new variable, "change, " was created by subtracting the score on the child routine variables at the time "before confinement" from that "during quarantine."

Parental Perception of the Emotional Effects of the Quarantine on Their Children
Nine hundred and eighty parents (85; 83.8 in Italy and 88.9% in Spain) observed changes in their children's emotional state and behaviors during the quarantine. The most common changes (present in at least 20% of the responses) were that, during quarantine, their children had more difficulty concentrating (76.6%), felt more bored than usual (52%), were more irritable (39%), were more restless (38.8%), were more nervous (38%), felt lonelier (31.3%), were more uneasy (30.4%), were more worried (30.1%), were more likely to argue with the rest of the family (29.7%), were more dependent on them (28%), were more anxious (28.4%), were angrier (25.9%), were more reluctant (24.7%), were sadder (23.3%), were afraid of COVID-19 infection (23.1%), were more worried when someone left the house (22%), and ate more than usual (21.9%). Table 2 details the percentage of primary caregivers who perceived changes in their children's emotional state and behaviors during the quarantine and the differences between Italy and Spain. Spanish children were significantly more psychologically affected than Italian children during the quarantine (88.9 vs. 83.8%; β = 0.38, SE = 0.19, Wald χ 2 95% CI [0, 0.77], p = 0.05), controlling for sociodemographic differences between samples  Primary caregivers reported that family coexistence during the quarantine was found to be moderately easy (M = 3.68, SD = 1.98, range = 1-5). Only 11.4% reported that family coexistence during the quarantine was difficult or very difficult, and more than half (61.8%) informed that family coexistence was easy or very easy. The neutral option was selected by 26.8%. The parents perceived the current situation due to COVID-19 to be quite serious (M = 3.63, SD = 0.96, range = 1-5). Approximately one-half (55.4%) perceived the situation to be serious or very serious. Only 11.6% considered the current situation to be a little serious or not serious. The rest (33%) perceived the situation to be somewhat serious. Parental level of stress was moderate (M = 3.18, SD = 1.02, range = 1-5). Approximately one-third of the parents (35.4%) reported being stressed or very stressed, and 39.4% chose the option "somewhat stressed." One in four (25.2%) parents indicated that they did not feel stressed because of the current situation. When comparing the data of Italy and Spain, adjusting for differences in sociodemographic variables between both countries, parents' age, and parental stress, no differences were observed in the perception of how easy it is for the family to live together during the quarantine (β = 0.04, SE = 0.06, Wald χ 2 95% CI [−0.07, 0.16], p = 0.43), how serious the current situation caused by the coronavirus is with regard to their well-being and their family's well-being (β = 0.04, SE = 0.05, Wald χ 2 95% CI [−0.06, 0.15], p = 0.41), and the level of parental stress (β = 0.02, SE = 0.06, Wald χ 2 95% CI [−0.10, 0.14], p = 0.72).

Relationship Between Primary Caregivers' Perception of COVID-19 and Their Children's Immediate Psychological Responses During the Quarantine
The primary caregivers' perception of how easy it is for the family to live together during the quarantine was related to 11 of the 31 child symptoms (Table 3). When family coexistence during the quarantine was rated as more difficult, the parents tended to rate their children as more restless, more anxious and uneasy, more nervous, more likely to argue with the rest of the family, angrier, more frustrated, more irritable, having more difficulty concentrating, presenting more behavioral problems, and less likely to be quiet (compared to before home confinement). Spearman correlations were indirect (except for being quiet) and low, ranging from −0.06 to −0.15.
Primary caregivers' perception of the seriousness of the current situation caused by the coronavirus with regard to their well-being and their family's well-being was associated with 15 of the 31 child symptoms. Caregivers who perceived the current situation as more serious with regard to their family's wellbeing tended to report that, during quarantine, their children were more concerned, were more restless, were more anxious, were sadder, were lonelier, were more nervous and uneasy, were more likely to argue with the rest of the family, cried more easily, were angrier, were more bored, had more difficulty concentrating, were more afraid of COVID-19 infection, and were more worried when one of them left the house (compared to before home confinement). Spearman correlations were direct and low, ranging from 0.06 to 0.15.
Primary caregivers' level of stress was related to 25 of the 31 child symptoms. Parents who perceived themselves as more stressed by the situation tended to report that, during quarantine, their children were more worried, were more restless, were more anxious, were sadder, were more reluctant, were lonelier, woke up more frequently, were more indecisive, were more uneasy, were more nervous, were more afraid to sleep alone, were more likely to argue with the rest of the family, cried more easily, were angrier, were more frustrated, were more bored, were more irritable, had more difficulty concentrating and sleeping, were more easily alarmed, were more afraid of COVID-19 infection, were more dependent on them, had more behavioral problems, and were more worried when one of them left the house (compared to before home confinement). Spearman correlations were direct, ranging from low (ρ = 0.07) to moderate (ρ = 0.26). However, parental stress was indirectly related to being quiet, suggesting that parents who are more stressed perceive their children as being less quiet, although this correlation was low (ρ = −0.06).
Differences between Italy and Spain were found in the use of screens during the quarantine (β = −0.83, SE = 0.13, Wald χ 2 95% CI [−1.01, −0.56], p < 0.001). During the quarantine, Spanish children tended to spend more time using screens than did Italian children, such that 89.7% of the Spanish children used screens for at least 60 min per day, whereas 81.6% of the Spearman correlations indicated that changes in child routines were related to parental perception on how easy it is for the family to live together during the quarantine, parental perception on how serious the situation is, and parental stress. When family coexistence during the quarantine was rated as easier, parents informed that their children tended to spend more time doing physical exercise (ρ = 0.08; p = 0.004). For parents who perceived the situation as more serious, their children made more use of screens (ρ = 0.07; p = 0.01) during quarantine compared to the rest. Parents with higher levels of stress tended to report that their children made more use of screens (ρ = 0.05; p = 0.01), spent less time on physical activity (ρ = −0.10; p ≤ 0.001) and slept fewer hours than the rest (ρ = −0.12; p ≤ 0.001). When the Italian sample was selected, changes in child routines were related to parental perception on how serious the situation is and parental stress. Parental perception of how easy coexistence is during quarantine was not related to changes in child habits during home confinement. Parents who perceived the situation as more serious had children who made greater use of screens (ρ = 0.10; p = 0.008), compared to the rest. Parents who were more stressed by the situation reported that their children slept fewer hours compared to the rest (ρ = −0.08; p = 0.02).
When the Spanish sample was selected, changes in child routines were related to parental perception on how easy it is for family to live together during quarantine and parental stress. When family coexistence during the quarantine was rated as easier, parents informed that their children tended to spend less time using screens (ρ = −0.09; p = 0.04), spend more time doing physical exercise (ρ = 0.16; p = 0.001), and sleep more hours (ρ = 0.11; p = 0.02). Parents who were more stressed by the situation reported that their children spent less time doing physical activity (ρ = −0.22; p ≤ 0.001) and slept fewer hours compared to the rest (ρ = −0.08; p = 0.02).

DISCUSSION
This study is the first one developed to examine the psychological impact of the COVID-19 quarantine on children and adolescents of the West. Italy and Spain are two of the countries most affected worldwide by COVID-19, and the emotional wellbeing of youth needs to be explored to provide parents and caregivers with guidelines to reduce the impact of the quarantine on their children.
Results indicate that 85.7% of the parents reported changes in their children's emotional state and behaviors during the quarantine. The most frequent symptom was difficulty concentrating, with 76.6% of the parents reporting this symptom. Boredom, irritability, restlessness, nervousness, feelings of loneliness, and being more uneasy and more worried were reported by more than 30% of parents. As expected, and according to the study of Xie et al. (2020) with Chinese children, the COVID-19 confinement also impacts negatively on the Italian and Spanish children's well-being. Results by country show that Spanish children were more affected than Italian children on most symptoms. Although more research is needed to clarify this finding, the permission given on March 31 by the Italian government to parents to take under-18-year-old youths for a short walk (access to parks, gardens, and all kinds of public spaces is still not allowed) might explain the differences between Spain and Italy. Whereas in Italy, after 3 weeks of home confinement, children were allowed to go out for a short walk close to home accompanied by one adult, in Spain, children could only go outside for a justified reason. Furthermore, many more Italian homes have gardens compared to Spanish homes (52 vs. 18%), so this provided children with the opportunity to be more active, benefiting their mental well-being. These differences in rules and the characteristics of the homes of the two countries may explain why Spanish children showed a worse behavioral and emotional response to the quarantine. Staying at home without the chance to go outside may increase responses of anxiety and other related problems such as sleep problems, physical complaints, and worries and also behavioral problems that involve the family, such arguing with other relatives, maybe because the children need to be more physically active. In contrast, Italian children were perceived by their parents as sadder, and lonely, maybe due to the longer duration of the quarantine in Italy compared to Spain. As expected, routines also changed during the quarantine for the children of both countries, spending more time using screens, spending less time doing physical activity, and sleeping more hours. For instance, during the quarantine, only 14.8% of the youth practice at least 60 min of physical activity, as recommended by the WHO for children between 5 and 17 years old, compared to before the quarantine, when that percentage reached 54.1%. In accordance with a review of studies that observed differences in habits between weekdays and vacation days, the present study found more healthy routines in youth before the quarantine (Brazendale et al., 2017). This finding is also in line with other reflections that warn about the consequences of children's home confinement, specifically affecting not only their mental well-being but also their weight status and the risk of increasing screen time (Lancet Child Adolescent Health, 2020).
Although only 11.4% of the Italian and Spanish parents informed that family coexistence was difficult or very difficult, most parents perceived the situation due to COVID-19 as serious or very serious, and one-third of the parents reported being stressed or very stressed, with no differences between the two countries. Furthermore, parents' perception of COVID-19 seems to be related to their children's psychological symptoms during the quarantine. When family coexistence during the quarantine was more difficult, the situation was more serious, or the level of stress was higher, parents tended to report more emotional problems in their children; specifically, the primary caregiver's level of stress was related to 25 of the 31 child symptoms. Child routines were also related to the parents' perception of COVID-19. Specifically, a higher level of parental stress was related to more use of screens, less time of physical activity, and fewer hours of children's sleep. Different correlation patterns between children's routines and parental variables were found in Spain and Italy, although parental stress was common in both. Although a causal relationship cannot be confirmed, it is expected that children's behavioral problems will negatively affect the family climate, and also, parents with a high level of stress may apply more inconsistent discipline with their children.

CONCLUSION
COVID-19 quarantine impacts considerably on Italian and Spanish youth's lives, and most parents perceive changes in their children's emotional state and behaviors during the quarantine compared to before the quarantine. Spanish children show more emotional and behavioral symptoms compared to Italian children, as reported by their parents, possibly because Italian youth have more opportunities to be more physically active. The emotional and behavioral symptoms of children from both countries seem to be positively related to the parents' wellbeing, specifically to their level of stress. On the basis of these findings, we can conclude that children and parents are both affected by such a stressful situation as the quarantine. The present study has some limitations. Although a multi-informant method would be desirable, self-reports were not adequate for the youngest children. As a main objective of this study was to evaluate emotional and behavioral changes in children before and during confinement, assessing for themselves whether they manifested each symptom more or less frequently was not considered adequate for children. Also, as behavioral symptoms were included in the survey (such as arguing with the rest of the family, restlessness, or irritability), it was considered that the parents were better informants than the children. Despite this limitation, this study is the first providing data on the psychological repercussions of the COVID-19 quarantine on children and adolescents from Western countries. Some practical implications can be derived from the results. First, the obtained data could help governments to decide the confinement rules to apply to children to preserve their mental health (such as considering the importance of going out for daily walks). Second, our results could guide parents and caregivers. For example, as being worried when parents leave home is common in children under confinement, clear and age-appropriate information could reduce their uncertainty and concerns. Also, since the greater the stress of the parents, the more symptoms in the children, not expressing frequent concerns in front of their children could help parents to protect their mental health. Finally, professionals should be alert to the more common psychological responses of youth to detect the need for intervention as early as possible. Vulnerable children and adolescents, including those with risk factors, should receive special attention . In line with this, as Liu et al. (2020) recommended, receiving training to detect children's psychological problems should be a main objective for pediatric health-care workers. Also, programs focused on providing children with psychosocial skills could help them cope with the COVID-19 situation .

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request. Requests to access the datasets should be directed to MO, morgiles@umh.es.

ETHICS STATEMENT
The studies involving human participants were reviewed and approved by the Ethics Board of the Miguel Hernández University of Elche. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.

AUTHOR CONTRIBUTIONS
MO designed the study and the survey. AM managed and analyzed the data. ED designed the Italian survey and collected the data. CM participated in the Italian survey adaptation and collected data. JE designed this study and wrote the draft of this article. All the authors reviewed the draft and contributed to the final version of the manuscript.

FUNDING
This work was supported by the Ministry of Science and Innovation of Spain and the European Regional Development Fund (PSI2017-85493-P).