Evolution of intersectional perceived discrimination and internalized stigma during COVID-19 lockdown among the general population in Spain

Abstract

Background
Stigma and discrimination have been associated with different diseases and pandemics, with negative consequences for the people who suffered them and for their communities. Currently, COVID-19 has become a new source of stigmatization.

Aims
The aim of the present study is to analyze longitudinally the evolution of intersectional perceived discrimination and internalized stigma among the general population of Spain, at three points in time throughout the confinement.

Method
Participants completed an online survey.

Results
Results show an increase in both variables from the first to the second evaluation, and a slight decrease from the second to the third evaluation. Moreover, these changes are explained by depression, anxiety and family support.

Conclusions
These findings indicate the factors that need to be considered to reduce the perception of discrimination and the internalization of stigma, and their detrimental consequences, during an especially stressful event such as the current pandemic outbreak.

Full text

https://doi.org/10.1177/0020764020975802
International Journal of
Social Psychiatry
2022, Vol. 68(1) 55 –63
© The Author(s) 2020
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sagepub.com/journals-permissions
DOI: 10.1177/0020764020975802
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E
CAMDEN
SCHIZOPH
Introduction
The outbreak of COVID-19 has promoted the application of
unprecedented measures in many countries. In relation with
the evolution of the situation in Spain, the state of emergency
was declared on March 14 and drastic isolation measures
were applied to all citizens. From March 30 to April 12, all
work not considered essential was suspended, aggravating
the already existing economic crisis. On May 4, the country
began opening up and the lockdown measures were gradually
lifted through June 21, when the country began a period
called the ‘new normality’. At the beginning of July, more
than 250,000 people had been infected in Spain, which was
leading Europe in the number of cases, with more than 28,000
deaths (Health Alert and Emergency Coordination Centre,
Government of Spain, 2020). The psychological conse-
quences of this situation for the Spanish population include
grater psychological distress, PTSD, depressive symptoms,
higher levels of stress, anxiety, loneliness, and perceived dis-
crimination (González-Sanguino et al., 2020a, 2020b).
Evolution of intersectional perceived
discrimination and internalized stigma
during COVID-19 lockdown among the
general population in Spain
Carolina Ugidos1, Aída López-Gómez2, Miguel Ángel
Castellanos3, Jesús Saiz1, Clara González-Sanguino4,
Berta Ausín4 and Manuel Muñoz4
Abstract
Background: Stigma and discrimination have been associated with different diseases and pandemics, with negative
consequences for the people who suffered them and for their communities. Currently, COVID-19 has become a new
source of stigmatization.
Aims: The aim of the present study is to analyze longitudinally the evolution of intersectional perceived discrimination
and internalized stigma among the general population of Spain, at three points in time throughout the confinement.
Method: Participants completed an online survey.
Results: Results show an increase in both variables from the first to the second evaluation, and a slight decrease from
the second to the third evaluation. Moreover, these changes are explained by depression, anxiety and family support.
Conclusions: These findings indicate the factors that need to be considered to reduce the perception of discrimination
and the internalization of stigma, and their detrimental consequences, during an especially stressful event such as the
current pandemic outbreak.
Keywords
Intersectional discrimination, internalized stigma, COVID-19
1 Chair Against Stigma Grupo 5-Complutense University of Madrid,
School of Psychology, Department of Social, Labor and Differential
Psychology, Complutense University of Madrid, Madrid, Spain
2 Chair Against Stigma Grupo 5-Complutense University of Madrid,
School of Psychology, Complutense University of Madrid, Madrid,
Spain
3
Chair Against Stigma Grupo 5-Complutense University of Madrid,
School of Psychology, Psychobiology and Methodology in Behavioral
Sciences Department, Complutense University of Madrid, Madrid,
Spain
4 Chair Against Stigma Grupo 5-Complutense University of Madrid,
School of Psychology, Personality, Evaluation and Clinical Psychology
Department, Complutense University of Madrid, Madrid, Spain
Corresponding author:
Carolina Ugidos, Chair Against Stigma Grupo 5-Complutense
University of Madrid, School of Psychology, Department of Social,
Labor and Differential Psychology, Complutense University of Madrid,
Campus de Somosagua, Ctra. de Húmera, s/n, 28223 Pozuelo de
Alarcón, Madrid 28040, Spain.
Email: cugidos@ucm.es
975802ISP0010.1177/0020764020975802International Journal of Social PsychiatryUgidos et al.
research-article2020
Original Article

56 International Journal of Social Psychiatry 68(1)
Stigma is a devaluating attribute that has negative conno-
tations for the stigmatized person, producing discredit associ-
ated with a disadvantage (Goffman, 1963). Stigmatization
often occurs towards certain social minorities, as well as
being associated with health problems in diseases that tradi-
tionally, mainly due to ignorance, have generated fear and
suspicion, such as AIDS or mental health problems (Eaton
et al., 2018; Pescosolido, 2013). Stigma can be divided into
three components in constant interaction: stereotypes (knowl-
edge structures about people in different groups), prejudice
(negative emotions produced when those stereotypes are
applied to that group), and discrimination (rejection behav-
iors directed towards that group) (Ottati et al., 2005). In addi-
tion, having multiple identities or social roles can cause
intersectional discrimination (Crenshaw, 1989). In other
words, the different categories of identity can co-exist and
cross over into the same individual, giving rise to an experi-
ence (McCall, 2005) with a multiplying effect due to the
interaction of the categories. On the other hand, it is also pos-
sible to talk about internalized stigma or self-stigma. This
concept refers to the stigma that each person feels when inter-
nalizing the stereotypes and beliefs about the stigma associ-
ated with various conditions (Corrigan & Watson, 2004).
Currently, the recent appearance of the COVID-19 pan-
demic and the complicated socioeconomic and health situ-
ation that it has generated worldwide may be a source of
stigmatization, as a certain amount of coronaphobia has
already appeared (Asmundson & Taylor, 2020; He et al.,
2020). For example, people who have just been diagnosed
with COVID-19 may suffer discrimination at the social
level and also internalize these beliefs and apply them to
themselves (for instance, thinking that the disease is their
responsibility or that, because of it, they may be dangerous
and rejected). This can generate emotions of self-preju-
dice, such as feelings of guilt, shame or sadness, which
will end up conditioning their behavior.
The effects of discrimination and internalized stigma
are numerous, including work stress, mental disorders
(Moya & Moya-Garófano, 2020), anxiety, depression,
substance abuse (Burgess et al., 2008), and lower self-
esteem and wellbeing (Pascoe & Richman, 2009). These
consequences may be especially severe in the context of a
disease outbreak. As outlined by Brooks et al. (2020) in
their review, people who are infected may delay seeking
care for fear of being discriminated (Person et al., 2004).
Moreover, discriminatory behavior and stigmatization
towards health professionals (Desclaux et al., 2017) and
minority groups (Pellecchia et al., 2015) was found in pre-
vious epidemics. In the COVID-19 context, Singh and
Subedi (2020) note that not only those patients that cur-
rently have COVID-19 and healthcare providers, but also
those who have recovered from the disease are facing dis-
crimination. In some cases, they have been denied entrance
to communities for fear of transmitting the virus to others.
In addition, it should be noted that political leaders have
misappropriated the COVID-19 crisis to reinforce racial
discrimination (Devakumar et al., 2020).
Considering the consequences, it is important to know
which factors influence these variables. Among the psycho-
social variables found to be related to stigma and discrimi-
nation, social support appears to be particularly relevant,
especially due to the isolation caused by the lockdown
measures adopted to prevent the spread of COVID-19.
Social support has shown to be a protective variable against
the effects of discrimination for different groups (Cristini
et al., 2011; Seawell et al., 2014), and even in the context of
this pandemic it has demonstrated that it reduces the psy-
chological impact of this stressful situation (Lei et al., 2020).
Similarly, in Spain, previous research has shown that rela-
tionship between perceived discrimination and social sup-
port in a sample of family caregivers of children with
intellectual disabilities (Recio et al., 2020), and between
internalized stigma and support from friends, coworkers,
and health care providers in people living with HIV
(Garrido-Hernansaiz & Alonso-Tapia, 2017). Furthermore,
several studies point to the effect of discrimination and
stigma on depression and anxiety (Burgess et al., 2008;
Moya & Moya-Garófano, 2020). For instance, in Spain, this
association has been found in people with obesity
(Magallares et al., 2017), in people with dwarfism
(Fernández et al., 2012), and in people with schizophrenia
(González et al., 2018). Research, however, does not usually
focus on the effect that cognitive biases produced by depres-
sion and anxiety (Beck, 2008) could have on the perception
of discrimination and the internalization of stigma.
Although several scientific articles have drawn atten-
tion to the possible increase of stigma and discrimination
due to COVID-19 (Asmundson & Taylor, 2020;
Devakumar et al., 2020; Logie & Turan, 2020; Singh &
Subedi, 2020; Teixeira da Silva, 2020; Zhai & Du, 2020),
only one study has been published that assesses the impact
of the pandemic and the resulting crisis situation on dis-
crimination and stigmatization of persons of Chinese
nationality across 70 countries (He et al., 2020). The find-
ings show that 25.11% of participants reported to have
experienced different forms of discrimination. Women,
young people and those who are less educated are more
likely to experience discrimination and even violent over-
reactions, while people with permanent resident status are
less likely to report such experiences. Interestingly,
respondents living in countries with a high number of con-
firmed cases of COVID-19 are less likely to report cases of
discrimination and overreaction. Social stigma reduces the
likelihood that infected people will come forward for help,
preventing medical practitioners from effectively contain-
ing and treating the disease in the early stages.
To our knowledge, no longitudinal studies have been
published assessing discrimination and internalized stigma
during the state of alarm declared to contain COVID-19.
The present study aims to conduct a longitudinal analysis

Ugidos et al. 57
of the evolution of intersectional perceived discrimination
and internalized stigma among the general population of
Spain at three points in time: 2 weeks after the beginning
of the confinement, 1 month after the beginning, and
2 months after, when the country began lifting restrictions
and returning to the ‘new normality’.
Method
Procedure
The longitudinal study took place between March 21 and 29
(first evaluation), between April 13 and 27 (second evalua-
tion) and between May 21 and June 4 (third evaluation).
Data was collected online through Google Forms in an
attempt to reach the maximum population possible. The first
survey consisted of 80 items (15 minutes long). At the end of
the questionnaire, a section was included describing the
research, as well as the consent form to participate in the
study and acceptance of the data protection laws regarding
the regulation (EU) 2016/679 of the European Parliament
and of the Council, of 27 April 2016, on the protection of
personal data. Participants were given the possibility of
completing the second and third evaluation. Those who
agreed received the survey via email during the second and
third data collection periods.
Participants
The sample was recruited by sending requests for participa-
tion to people belonging to databases of different institu-
tions: students and workers in public organizations, such as
Complutense University of Madrid and the Chair for
Stigma, and private organizations, such as the company
Group 5. These databases are complete enough to make a
reasonable sampling of the Spanish population. To increase
the sample size as much as possible participants were asked
to help with its dissemination. The percentage of people
recruited in this way was small, estimated at less than 5%.
The sample of the first evaluation had 3,480 participants,
made up of the general population. Participants were given
the opportunity to take part in subsequent surveys by pro-
viding their email on the first questionnaire. After contact-
ing all the participants who agreed to be part of the second
evaluation, 1,041 people answered the second question-
naire. Similarly, 568 people participated in the third and last
survey. The inclusion criteria for the three rounds were: to
be over 18 years of age, and to be living in Spain during the
COVID-19 state of emergency. In the resulting sample, a
majority of women (81%) was obtained as opposed to 51%
of the general population. With respect to age, a greater
equivalence was obtained, although with a higher percent-
age of people under 60 years than in the general population:
29% (18–30), 64% (31–59), and 7% (60–80) for the three
respective groups, compared to 10%, 44%, and 19% for the
general population (the remaining 5% do not meet the crite-
ria for inclusion/exclusion). The influence of these differ-
ences is discussed in the discussion section.
Variables and instruments
The following variables and instruments were included in
the assessment:
Sociodemographic variables. Using ad hoc questions, data
was collected on age (subsequently grouped into clusters:
18–30, 31–59, 60–80); gender identity; marital status (sin-
gle, married, divorced, separated, widower); educational
level (elementary studies, high school, vocational training,
university, postgraduate); economic situation (subjective
perception from very bad to very good).
COVID-19 related variables. Suffering from symptoms (yes,
no); existence of a family members or close relatives who
are infected (yes, no); perception of the information
received on the alarm situation (considering that they have
sufficient information, or that they are over-informed).
Intersectional discrimination. Intersectional discrimination
was evaluated by means of the Intersectional Day-to-Day
Discrimination Index (InDI-D) (Scheim & Bauer, 2019), in
its Spanish version, which was translated by the authors of
this study. This scale provides a measure of the intersec-
tional discrimination that can be produced by different con-
ditions: gender, ethnicity, mental health diagnosis, and in
this case, the presence of COVID-19 was also included. We
used the main scale formed by 9 Likert-type items (e.g.
‘Since the sanitary emergency caused by COVID-19 in
Spain, have you been treated as if you were someone hos-
tile, unhelpful or rude?’) with four response options (1
‘never’ – 4 ‘many times’). The different questions evaluated
the presence of intersectional discrimination from the begin-
ning of the alarm situation generated by the coronavirus.
The higher the score the more discrimination suffered. The
adjusted ICC for test-retest reliability of the original version
was 0.70 (95% CI: 0.62, 0.78). For the Spanish version, the
scale’s consistency was adequate (α = 0.76).
Internalized stigma. Internalized stigma was evaluated with
two items adapted from the Internalized Stigma of Mental
Illness (ISMI) scale (Boyd Ritsher et al., 2003). The items
(‘Since the emergency situation generated by the coronavi-
rus, have you avoided contacting people – in those cases
permitted during lockdown – to avoid rejection?’; ‘Since
the emergency situation generated by the coronavirus,
have you felt that the people who are not in your situation
are unable to understand you?’) were modified to evaluate
intersectional internalized stigma, the self-stigma that can
be generated by diverse conditions. These items refer to
the alienation and social withdrawal dimensions taken

58 International Journal of Social Psychiatry 68(1)
from the original scale. It was evaluated with the same
Likert-type scale as the one used to measure the intersec-
tional perceived discrimination.
Social support. Social support was evaluated by means of the
Multidimensional Scale of Perceived Social Support
(EMAS) (Zimet et al., 1988), adapted to a Spanish version
(Landeta & Calvete, 2002). The scale, made up of 12 Likert-
type items with 7 possible responses (1 ‘totally disagree’–7
‘totally agree’), evaluates the levels of perceived social sup-
port, identifying where the support comes from and how it is
perceived. The EMAS explores three possible sources of
perceived social support: family (4 items), friends (4 items),
and relevant people (4 items), and offers a full measure of
social support. Cronbach’s α is 0.89 for the Spanish
version.
Mental health. Mental health was assessed with the PHQ-4
composed by the Patient Health Questionnaire 2 (PHQ-2)
(Kroenke et al., 2009) and the Generalized Anxiety Disorder
Scale (GAD-2) (Spitzer et al., 2006). The PHQ-2 was used in
its Spanish version (Diez-Quevedo et al., 2001) and is a brief
self-report questionnaire that addresses the frequency of
depressive symptoms. It consists of 2 Likert-type questions
ranging from 0 ‘never’ to 3 ‘every day’. Higher scores indi-
cate greater symptomatology, providing a severity score that
ranges from 0 to 6. A score of >3 points was established as
the cut-off point indicating a possible case of depression
(Muñoz-Navarro et al., 2017). The original scale presented a
sensitivity of 0.9 and a specificity of 0.61 (Kroenke et al.,
2009). GAD-2 was also used in its Spanish version (Garcia-
Campayo et al., 2014). The GAD-2 Questionnaire includes
the first two items of the GAD-7 Likert format, with a maxi-
mum score of 6 points. The cut-off point in this case is 3,
above which possible anxiety is indicated (Muñoz-Navarro
et al., 2017). The sensitivity of the original test was 0.88,
with a specificity of 0.61.
Analysis
To analyze the effect of longitudinal measures, linear
mixed models were calculated for perceived discrimina-
tion and internalized stigma. As data contain missing val-
ues (participants who did not respond to successive
surveys), the random effects were calculated as random
slopes (without random intercepts) so that the models
could be estimated. The predictor variables that varied
across time were considered as non-correlated. The results
include the value of Nakagawa’s Psuedo-R2 (both mar-
ginal and conditional). The marginal R2 considers exclu-
sively the variances of the fixed component while the
conditional R2 considers both the fixed and random
effects. Moreover, post hoc comparisons were calculated
using the estimated marginal means with the Tukey adjust-
ment. The analyses have been performed using R (v3.5.6)
with the lme4 and emmeans packages.
The study was approved by the Deontological Commis-
sion of the Faculty of Psychology of the Complutense
University of Madrid with reference ‘pr_2019_20_029’.
Results
Sociodemographic and COVID-19 data
The sample is mostly formed by women (80%), people aged
between 31 and 59 years (64%), those who are single (52%),
have a university degree (38%) and a good or very good
perceived economic situation (60%). Regarding COVID-19
variables, the majority of the participants did not have
symptoms of COVID-19 (80%), nor a diagnosed relative
(70%), and most of them considered they have received
enough information about this disease (58%). The percent-
age of these variables remains fairly stable across the three
evaluations. This information can be found in Table 1.
Table 1. Sociodemographic and COVID-19 data.
T0 T1 T2
N (%) N (%) N (%)
Gender
Female 2,584 (75%) 841 (81%) 453 (81%)
Male 860 (25%) 202 (19%) 104 (19%)
Age
18 to 30 1,216 (35%) 306 (29%) 148 (27%)
31 to 59 2,035 (59%) 670 (64%) 364 (65%)
60 to 80 200 (6%) 69 (7%) 46 (8%)
Marital status
Single 1,900 (55%) 542 (52%) 268 (48%)
Married 1,231 (36%) 386 (37%) 227 (41%)
Divorced 214 (6%) 82 (8%) 42 (8%)
Separated 67 (2%) 28 (3%) 17 (3%)
Widower 39 (1%) 7 (1%) 4 (1%)
Education
Elementary 98 (3%) 15 (1%) 6 (1%)
High school 599 (17%) 149 (14%) 69 (12%)
Vocational training 439 (13%) 125 (12%) 68 (12%)
University 1,294 (37%) 401 (38%) 216 (39%)
Postgraduate 1,021 (30%) 355 (34%) 199 (36%)
Perceived economic situation
Bad-very bad 348 (10%) 111 (11%) 58 (10%)
Good-very good 1,975 (59%) 621 (60%) 359 (65%)
Neither good nor bad 1,042 (31%) 304 (29%) 137 (25%)
COVID-19 symptoms
No 2,974 (86%) 836 (80%) 445 (80%)
Yes 477 (14%) 209 (20%) 113 (20%)
COVID-19 diagnosis for a relative
No 2,474 (72%) 638 (61%) 380 (68%)
Yes 977 (28%) 407 (39%) 178 (32%)
Information received about COVID-19
Insufficient 614 (18%) 184 (18%) 96 (17%)
Good 1,983 (57%) 594 (57%) 326 (58%)
Over-informed 854 (25%) 267 (26%) 136 (24%)

Ugidos et al. 59
Longitudinal changes on intersectional
discrimination and internalized stigma
As shown in Figure 1, from the first to the second evalu-
ation, results show a significant increment in intersec-
tional discrimination (Z(T0-T1) = 15.02, p < .001) and
internalized stigma (Z(T0-T1) = 16.27, p < .001).
However, there is a small decrease in internalized
stigma (Z(T1-T2) = 2.36, p = .047) between the second
and third evaluation, while the difference in intersec-
tional discrimination is not significant (Z(T1-T2) = 0.34,
p = .936).
Linear mixed models
The model for intersectional discrimination explains
10% of the variance of the fixed effects, with depressive
and anxious symptomatology and less family support as
the main predictors. These results can be observed in
Table 2. On the other hand, the model for internalized
stigma, as shown in Table 3, explains 14% of the vari-
ance of the fixed effects, also with depressive and anx-
ious symptomatology and less family support as the
main predictors.
Discussion
This is the first longitudinal study that analyzes the evolu-
tion of intersectional perceived discrimination and inter-
nalized stigma among the general population of Spain. The
results show their evolution during the confinement period,
and the variables that influence them. Specifically, the
findings obtained indicate the effect of mental health and
family support on the development of both dependent
variables.
From the first to the second evaluation, results show a
significant increase in intersectional discrimination and
internalized stigma. However, there is a small decrease in
internalized stigma between the second and third evalua-
tion, while the difference in intersectional discrimination
is not significant. These results can be explained by the
fact that the first data collection took place when the
increase of COVID-19 infections among the Spanish pop-
ulation started. During the first month of confinement the
number of COVID-19 infections increased exponentially,
which may have caused more people to experience dis-
crimination for being infected or for other reasons. These
could include loss of employment, the need for many peo-
ple to stay at home and give up a job to be able to reconcile
Figure 1. Longitudinal changes on intersectional perceived discrimination and internalized stigma.

60 International Journal of Social Psychiatry 68(1)
caring for children and other family members, living in
places with a high percentage of infected people (such as
Madrid or Catalonia), being a worker at high risk of infec-
tion such as healthcare professionals or supermarket cash-
iers, among others. It should also be noted that although
there are no pre-pandemic measures on stigma, the trends
found show that discrimination and internalized stigma
increase with the evolution of the crisis, decrease with the
beginning of recovery and return to normal, although with-
out returning to previous levels.
The variables that best predict perceived intersectional
discrimination and internalized stigma are depression and
anxiety, and less family support. These results could be
explained by the fact that family support is a protective vari-
able, allowing people to feel included in a family nucleus.
Social support can buffer the harmful effects of stressful
events by providing a sense of acceptance and self-worth
(House, 1981), and thus reducing internalized stigma.
Similarly, family support could influence the appraisal of
stigmatizing events (Aspinwall & Taylor, 1997), decreasing
the perception of discrimination. Only family support, not
support from other sources, has an impact on these variables.
This might occur due to the confinement. During this period
people could only interact in person with the people living
with them, who, in most cases, are their relatives. Several
studies have shown the protective effect of social support for
different groups of people, such as immigrant adolescents or
African-American women (Cristini et al., 2011; Seawell
et al., 2014). Likewise, Ahuja et al. (2020) found collectivis-
tic tendencies (feeling of belongingness, greater strength of
social connections and importance given to needs of one’s
family) buffer the levels of uncertainty and stress caused by
this infectious disease. Other studies also point to the reduced
impact of psychosocial stressors on individuals with better
social support from their family and social networks (Lei
et al., 2020). In order to mitigate the effects of social isola-
tion, in Spain, mutual support networks have been activated
in various neighborhoods across the country. This is not new
in the Spanish background, in which the neighborhood and
its associative fabric became an agent of resistance against
the vulnerabilities produced by the 2008 crisis (Cano-Hila &
Argemí-Baldich, 2020). In this context, the neighborhood is
understood as a space for strengthening social capital,
solidarity, community building, and social cohesion
(Blokland, 2017; Kennett & Forrest, 2006).
As for the variables of depression and anxiety, previous
research conducted in Spain has found how discrimination
was related to a greater psychological impact (González-
Sanguino et al., 2020a, 2020b). In this regard, some authors
such as Beck (2008) explain that depressed patients show a
tendency to develop highly dysfunctional attitudes that can
‘misappropriate’ information processing by producing cog-
nitive biases. Similarly, in the research carried out by
Caouette and Guyer (2016), the relationship between depres-
sion and emotional responses of social acceptance and rejec-
tion was studied. The results showed that depression
interfered through attenuated cognitive response to social
acceptance and rejection. In other words, cognitive biases
seemed to contribute to this emotional insensitivity context.
Thus, ‘the individual affectively “disengages” from valenced
social feedback in anticipation of harmful outcomes’. These
biases could explain the greater perception of discrimination,
and consequently, the internalization of the stigma.
Various agencies and scientific publications have made
recommendations and launched campaigns to combat the
stigma associated with the pandemic (IFRC, UNICEF, &
WHO, 2020; Singh & Subedi, 2020) In general, recom-
mendations and actions taken often stress the importance
of being careful of the language used when talking about
the disease, avoiding the spread of false news and being
careful with communication, disseminating precise infor-
mation related to COVID-19 to the public, facilitating the
request for help and, in general, providing comprehensive
support to frontline healthcare providers both from admin-
istrators and society. This is in line with the Health Stigma
and Discrimination Framework, which posits once stigma
is applied to people with a specific disease, such as
COVID-19, interventions have to shift harmful attitudes
and behaviors that compromise the health and wellbeing of
affected communities (Stangl et al., 2019). Furthermore,
based on the findings attained in this study, it would be
recommendable to enable the creation of support networks
(through online means if there are mobility restrictions),
especially for people who are not living with their families
during the confinement, and facilitate the access to psy-
chological treatment for depression and anxiety.
Table 2. Linear mixed model for intersectional perceived
discrimination.
Fixed effects: mean sq df1df2F p
Time 189.52 1 1,027.9 107.57 <.001***
PHQ4 353.35 1 4,642.3 200.57 <.001***
SS-family 194.61 1 4,707.1 110.46 <.001***
Random effects Pseudo-R2
Time|id 0.131 Conditional 0.341
Residual 0.458 Marginal 0.108
*p < 0.05, **p < 0.01, ***p < 0.001.
Table 3. Linear mixed model for internalized stigma.
Fixed effects: mean sq df1df2F p
Time 58.15 1 1,048.7 126.73 <.001***
PHQ4 174.73 1 4,816.5 380.82 <.001***
SS-family 45.04 1 4,870.0 98.15 <.001***
Random effects Pseudo-R2
Time|id 0.131 Conditional 0.280
Residual 0.458 Marginal 0.144
*p < 0.05, ** p < 0.01, ***p < 0.001

Ugidos et al. 61
As limitations of this study, we include the loss of par-
ticipants throughout the assessments, especially in the
third evaluation, which may be a sign of a return to nor-
mality and loss of interest in the phenomenon. Moreover,
as indicated in the participants section, despite the effort in
recruitment, the resulting sample is not exactly equivalent
to the Spanish population. This fact does not distort the
results found, since the objective is not to provide epide-
miological information or prevalence data but to compare
the averages obtained by various social groups in the vari-
ables of interest and to analyze the differential change
between temporal measures. In this sense, as long as the
sample meets the requirements of the statistical tests used,
we believe it is valid for the study. However, it is necessary
to be careful in the interpretation of the results and under-
stand that they are limited by the characteristics of the
sample obtained.
Despite these limitations, this is the first longitudinal
study analyzing the evolution of intersectional perceived
discrimination and internalized stigma during a pandemic
outbreak. The results presented show new consequences
derived from the pandemic related to the phenomenon of
stigmatization, and remind us of the need to address this
phenomenon by understanding its key variables.
In conclusion, the findings obtained in this study have
important implications in the developing of effective strat-
egies to tackle the study variables. More specifically, it is
necessary to reduce depression and anxiety, and boost
family support in order to buffer the perception of discrim-
ination and internalization of stigma, and thus their detri-
mental consequences.
Acknowledgements
Our gratefulness to the Chair Against Stigma Grupo
5-Complutense University of Madrid for their help in the collec-
tion of the sample for this study.
Authors’ contributions
All authors contributed to the study conception and design.
Material preparation was done by Jesús Saiz, Clara González-
Sanguino and Berta Ausín; data collection was performed by
Carolina Ugidos and Aída López-Gómez; and the statistical anal-
ysis was conducted by Miguel Ángel Castellanos. The first draft
of the manuscript was written by Carolina Ugidos and Aída
López-Gómez and all authors commented on previous versions
of the manuscript. All authors read and approved the final
manuscript.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
Partial financial support was received from the Chair Against
Stigma Grupo 5-Complutense University of Madrid to pay for a
professional language editing service.
Ethics approval
This study was performed in line with the principles of the
Declaration of Helsinki. This study was approved by the
Deontological Commission of the Complutense University of
Madrid’s Faculty of Psychology.
Consent to participate
Written informed consent was obtained from all individual par-
ticipants included in the study.
Consent to publish
Informed consent was obtained from the participants included in
the study regarding publishing the results for academic purposes.
Code availability
Not applicable.
ORCID iD
Carolina Ugidos https://orcid.org/0000-0002-1512-364X
Availability of data and material
Data is available at ClinicalTrials.gov, under the protocol ID:
Universidad Complutense Madrid, and the title: Psychological
Impact of the Health Alarm Situation Derived from the Covid-19
Coronavirus in the Spanish Population.
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