Exploring Gender-Based Intersectionality in Patient-Reported Experience of Integrated Care in Multiple Sclerosis

Abstract

Introduction

People with multiple sclerosis (pwMS) require coordinated care across multiple professionals and services. Patient-reported experience measures (PREMs) can help assess whether care is perceived as integrated and person-centred. Gender-related differences in healthcare needs, disease burden, and interactions with healthcare systems may contribute to inequalities in perceived care experience. However, these differences may vary according to individual characteristics.

Objectives

To investigate whether gender is associated with PREMs of integrated care, measured using the Integrated Care Experience Scale for Multiple Sclerosis (ICES-MS), and to explore potential intersectional effects between gender and individual-level characteristics.

Methods

Data were obtained from a national survey on pwMS conducted by the Italian MS Foundation in 2026. The primary outcome was the ICES-MS total score, rescaled to 0-100, with higher scores indicating better experience of integrated and person-centred care. Multilevel linear regression models with a random intercept for MS Clinical Centre were fitted to account for clustering of patients within centres. The main individual-level model included gender, age, disability level (mild, moderate, severe), area of residence (North, Center, South/Islands), occupational status (employed, unemployed), and disease duration. To explore intersectionality, separate interaction models were fitted between gender and age, disability level, area of residence, occupational status, and disease duration. Adjusted predicted means were estimated for relevant subgroups.

Results

Overall, 1,520 pwMS from 222 MS Clinical Centres were included. In the main individual-level model, being a man was associated with a slightly higher ICES-MS scores compared to with being a woman (β=2.69; 95% CI: 0.20 to 5.17; p=0.034). Compared with severe disability, mild disability was strongly associated with higher ICES-MS scores (β=9.76; 95% CI: 5.90 to 13.61; p<0.001), while moderate disability showed a borderline association (β=3.97; 95% CI: -0.03 to 7.97; p=0.052). Area of residence was also significantly associated with ICES-MS scores, with higher scores observed in all areas compared to South/Islands. Longer disease duration was associated with lower scores (β=-0.15 per year; 95% CI: -0.28 to -0.03; p=0.017), whereas age and occupational status were not significantly associated with the outcome.

No statistically significant interactions were found between gender and age, disability level, area of residence, occupational status, or disease duration. Adjusted predicted means showed consistent descriptive patterns: ICES-MS scores tended to be higher among men, among people with mild disability, in the North and the Centre, and in patients with shorter disease duration. However, since the interaction terms were not statistically significant, these findings suggest additive differences rather than clear evidence of intersectional effects between gender and individual characteristics.

Conclusions

Gender, disability level, area of residence, and disease duration were associated with PREMs of integrated care among pwMS. However, no robust evidence of gender-based intersectional effects was observed across the individual characteristics examined. Multilevel modelling provided an appropriate framework to account for the hierarchical structure of the data and to estimate adjusted subgroup differences. These findings suggest that gender differences in ICES-MS scores exist, suggesting that interventions aimed at improving integrated care experience should primarily address clinical complexity and disease progression, while monitoring potential gender-related differences.