Challenges in the Management of Care for Patients with Multiple Sclerosis: A Qualitative Study from the Perspectives of Patients, Family Caregivers, and Healthcare Providers

Challenges in the Management of Care for Patients with Multiple Sclerosis: A Qualitative Study from the Perspectives of Patients, Family Caregivers, and Healthcare Providers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Challenges in the Management of Care for Patients with Multiple Sclerosis: A Qualitative Study from the Perspectives of Patients, Family Caregivers, and Healthcare Providers Somayeh Azimpour, Nasrollah Alimohammadi, Fatemeh Nazari, Fereshteh Ashtari This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7105887/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Multiple sclerosis (MS) is a chronic, progressive, and disabling autoimmune disease of the central nervous system that requires continuous, coordinated, and multidimensional care. Despite advancements in medical science, patients still face numerous barriers in accessing effective care. This study aimed to identify the challenges of MS care management from the perspectives of patients, family caregivers, and healthcare providers. Methods : This descriptive qualitative study was conducted in Iran from 2024 to 2025 using purposive sampling. Data were collected through 50 semi-structured interviews with patients diagnosed with MS, family caregivers, and healthcare professionals. Data were analyzed using the Lundman and Graneheim content analysis approach, supported by MAXQDA 2020 software. Results : Inductive analysis yielded two main categories, seven subcategories, and 24 sub-subcategories. The two main categories were: (1) structural and professional barriers in the management of care services, and (2) Challenges faced by patients and family caregivers in the care process. Conclusion : The findings revealed that MS care is hindered by various structural, professional, and managerial barriers within the healthcare system, including a Shortage of specialized human resources, inadequate infrastructure, poor insurance coverage, poor interprofessional coordination, and fragmented referral and follow-up systems. In addition, psychologicalburden on patients and caregivers, misconceptions, social stigma, and physical barriers such as transportation difficulties negatively impact continuity of care and quality of life. These results highlight the need for policy reforms, interdisciplinary team training, home-based care expansion, insurance improvements, and patients and their families to enhance care quality and reduce the psychological and financial burden on patients and families. Multiple Sclerosis (MS) Treatment Challenges Care Management Caregivers Healthcare Providers Introduction Multiple sclerosis (MS) is a chronic, progressive, inflammatory, and autoimmune disorder of the central nervous system characterized by demyelination, leading to neurological impairments[ 1 ]. Affecting approximately 2.8 million people worldwide, it is one of the most common neurological conditions among young and middle-aged adults and is steadily increasing in prevalence[ 2 , 3 ]. In Iran, according to the National MS Registry, the highest numbers of registered cases are in Tehran (36,853), Shiraz (9,686), and Isfahan (7,328) as of 2021[ 4 , 5 ]. While the exact etiology remains unclear, genetic, environmental, and infectious factors contribute to disease onset[ 6 ]. MS presents in various clinical forms, with relapsing-remitting MS being the most prevalent[ 7 , 8 ]. Depending on lesion location, symptoms can range from muscle weakness, fatigue, and pain[ 9 ] to visual disturbances, bladder and bowel dysfunction, and sexual dysfunction[ 10 ], and neuropsychiatric issues such as depression, anxiety, cognitive decline, and memory impairment[ 11 ]. MS also leads to significant social consequences, including unemployment, financial hardship[ 12 ], and disrupted family relationships[ 9 ]. One of the serious consequences of multiple sclerosis is the increased risk of mortality. According to the findings of a meta-analysis, individuals with MS are at a higher risk of death from cardiovascular, respiratory, infectious diseases, and even suicide[ 13 ]. As the disease progresses, the need for continuous and multidimensional care increases[ 3 ]. Family caregivers often provide. This care imposes significant psychological and financial burdens on families, potentially leading to caregiver burnout and reduced quality of life[ 14 ]. Moreover, the high cost of treatment poses a serious challenge for both families and the healthcare system[ 3 ]. According to the Iranian MS Society, the average monthly treatment cost per patient is approximately $ 1,000, with the annual national burden estimated at over $ 760 million[ 4 ]. Given the chronic, progressive, and complex nature of multiple sclerosis (MS), its effective management requires a comprehensive, coordinated, and interdisciplinary approach within the healthcare system[ 15 ]. The aim is to enhance care safety, prevent complications, reduce disability, improve quality of life, and ultimately empower patients to reintegrate into their social and family lives[ 16 ]. During acute phases requiring hospitalization, the healthcare team—including physicians, nurses, psychologists, and other professionals—provides urgent, multidimensional care. While essential to stabilizing patients, such care places significant emotional and occupational strain on providers due to the severity of symptoms and complexity of needs. A study by Gustavo Saposnik et al. (2022) reported that acute MS care is associated with increased levels of burnout, occupational stress, and emotional burden among healthcare professionals[ 17 ]. Multiple sclerosis (MS) remains challenging for patients and caregivers despite therapeutic advances, such as novel disease-modifying drugs, plasmapheresis, stem cell transplantation, and psychosocial and nutritional support[ 18 ]. Studies indicate that high treatment costs, limited access to specialized services, inadequate insurance coverage, a shortage of skilled healthcare professionals, and poor service coordination are common challenges in MS care. These issues not only reduce the quality of life but also impose a significant psychological burden on patients[ 19 , 20 ]. Effectively addressing these issues requires dynamic health policies, innovative service delivery models, and the expansion of supportive frameworks at both national and international levels[ 21 ]. MS prevalence is rising worldwide[ 11 ], yet disparities in diagnostic, specialty, and rehabilitative services are particularly pronounced in low- and middle-income countries, including Iran[ 22 ]. As one of the highest-prevalence MS regions in the Middle East, Iran faces multiple challenges in providing effective care[ 23 , 24 ]. Accordingly, this descriptive qualitative study was conducted to identify the challenges of MS care management from the perspectives of patients, family caregivers, and healthcare providers, aiming to inform policy development and enhance the quality of care. Materials and Methods Study Design and Setting This descriptive qualitative study, conducted as part of a doctoral nursing dissertation, was carried out from 2024 to 2025 in MS referral hospitals affiliated with the Isfahan University of Medical Sciences, Iran. Participants included 12 patients with MS (aged over 18) (See Table 1), 4 primary family caregivers (See Table 2), and 36 healthcare providers (including physicians, nurses, physiotherapists, occupational therapists, optometrists, speech therapists, nutritionists, psychologists, social workers, and insurance representatives) (See Table 3), all selected through purposive sampling with maximum variation. MS diagnosis was confirmed by neurologists based on the revised McDonald criteria. Inclusion criteria for patients were willingness to participate, fluency in Persian, and absence of active psychiatric disorders. Caregivers were required to be directly involved in patient care, mentally healthy, and able to communicate effectively. Healthcare providers needed at least one year of relevant experience, good communication skills, and availability to participate. Data collection continued until conceptual saturation was reached. Data Collection Data were collected through individual semi-structured interviews. The time and place of the interviews were scheduled in advance based on participant preference. Interviews with patients were conducted in a quiet inpatient setting, with caregivers in mutually agreed-upon locations, and with healthcare providers in private areas of their workplace. Each session lasted approximately 30 to 45 minutes. After explaining the study's objectives, informed consent was obtained, and all interviews were audio-recorded. Initial questions were open-ended and exploratory, such as: “Can you describe your first experience with MS?” or “What challenges have you faced in the course of care or treatment?” Healthcare providers were asked questions like, “What challenges do you face in caring for MS patients?” Follow-up questions were used to probe deeper and clarify responses. Data Analysis Data were analyzed using the qualitative content analysis approach described by Lundman and Graneheim[25]. After each interview, audio files were carefully transcribed verbatim. The transcripts were reviewed repeatedly to identify meaning units, which were then condensed and coded. Similar codes were grouped into conceptual categories, and through inductive analysis, overarching themes reflecting shared participant experiences were developed. MAXQDA version 2020 was used to facilitate data organization and coding management. Trustworthiness To ensure the trustworthiness of the data, four criteria were applied: credibility, dependability, confirmability, and transferability[25]. Credibility was enhanced through repeated review of data, codes, and categories, along with member checking and feedback from the research team. Dependability was supported by team-based data analysis and external peer review. Confirmability was achieved through detailed documentation of the research process and analysis steps. Transferability was strengthened by including participants with diverse roles and experiences. Findings Participants included patients with MS, family caregivers, and healthcare providers. The age range of patients was 29–55 years (mean: 38.5), healthcare providers 24–56 years (mean: 41.46, with an average of 13 years’ experience), and caregivers 24–60 years (mean: 49). Data were analyzed using an inductive content analysis approach, resulting in two main categories, seven subcategories, and 24 sub-subcategories. The main categories were: (1) systemic and structural barriers in managing care services, and (2) challenges faced by patients and family caregivers in the care and treatment process of MS (See Table 4). (1) Structural and Professional Barriers in the Management of Care Services for MS Patients This category encompasses a range of infrastructural, managerial, and professional challenges within the health system that hinder the effective and integrated delivery of care to patients with multiple sclerosis. These barriers manifest across policy, human resources, service structure, and clinical processes. Identifying these issues is essential for informing structural reforms and improving care quality. This category includes three subcategories. Subcategory 1: Shortages in Health System Resources and Infrastructure This subcategory addresses infrastructural limitations and deficiencies in human, financial, physical, and service-related resources that hinder comprehensive MS care. It includes seven sub-subcategories: 1.1 Structural Issues in Financial and Insurance Policies This sub-subcategory highlights the weaknesses and inconsistencies in financial and insurance policymaking related to MS care. Findings revealed that inefficient insurance coverage, fragmented systems, and a lack of incentives for healthcare centers to collaborate with insurers significantly disrupt patients’ equitable and continuous access to care and rehabilitation. These challenges not only increase financial burdens but also lead to dissatisfaction and interruptions in treatment. As noted by an MS Disease expert: "One of the main problems is access to services. For instance, rehabilitation and dental schools, which are run by medical universities, ironically resist contracting with insurance providers the most. They charge patients directly, and many patients simply can't afford to pay." (Participant No. 42) 2.1 Shortage of Trained and Specialized Healthcare Personnel This sub-subcategory highlights the lack of adequately trained professionals in MS care. The findings show that many treatment centers, particularly public ones, face a shortage of specialists familiar with the complex needs of MS patients. This shortage leads to increased workloads for existing staff, diminished quality of care, and patient dissatisfaction. Inadequate specialized training and the involvement of unqualified personnel further exacerbate treatment challenges. A plasma exchange nurse explained: "I cover three hospitals, and there’s no staff. Plasmapheresis is a specialized task—it takes a long time to learn. The patient's blood—around 700cc—is in the machine. If the nurse isn’t trained and the patient goes into hypovolemic shock, they could die. I received three months of training before getting certified." (Participant No. 18) 3.1. Limited Home Care and Support Services This subcategory highlights the lack of structured systems for delivering out-of-hospital care and support to MS patients. Findings revealed that home care services, especially for advanced-stage patients, are either unavailable or extremely limited. The absence of multidisciplinary home care teams and supportive services—such as spiritual care and rehabilitation—disrupts continuity of care and places a heavy burden on families. A spiritual care provider noted: "The biggest challenge in spiritual care is structural. There’s no official organizational unit for spiritual care—neither in the Ministry, nor in universities, nor in hospitals. There’s no faculty, department, or clinic dedicated to it, not even in MS centers." (Participant No. 37) A patient added: "I wish there were supportive agencies that came to homes, especially for patients with mobility issues who use walkers or similar aids. In-home physiotherapy at an affordable cost would help." (Participant No. 1) 4.1. Inadequate Supportive and Regulatory Infrastructure This subcategory addresses the absence of essential supportive and supervisory structures needed for effective MS care. Key issues include a lack of counseling services, the absence of caregiver support systems, insufficient oversight of non-specialized interventions, and financial competition among care centers. A social worker noted: "We have many bedridden patients, but there are no dedicated support services for their caregivers." (Participant No. 39) 5.1 Deficiencies in Professional Health Education Systems This subcategory reflects gaps in the education and training of healthcare professionals. These include limited awareness of MS symptoms, lack of training on comprehensive and interdisciplinary care, and neglect of patients’ psychological and spiritual needs. Such gaps hinder the provision of holistic care. A psychiatrist remarked: "A major factor is lack of awareness. Physicians and nurses treating MS patients often fail to recognize mental symptoms or understand the importance of addressing them alongside physical symptoms." (Participant No. 34) 6.1. Lack of Physical and Equipment Infrastructure Deficiencies in physical and medical infrastructure—such as limited hospital beds, inadequate equipment, and constrained clinical space—have imposed additional pressure on healthcare staff and negatively affected care quality. These shortages create widespread operational and managerial challenges in the treatment process. A nurse shared: "Since MS patients often need regular infusions, we have far fewer beds than required. Thousands of patients are under treatment, but the outpatient clinic has very limited infusion beds, leading to delays in timely drug administration." (Participant No. 22) 7.1. Gap Between Services Provided and Patient Expectations The mismatch between available services and patient expectations negatively affects patient experience and satisfaction. Limited time for doctor–patient interaction, inadequate communication, and unmet expectations contribute to dissatisfaction and reduced care quality. One patient explained: "My doctor doesn’t spend enough time with me—just a quick one-minute visit. I can’t fully express my problems. There’s pressure to rush through appointments, and I end up forgetting important things. I expect better care than this." (Participant No. 6) Subcategory 2: Organizational and Managerial Challenges in the Care Process This subcategory highlights managerial and structural barriers such as the lack of an effective referral system, neglect of a holistic care approach, poor interdepartmental coordination, weak teamwork, limited insurance coverage, and time-consuming administrative processes. These factors disrupt the continuity and effectiveness of care for MS patients and hinder timely and integrated service delivery. 1.2. Structural Deficiencies in Referral and Follow-Up Processes Findings revealed that the lack of an integrated system for identifying, referring, and following up with MS patients leads to confusion and discontinuity in care. Inadequate referrals to specialized services and the absence of follow-up mechanisms, such as nurse coordinators or medical record tracking, significantly disrupt the continuity and quality of care. A nurse noted: “We don’t have a follow-up nurse to coordinate treatment and care activities” (Participant 21). Similarly, a speech therapist stated: “The main reason patients don’t come to speech therapy is that doctors don’t refer them—they’re not even aware we can help” (Participant 29). 2.2. Neglect of a Holistic Approach in Service Design The healthcare system's focus on medical interventions has led to the neglect of essential components such as nutrition, optometry, spiritual care, and complementary medicine in MS management. The absence of integrated care centers offering multidisciplinary services has reduced both care effectiveness and patient satisfaction. A physiotherapist explained: “In MS, nutritional status is critical, but often ignored. Everyone focuses only on medication or rehab. If nutrition and psychological support are strong, I can get much better outcomes from physiotherapy” (Participant 25). 3.2. Lack of Interprofessional Coordination and Teamwork Data revealed that the absence of an integrated care team and poor interprofessional collaboration among healthcare providers lead to fragmented services and reduce the effectiveness of multidisciplinary MS care. An occupational therapist explained: “Without a treatment team, patients receive poor care. If nurses, doctors, physiotherapists, and others coordinated, we could avoid unnecessary treatments and equipment. But now everyone works separately” (Participant 28). 4.2. Inadequate Insurance Coverage for Medications and Rehabilitation Services Limited insurance support for rehabilitation, supplementary medications, and assistive devices imposes a significant financial burden on patients, disrupting continuity of care. An ophthalmologist noted: “Insurance doesn’t cover the high cost of low vision aids, including visits and devices” (Participant 31). A health insurance specialist added: “Rehabilitation services like occupational therapy are not covered” (Participant 44). 5.2. Delays in Accessing Care Services Inefficient appointment systems and long waiting times, especially in public centers, were reported to hinder the treatment process, causing frustration, dissatisfaction, and in some cases, treatment discontinuation. A chronic disease coordinator remarked: “Public centers offering rehabilitation services are overcrowded, and MS patients face long waits” (Participant 42). Subcategory 3: Operational Gaps in the Delivery and Provision of Care Services This subcategory highlights executive challenges in the supply of medications, equipment, and the effective delivery of care services. Findings showed that instability in drug availability, poor resource management, and disorganized service provision—especially in public centers—led to delays in treatment, patient dissatisfaction, and reduced care effectiveness. 1.3. Medication and Equipment Supply Issues Participants reported shortages of essential medications, difficulty accessing certain drugs, delays in hospital pharmacy supply, and problems with home delivery. These issues disrupted treatment continuity and imposed psychological and financial stress on patients. A nurse noted: “Sometimes getting medication is very difficult, and patients wait for months” (Participant 20). 2.3. Managerial and Operational Failures in Service Delivery Patients faced confusion during service navigation, a lack of guidance, and inefficient resource allocation. Poor distribution of equipment, limited clinical space, inadequate hospital capacity management, and unclear task distribution among staff were cited as barriers to consistent and quality care. A dietitian stated: “There are very few centers focused on MS nutrition; in fact, we lack professionals who understand and provide specific dietary recommendations for MS. That’s our biggest gap” (Participant 35). 2) Challenges Faced by Patients and Family Caregivers in the MS Care Process This category highlights the difficulties experienced by patients with multiple sclerosis and their family caregivers during the care process. Psychological, financial, informational, and support-related pressures—as well as limited access to services—have reduced their ability to manage the disease effectively. These challenges have also disrupted treatment adherence and negatively impacted their quality of life. This category includes four subcategories. Subcategory 1: Economic Burdens in the Treatment and Rehabilitation Pathway This subcategory refers to financial barriers that hinder the treatment and rehabilitation of MS patients. Findings revealed that high and ongoing costs have led to treatment delays, interrupted rehabilitation, and, in some cases, withdrawal from care services. These financial strains have also been associated with stress, social isolation, and reduced quality of life. 1-1. Economic Burden of Treatment and Rehabilitation Services The findings revealed that high costs related to medical care, rehabilitation sessions, and diagnostic and assistive equipment impose a substantial financial burden on patients and their families. Inadequate insurance coverage further exacerbates this issue, often resulting in treatment delays and reduced access to effective care. A family caregiver shared: “They told me to get a respiratory support device, but it was expensive. Even renting it was costly.” (Participant 47) 2-1. Financial Barriers to Continuity of Care Data indicated that low income and financial stress—often due to unemployment or reduced earnings—led to interruptions in treatment, withdrawal from rehabilitation, and choices driven by affordability rather than clinical need. These limitations compromise the continuity and effectiveness of care. A neurologist explained: “Many patients have serious financial difficulties, which prevent them from receiving necessary treatment.” (Participant 13) Subcategory 2: Psychosocial Stressors Experienced by Patients and Caregivers Data revealed that anxiety, stress, burnout, and financial and social concerns are common among patients and caregivers. Prolonged caregiving without adequate support often leads to emotional exhaustion, diminished quality of life, and strained family dynamics, social interactions, and treatment adherence. 1-2. Distrust and Negative Perceptions Toward Treatment Participants cited prior unsuccessful experiences, uncertainty about treatment outcomes, and delayed therapeutic responses as key reasons for distrust. This skepticism sometimes led to treatment discontinuation, disregard for professional advice, and neglect of complementary care. A vision specialist stated: “Part of the problem is a lack of trust in the medical team—patients aren’t sure whether paying for care will help.” (Participant 32) 2-2. Caregiver Burnout and Role-Related Stress Caregivers reported persistent fatigue, repetitive responsibilities, conflict between personal and caregiving needs, and high emotional strain. These challenges gradually undermined their mental well-being and reduced the quality of care provided. A family caregiver shared: “My husband was hospitalized and I stayed with him all the time. I was so exhausted that I could barely walk, and my family was worried about me too.” (Participant 48) 3-2. Emotional and Social Conflicts Faced by Family Caregivers Concerns about the patient's financial future, social acceptance, marriage prospects, and balancing caregiving with personal life caused emotional distress and mental health strain among caregivers. One caregiver noted: “No one knows what will happen to my daughter in the future. I’m very worried.” (Participant 46) Subcategory 3: Psychological and Cultural Barriers to Care Access The findings revealed that misconceptions about treatment, fear of stigma or side effects, and lack of information significantly restrict access to care. These barriers stem from inadequate patient education, negative attitudes toward chronic illness, and low cultural readiness for multidisciplinary services. 1-3. Patient and Family Misbeliefs Regarding Treatment Some participants held erroneous beliefs—such as fearing addiction to psychiatric medications, thinking treatment is unnecessary during pregnancy or breastfeeding, or doubting the efficacy of rehabilitation—which led to delays, discontinuation, or resistance toward comprehensive care. One speech therapist remarked: “Patients often expect medication rather than therapy; when speech therapy exercises begin, they resist because it’s not a pill they can take.” (Participant 30) 2-3. Fear of Stigma and Shame Fear of judgment, shame, and concern over being labeled mentally ill prevented some patients and caregivers from seeking psychological services. These hidden barriers limit access to critical mental health care. A psychologist stated: “Patients feel embarrassed to see a psychologist; they worry others will think they are mentally unwell, so they avoid seeking help.” (Participant 33) 3-3. Lack of Awareness About the Importance of Care and Available Services Participants reported that patients and families often lack awareness of psychological symptoms, the role of mental health in physical recovery, and the availability of supportive services like spiritual care, psychotherapy, and rehabilitation. This gap in awareness undermines comprehensive, effective care. A spiritual caregiver explained: “The problem is that patients are unfamiliar with spiritual care and unaware of its benefits.” (Participant 38) Subcategory 4: Physical and Operational Barriers to Healthcare Access Findings indicated that a lack of adequate transportation facilities, mobility limitations, and challenges accessing medical centers significantly hinder patients’ ability to attend appointments. These barriers reduce treatment adherence and heighten patients’ feelings of isolation. 1-4. Transportation Issues and Mobility Challenges Participants reported difficulties in transporting physically disabled patients due to the lack of appropriate vehicles and limited family support. These issues, particularly in advanced disease stages, often led to missed appointments and reduced motivation to continue care. A caregiver shared: “Getting the patient to the hospital or doctor’s office is very hard. Sometimes, we don’t even take them because it’s just too difficult.” (Participant 49) Discussion This study aimed to explore the challenges of MS care management from the perspectives of patients, family caregivers, and healthcare providers. One of the main categories identified was “structural and professional barriers in the management of care services,” which included policy gaps, workforce shortages, inadequate infrastructure, and weak implementation processes. Issues such as the lack of home-based services, limited medical equipment, and poorly designed clinical environments were also found to hinder the quality and accessibility of care. These findings highlight a significant mismatch between the complex needs of MS patients and the current structure of the healthcare system. To enhance care quality, health policies must prioritize system reform, resource strengthening, and the development of integrated and continuous care services[ 26 ]. One of the key findings of this study was that insufficient resources and infrastructure within the healthcare system hinder the delivery of continuous and effective care for MS patients. Participants identified shortcomings in financial and insurance policies, workforce shortages—particularly in rehabilitation, mental health, and nursing—limited home-based and psychosocial support services, inadequate professional training, lack of necessary equipment, and a mismatch between patient needs and available services. In the financial domain, inadequate insurance coverage for rehabilitation, medications, and assistive devices imposes a heavy burden, a challenge affecting over 54% of MS patients in Iran, as reported by Gharibi et al. (2021)[ 26 ]. Similarly, Jahromi et al. (2023) emphasized workforce shortages as a major barrier to comprehensive care. Weak home care structures and psychosocial supports exacerbate family stress and disrupt treatment continuity, while insufficient professional preparation leaves many care providers unready[ 19 ]. Additionally, the lack of physical and rehabilitative infrastructure—especially in underserved regions—diminishes patients’ motivation to pursue treatment. Finally, the gap between patient expectations and available services reflects insufficient stakeholder engagement in service design, an issue highlighted by Hosseini et al. (2022)[ 27 ]. Collectively, these findings underscore the urgent need for insurance reform, multidisciplinary workforce development, expansion of home-based care, infrastructure strengthening, and inclusive, patient-centered service planning. This study revealed that organizational and managerial deficiencies, alongside structural barriers, play a crucial role in undermining the effectiveness of MS care. Deficiencies in referral and follow-up systems, the absence of integrated care services, and poor interprofessional coordination disrupted treatment continuity and created confusion for patients, an issue also highlighted by Madani et al. (2025) as a primary barrier to sustained care [ 28 ]. Additionally, weak collaboration among care team members and insufficient attention to psychological and social dimensions of the disease impeded comprehensive care, findings that align with systematic review results [ 20 ]. Furthermore, inadequate insurance coverage for medications and rehabilitation services[ 19 ], combined with lengthy appointment scheduling processes, decreased patient motivation, and increased financial strain, is another challenge emphasized by Madani et al. (2025) [ 28 ]. Addressing these challenges requires the establishment of coordinated care frameworks, the development of integrated treatment models, and a comprehensive review of insurance policies. The study’s findings indicate that operational shortcomings in securing medications and equipment, coupled with managerial inefficiencies in service distribution, directly undermine the quality of care for MS patients. Participants reported shortages of essential drugs, price volatility, and restricted access to specialized equipment—issues consistent with documented supply chain disruptions in Iran. Additionally, inadequate planning for specific services, such as periodic infusions, imposed additional burdens on patients and families. This challenge mirrors the conclusions of Chungyi Chiu (2017), who identified resource distribution failures as a primary contributor to care discontinuity[ 29 ]. These findings underscore an urgent need to reform operational structures, strengthen oversight systems, and implement effective resource management to enhance care continuity and quality. The findings of this study indicate that individuals with MS and their family caregivers confront a spectrum of economic, psychosocial, cultural, and logistical barriers in accessing care, beyond the clinical challenges of the disease. These obstacles—represented in subthemes such as psychosocial stress, financial strain, misconceptions, and physical access limitations—have led to fragmented treatment, increased emotional burden, and diminished quality of life for both patients and caregivers. These results underscore the need for holistic, interdisciplinary, and cross-sector interventions in MS care planning. A particularly critical dimension is the financial burden associated with treatment and rehabilitation. Our data show that, without sufficient insurance support, high out-of-pocket costs often lead to treatment interruptions and reliance on less effective alternatives. Consistent with Rezaee et al. (2022), who reported that medications account for up to 80% of total MS treatment costs[ 23 ], and Soltani et al. (2024), which found that approximately 72% of individuals below the poverty line cannot afford rehabilitation expenses[ 30 ], financial hardship has also been linked to “treatment poverty”—driven by debt or prioritizing medical costs over basic needs—particularly in low-income families. Jahromi et al. (2023) further revealed that Iranian MS patients spend, on average, more than 40% of their household income on care. This economic stress not only hinders treatment continuity but also impacts the mental health of both patients and caregivers[ 19 ]. Therefore, enhancing insurance coverage, expanding public rehabilitation services, and implementing targeted financial support are essential strategies to alleviate this burden. Psychosocial stressors emerged as one of the key factors undermining the care process for individuals with multiple sclerosis. The findings of this study revealed that negative attitudes toward treatment—often stemming from prior unsuccessful experiences or cultural beliefs—led to mistrust and discontinuation of care[ 19 ]. Family caregivers were particularly vulnerable to emotional exhaustion due to continuous responsibilities, emotional strain, and role conflicts. This aligns with findings from qualitative studies conducted in Ahvaz[ 31 ], which also reported anxiety about the patient’s future and the impact of caregiving on caregivers’ personal and professional lives[ 31 ]. These concerns created an additional psychological burden, negatively affecting the quality of life of both patients and caregivers[ 32 ]. This psychological stress cycle was found to contribute to disrupted treatment adherence and increased caregiver strain. These findings highlight the urgent need for targeted interventions such as psychosocial support, caregiver training programs, and awareness-raising initiatives for patients and families to strengthen care continuity and improve overall well-being[ 14 ]. The findings of this study revealed that misconceptions, stigma-related fears, and lack of awareness among patients with multiple sclerosis (MS) and their families are significant barriers to effective care. Misbeliefs—such as the addictive nature of psychiatric medications or the ineffectiveness of rehabilitation—have, in some cases, led to treatment discontinuation, as also reported by Pourhaji et al. (2023)[ 11 ]. Additionally, fear of social labeling has discouraged patients and caregivers from seeking psychological and spiritual care, a phenomenon consistent with the findings of Masoudi et al. (2014)[ 31 ]. Furthermore, limited awareness of the importance of treatment and available services has contributed to delayed initiation of care and a tendency toward unscientific methods. Hosseini et al. (2022) also emphasized that inadequate health literacy significantly compromises the quality of care[ 32 ]. These results underscore the urgent need to improve health literacy, promote public education, and foster a supportive cultural environment to enhance the accessibility and effectiveness of MS care. This study identified transportation-related challenges as one of the major barriers in the care pathway for patients with multiple sclerosis (MS), particularly those with physical disabilities. Limited mobility, high transportation costs, lack of suitable transport services, and long distances to treatment centers were key factors contributing to missed appointments and interruptions in care continuity. Similar findings were reported in a qualitative study conducted in Tehran, where the absence of home-based care services was cited as a primary cause of treatment disruption[ 33 ]. A review of the literature also indicates that 5–67% of MS patients experience transportation-related barriers, which are associated with treatment delays, increased psychological stress, and reduced motivation for ongoing care[ 34 ]. Additionally, the absence of an efficient appointment system, difficulty coordinating caregiver support, and inadequate clinical environments were noted as factors contributing to treatment discontinuation in some cases. To address these challenges, the expansion of home care services, the development of specialized transportation systems, and the integration of telemedicine are recommended. The effectiveness of such interventions in enhancing treatment adherence and reducing healthcare costs has been supported by El-khalik Ahmed (2023)[ 35 ]. Strengths and Limitations This study explored the experiences of patients with multiple sclerosis, family caregivers, and healthcare providers, identifying key challenges and barriers in the management of MS care. A major strength of the study was its focus on first-hand narratives from individuals directly involved in the care process, offering rich and practical insights into the complexities and multidimensional needs associated with living with and managing MS. However One limitation of this study was the potential influence of participants’ psychological, emotional, and environmental conditions during interviews, which could have affected how experiences were expressed and the quality of the data. To mitigate this, interviews were conducted in calm and familiar settings, and the interviewer created a trusting atmosphere to encourage open and honest sharing. Conclusion The present study revealed that the structural, economic, psychological, and operational challenges within the care system for patients with multiple sclerosis (MS) are highly complex and interwoven. Therefore, policymaking in the field of MS must increasingly adopt a holistic, multidisciplinary, and team-based approach. Enhancing insurance coverage, expanding supportive services, improving access to specialized facilities, and promoting education, public awareness, and efficient resource management can significantly facilitate the optimization of care delivery for individuals living with MS. Abbreviations MS: multiple sclerosis, RRMS: relapsing-remitting, HC: Home Care Declarations Acknowledgements The authors extend their sincere gratitude to Isfahan University of Medical Sciences for its support in conducting this research. Author Contributions Somayeh Azimpour: Conceptual design of the study, conducting interviews, data analysis, and drafting the initial manuscript. Nasrollah Alimohammadi:* Study design, participation in data analysis, scientific and editorial revision of the manuscript, project management, and overall supervision. Fatemeh Nazari: Contribution to data analysis and revision of manuscript drafts. Fereshteh Ashtari: Oversight of the research process, final revision of the manuscript, and scientific guidance throughout the writing stages. Funding This study was financially supported by Isfahan University of Medical Sciences under grant number 3403443. Ethics Statement and Consent This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki [https://www.wma.net/policies-post/wma-declaration-of-helsinki/]. Ethical approval was obtained from the Research Ethics Committee of Isfahan University of Medical Sciences, under the approval number IR.MUI.MED.REC.1403.259. Before participation, all individuals received detailed information about the study objectives, the process of audio recording, the use of data, and their rights as participants. Written informed consent was obtained from each participant. Confidentiality, anonymity, and the right to withdraw from the study at any stage were guaranteed. Clinical trial number not applicable. Data Availability The data are provided within the manuscript or as supplementary files. All data are available from the corresponding author upon reasonable request. Competing Interests The authors declare no competing interests. References Yamout B: Update in multiple sclerosis . eNeurologicalSci 2025, 38 :100553. Witzig-Brändli V, Zech L, Lange C, Adlbrecht L, Gschwend S, Mayer H, Kohler M: A self-management intervention for people with multiple sclerosis: The development of a programme theory in the field of rehabilitation nursing . Evaluation and program planning 2023, 99 :102302. Karimi S, Derakhshan M, Tondro A: Frequency of registered cases of multiple sclerosis . Maedica 2023, 18 (2):216. Safavi M, Farahani H: The effect of self-care education on the performance of multiple sclerosis patients: a randomised control trial . Avicenna Journal of Nursing and Midwifery Care 2018, 25 (5):208-216. Multiple sclerosis In . ; 2022. Rooddehghan Z, Nezhad MM, Zakerimoghadam M, Karimi R: Effect of patient-centered and family-centered self-care education program on the quality of life of patients with multiple sclerosis: a quasi-experimental study . BMC nursing 2023, 22 (1):391. Kuhlmann T, Moccia M, Coetzee T, Cohen JA, Correale J, Graves J, Marrie RA, Montalban X, Yong VW, Thompson AJ: Time for a new mechanism-driven framework to define multiple sclerosis progression . The Lancet Neurology 2022, 22 (1):78. Charabati M, Wheeler MA, Weiner HL, Quintana FJ: Multiple sclerosis: Neuroimmune crosstalk and therapeutic targeting . Cell 2023, 186 (7):1309-1327. Ben-Zacharia AB, Lee J-M, Kahle JS, Lord B: Shared decision-making in multiple sclerosis physical symptomatic care: a systematic review . Therapeutic Advances in Chronic Disease 2023, 14 :20406223231172920. Kołtuniuk A, Pawlak B, Krówczyńska D, Chojdak-Łukasiewicz J: The quality of life in patients with multiple sclerosis–Association with depressive symptoms and physical disability: A prospective and observational study . Frontiers in psychology 2023, 13 :1068421. Pourhaji F, Peyman N, Taraghdar MM, Jamali J, Tehrani H: Explaining the burden of psychosocial factors on the worsening symptoms of MS: a qualitative study of patients' experiences . BMC neurology 2023, 23 (1):98. Momenabadi V, Kaveh MH, Nakhaee N, Shirazi KK, Sedighi B, Tabatabaei SHR: Health promoting self-care behaviors in patients with multiple sclerosis in the Southeast of Iran: Developing a model for practice . Basic and Clinical Neuroscience 2020, 11 (5):687. Smyrke N, Dunn N, Murley C, Mason D: Standardized mortality ratios in multiple sclerosis: Systematic review with meta ‐analysis . Acta Neurologica Scandinavica 2022, 145 (3):360-370. Maguire R, Maguire P: Caregiver burden in multiple sclerosis: recent trends and future directions . Current Neurology and Neuroscience Reports 2020, 20 :1-9. Michael S, Hugh K, Guido G: Evaluating the evidence behind multidisciplinary roles for a multiple sclerosis unit: A systematic literature review . Multiple Sclerosis and Related Disorders 2025:106342. Shipley J, Beharry J, Yeh W, Seery N, Foong YC, Ayton D, Siriratnam P, Tan T, Beadnall H, Barton J: Consensus recommendations on multiple sclerosis management in Australia and New Zealand: part 1 . Medical journal of Australia 2025, 222 (7):356-364. Saposnik G, Bueno-Gil G, Sempere ÁP, Del Río-Muñoz B, Lendínez-Mesa A, Azanza-Munarriz C, Becerril-Ríos N, Goicochea-Briceño H, Horno R, Sánchez-Franco C: Sick leave and occupational burnout among nurses caring for patients with multiple sclerosis . Multiple Sclerosis and Related Disorders 2022, 63 :103916. Bunganic R, Blahutova S, Revendova K, Zapletalova O, Hradilek P, Hrdlickova R, Ganesh A, Cermakova Z, Bar M, Volny O: Therapeutic plasma exchange in multiple sclerosis patients with an aggressive relapse: an observational analysis in a high-volume center . Scientific Reports 2022, 12 (1):18374. Jahromi N, Eskandarieh S, Maleki N, Sistany-Allahabadi N, Sahraian MA: Challenges of patients with multiple sclerosis in receiving health care services in Iran . Current Journal of Neurology 2023, 22 (1):16. Mayo CD, Farzam-Kia N, Ghahari S: Identifying barriers to and facilitators of health service access encountered by individuals with multiple sclerosis . International Journal of MS care 2021, 23 (1):37-44. Solomon AJ, Marrie RA, Viswanathan S, Correale J, Magyari M, Robertson NP, Saylor DR, Kaye W, Rechtman L, Bae E: Global barriers to the diagnosis of multiple sclerosis: data from the Multiple Sclerosis International Federation Atlas of MS . Neurology 2023, 101 (6):e624-e635. Almubaslat F, Sanchez-Boluarte SS, Diaz MM: A review of neurological health disparities in Peru . Frontiers in Public Health 2023, 11 :1210238. Rezaee M, Keshavarz K, Izadi S, Jafari A, Ravangard R: Economic burden of multiple sclerosis: a cross-sectional study in Iran . Health Economics Review 2022, 12 :1-10. Moghtaderi A, Shahidi-Pourakbari M, Izadi S, Khosravi A, Hashemzehi Z: Ongoing increase in incidence and prevalence of multiple sclerosis in south-eastern Iran: a three decade study . Multiple Sclerosis and Related Disorders 2023, 71 :104557. Graneheim UH, Lundman B: Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness . Nurse education today 2004, 24 (2):105-112. Gharibi F, Imani A, Dalal K: The catastrophic out-of-pocket health expenditure of multiple sclerosis patients in Iran . BMC Health Services Research 2021, 21 :1-8. Homayuni A, Hosseini Z: An intervention design for promoting quality of life among patients with multiple sclerosis: a protocol with a planning approach for a mixed methods study . BMC neurology 2023, 23 (1):42. Madani H, Nasrabadi AN, Ghiyasvandian S: Explaining the Barriers to Adherence to Treatment Regimens in Multiple Sclerosis Patients: A Qualitative Content Analysis . Crescent Journal of Medical & Biological Sciences 2025, 12 (2). Chiu C, Bishop M, Pionke J, Strauser D, Santens RL: Barriers to the accessibility and continuity of health-care services in people with multiple sclerosis: a literature review . International Journal of MS Care 2017, 19 (6):313-321. Soltani S, Arvan K, Matin BK, Ghoddoosinejad J, Moradi F, Salehiniya H: People with Disabilities and Financial Challenges in Access to Rehabilitation Services: Evidence of Socioeconomic Inequality in Iran . Medical Journal of the Islamic Republic of Iran 2024, 38 :31. Masoudi R, Abedi HA, Abedi P, Mohammadianinejad SE: Iranian family caregivers’ challenges and issues in caring of multiple sclerosis patients: A descriptive explorative qualitative study . Iranian journal of nursing and midwifery research 2014, 19 (4):416-423. Hosseini Z, Homayuni A, Etemadifar M: Barriers to quality of life in patients with multiple sclerosis: a qualitative study . BMC neurology 2022, 22 (1):174. Saadati Qamsari A, Noorizadeh Dehkordi S, Dadgoo M: Mobility barriers for people with multiple sclerosis: A qualitative study . Function and Disability Journal 2018, 1 (4):18-27. Syed ST, Gerber BS, Sharp LK: Traveling towards disease: transportation barriers to health care access . Journal of community health 2013, 38 :976-993. Ahmed MAE-k, Zakaria MF, Elaziz AAEA, Fouad MM, Elbokl AM, Swelam MS: Assessment of the role of telemedicine in the outcome of multiple sclerosis patients . The Egyptian Journal of Neurology, Psychiatry and Neurosurgery 2023, 59 (1):99. Tables Table 1. Demographic Characteristics of Patients Participant Code Age Gender Marital Status Disease Duration (Years) P.No 1 36 Female Married 9 P.No 2 33 Female Single 22 P.No 3 37 Female Married 20 P.No 4 42 Female Single 8 P.No 5 33 Female Married 8 P.No 6 36 Male Married 11 P.No 7 55 Male Married 24 P.No8 48 Male Married 15 P.No 9 49 Male Married 1 P.No 10 29 Male Single 6 P.No 11 31 Male Married 10 P.No 12 33 Female Married 12 Table 2. Demographic Characteristics of Family Caregivers Participant Code Age Gender Marital Status Years of Caregiving Experience P.No 45 57 Female Married 1 P.No 46 55 Female Married 20 P.No 47 24 Female Single 18 P.No 48 52 Female Married 8 P.No 49 50 Male Married 10 P.No 50 60 Male Married 15 Table 3. Demographic Characteristics of MS Care Providers Participant Code Age Gender Marital Status Field of Study Education Level Work Experience (Years) P.No 13 55 Female Married Medicine (MS Fellow) Fellowship 28 P.No 14 56 Male Married Medicine (MS Fellow) Fellowship 30 P.No 15 42 Female Married Neurology Specialty 9 P.No 16 42 Female Married Nursing BSc 12 P.No 17 51 Female Married Nursing BSc 4 P.No 18 46 Female Married Nursing BSc 22 P.No 19 29 Female Single Nursing MSc 1 P.No 20 32 Male Single Nursing MSc 6 P.No 21 40 Female Single Nursing PhD 20 P.No 22 36 Female Single Nursing BSc 14 P.No 23 29 Female Single Nursing BSc 2 P.No 24 47 Male Married Physiotherapy PhD 22 P.No 25 43 Male Married Physiotherapy PhD 12 P.No 26 40 Female Married Physiotherapy PhD 13 P.No 27 28 Female Single Occupational Therapy BSc 5 P.No 28 42 Male Married Occupational Therapy PhD 16 P.No 29 29 Male Married Speech Therapy BSc 6 P.No30 55 Female Married Speech Therapy PhD 24 P.No 31 33 Female Single Ophthalmology Specialty 10 P.No 32 24 Female Single Optometry BSc 2 P.No 33 35 Male Married Psychology PhD 9 P.No 34 43 Female Married Psychiatry Specialty 4 P.No 35 32 Female Married Nutrition PhD 8 P.No 36 40 Female Married Nutrition PhD 7 P.No 37 44 Male Married Spiritual Care PhD 13 P.No 38 53 Male Married Spiritual Care PhD 20 P.No 39 33 Female Married Social Work BSc 20 P.No 40 58 Female Married Social Work BSc 15 P.No 41 45 Female Married Diploma Diploma 15 P.No 42 45 Female Married Nursing BSc 15 P.No 43 48 Female Married General Medicine GP 15 P.No 44 52 Male Married Insurance Services PhD 28 Table 4. Main Categories, Subcategories, and Sub-subcategories Main Category Subcategory Sub-subcategory Challenges Faced by Patients and Family Caregivers in the MS Care Process Financial and Economic Barriers in Treatment and Rehabilitation Economic burden of treatment and rehabilitation services Financial constraints affecting the continuity of care Psychosocial Pressures on Patients and Caregivers Mistrust and negative attitudes toward the effectiveness of care Burnout and stress from caregiving roles Psychological and social conflicts among family caregivers Psychological and Cultural Barriers to Accessing Care Misconceptions about treatment and care Shame or reluctance to seek help Lack of awareness about the necessity of treatment and available services Physical and Logistical Barriers to Accessing Care Transportation challenges and mobility issues for patients with disabilities Structural and Professional Barriers in the Management of MS Care Services Lack of Resources and Infrastructure in the Health System Structural problems in financial and insurance policies Shortage of trained and specialized human resources Weaknesses in home care and supportive services Inadequate supportive and supervisory infrastructure Deficiencies in professional education systems Inadequate physical infrastructure and medical Equipment Discrepancies between provided services and patient expectations Organizational and Professional Issues in Care Pathway Structural shortcomings in referral and follow-up processes Neglect of a holistic approach in service design Fragmentation and poor coordination among healthcare and support units Lack of interprofessional coordination and teamwork Inefficient insurance coverage for medication and rehabilitation services Time-consuming access to medical and care services Operational Challenges in Service Provision and Delivery Issues in the supply of medications and medical equipment Managerial and operational inefficiencies in service distribution Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7105887","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":502911785,"identity":"2b451a7d-6eb0-45f5-a7e8-a059e7ad7ea4","order_by":0,"name":"Somayeh Azimpour","email":"","orcid":"","institution":"PhD student in Nursing, Student Research Committee, School of Nursing and Midwifery, Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Somayeh","middleName":"","lastName":"Azimpour","suffix":""},{"id":502911786,"identity":"db4c9bec-deeb-48d8-8285-f358f6e92c56","order_by":1,"name":"Nasrollah Alimohammadi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYDACdsYGBiACAYMDH8A0hMuDUwszkpaDM4jTAlfDYMCMWxkS4G9mbt3wcYddtG774Y2HbXdsY9CdkdzA8KOGQca8AbsWicOMbTdnnknO3XYmreBw7pnbDGY3EhsYe44x8MgcwGENUMtt3jbm3G0HcgwO57ZBtDDwNjDwSODQIQ/RUp+77fwbg8OWUC2Mf/FoMYBoOZy77UYOmA3WwozPFkOwX9qOA7U8KzjY23abx+zMw4bDMsckcGqRO97+7MbHtmqgw5I3f/jZdlvO7Hj6w4dvamzscWnBAOCoOQAMSmI1jIJRMApGwSjAAgCmPWOR8r9YUgAAAABJRU5ErkJggg==","orcid":"","institution":"Professor, Nursing and Midwifery Care Research Center, Department of Critical Care Nursing, School of Nursing and Midwifery, Isfahan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Nasrollah","middleName":"","lastName":"Alimohammadi","suffix":""},{"id":502911787,"identity":"3ab8c183-7f98-4243-9cdd-8b03ff1a5106","order_by":2,"name":"Fatemeh Nazari","email":"","orcid":"","institution":"Assistant Professor, Nursing and Midwifery Care Research Center, Department of Adult Health Nursing, School of Nursing and Midwifery, Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Fatemeh","middleName":"","lastName":"Nazari","suffix":""},{"id":502911788,"identity":"d4fe070d-01f2-405f-b4a1-a186f1950d7c","order_by":3,"name":"Fereshteh Ashtari","email":"","orcid":"","institution":"Professor of Neurology, Department of Neurology, Isfahan Neurosciences Research Center, Isfahan University of Medical Science","correspondingAuthor":false,"prefix":"","firstName":"Fereshteh","middleName":"","lastName":"Ashtari","suffix":""}],"badges":[],"createdAt":"2025-07-12 05:38:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7105887/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7105887/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":94648634,"identity":"8e960e3b-3774-4825-8c7f-852b38ef8b9d","added_by":"auto","created_at":"2025-10-29 09:09:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3196523,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7105887/v1/46afb21f-efa3-481c-b970-6edb2420eb9b.pdf"},{"id":89595787,"identity":"202f96a7-68b2-49c4-ae77-45274303c8e6","added_by":"auto","created_at":"2025-08-21 16:50:03","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14840,"visible":true,"origin":"","legend":"","description":"","filename":"interview.docx","url":"https://assets-eu.researchsquare.com/files/rs-7105887/v1/86ddf6254cf9cbf3ea90b045.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Challenges in the Management of Care for Patients with Multiple Sclerosis: A Qualitative Study from the Perspectives of Patients, Family Caregivers, and Healthcare Providers","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMultiple sclerosis (MS) is a chronic, progressive, inflammatory, and autoimmune disorder of the central nervous system characterized by demyelination, leading to neurological impairments[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Affecting approximately 2.8\u0026nbsp;million people worldwide, it is one of the most common neurological conditions among young and middle-aged adults and is steadily increasing in prevalence[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In Iran, according to the National MS Registry, the highest numbers of registered cases are in Tehran (36,853), Shiraz (9,686), and Isfahan (7,328) as of 2021[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While the exact etiology remains unclear, genetic, environmental, and infectious factors contribute to disease onset[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. MS presents in various clinical forms, with relapsing-remitting MS being the most prevalent[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Depending on lesion location, symptoms can range from muscle weakness, fatigue, and pain[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] to visual disturbances, bladder and bowel dysfunction, and sexual dysfunction[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and neuropsychiatric issues such as depression, anxiety, cognitive decline, and memory impairment[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. MS also leads to significant social consequences, including unemployment, financial hardship[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and disrupted family relationships[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. One of the serious consequences of multiple sclerosis is the increased risk of mortality. According to the findings of a meta-analysis, individuals with MS are at a higher risk of death from cardiovascular, respiratory, infectious diseases, and even suicide[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAs the disease progresses, the need for continuous and multidimensional care increases[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Family caregivers often provide. This care imposes significant psychological and financial burdens on families, potentially leading to caregiver burnout and reduced quality of life[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Moreover, the high cost of treatment poses a serious challenge for both families and the healthcare system[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. According to the Iranian MS Society, the average monthly treatment cost per patient is approximately \u003cspan\u003e$\u003c/span\u003e1,000, with the annual national burden estimated at over \u003cspan\u003e$\u003c/span\u003e760 million[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eGiven the chronic, progressive, and complex nature of multiple sclerosis (MS), its effective management requires a comprehensive, coordinated, and interdisciplinary approach within the healthcare system[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The aim is to enhance care safety, prevent complications, reduce disability, improve quality of life, and ultimately empower patients to reintegrate into their social and family lives[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. During acute phases requiring hospitalization, the healthcare team\u0026mdash;including physicians, nurses, psychologists, and other professionals\u0026mdash;provides urgent, multidimensional care. While essential to stabilizing patients, such care places significant emotional and occupational strain on providers due to the severity of symptoms and complexity of needs. A study by Gustavo Saposnik et al. (2022) reported that acute MS care is associated with increased levels of burnout, occupational stress, and emotional burden among healthcare professionals[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Multiple sclerosis (MS) remains challenging for patients and caregivers despite therapeutic advances, such as novel disease-modifying drugs, plasmapheresis, stem cell transplantation, and psychosocial and nutritional support[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Studies indicate that high treatment costs, limited access to specialized services, inadequate insurance coverage, a shortage of skilled healthcare professionals, and poor service coordination are common challenges in MS care. These issues not only reduce the quality of life but also impose a significant psychological burden on patients[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Effectively addressing these issues requires dynamic health policies, innovative service delivery models, and the expansion of supportive frameworks at both national and international levels[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. MS prevalence is rising worldwide[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], yet disparities in diagnostic, specialty, and rehabilitative services are particularly pronounced in low- and middle-income countries, including Iran[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. As one of the highest-prevalence MS regions in the Middle East, Iran faces multiple challenges in providing effective care[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Accordingly, this descriptive qualitative study was conducted to identify the challenges of MS care management from the perspectives of patients, family caregivers, and healthcare providers, aiming to inform policy development and enhance the quality of care.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis descriptive qualitative study, conducted as part of a doctoral nursing dissertation, was carried out from 2024 to 2025 in MS referral hospitals affiliated with the Isfahan University of Medical Sciences, Iran. Participants included 12 patients with MS (aged over 18) (See Table 1), 4 primary family caregivers (See Table 2), and 36 healthcare providers (including physicians, nurses, physiotherapists, occupational therapists, optometrists, speech therapists, nutritionists, psychologists, social workers, and insurance representatives) (See Table 3), all selected through purposive sampling with maximum variation. MS diagnosis was confirmed by neurologists based on the revised McDonald criteria. Inclusion criteria for patients were willingness to participate, fluency in Persian, and absence of active psychiatric disorders. Caregivers were required to be directly involved in patient care, mentally healthy, and able to communicate effectively. Healthcare providers needed at least one year of relevant experience, good communication skills, and availability to participate. Data collection continued until conceptual saturation was reached.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected through individual semi-structured interviews. The time and place of the interviews were scheduled in advance based on participant preference. Interviews with patients were conducted in a quiet inpatient setting, with caregivers in mutually agreed-upon locations, and with healthcare providers in private areas of their workplace. Each session lasted approximately 30 to 45 minutes. After explaining the study's objectives, informed consent was obtained, and all interviews were audio-recorded.\u003c/p\u003e\n\u003cp\u003eInitial questions were open-ended and exploratory, such as: “Can you describe your first experience with MS?” or “What challenges have you faced in the course of care or treatment?” Healthcare providers were asked questions like, “What challenges do you face in caring for MS patients?” Follow-up questions were used to probe deeper and clarify responses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analyzed using the qualitative content analysis approach described by Lundman and Graneheim[25]. After each interview, audio files were carefully transcribed verbatim. The transcripts were reviewed repeatedly to identify meaning units, which were then condensed and coded. Similar codes were grouped into conceptual categories, and through inductive analysis, overarching themes reflecting shared participant experiences were developed. MAXQDA version 2020 was used to facilitate data organization and coding management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrustworthiness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo ensure the trustworthiness of the data, four criteria were applied: credibility, dependability, confirmability, and transferability[25]. Credibility was enhanced through repeated review of data, codes, and categories, along with member checking and feedback from the research team. Dependability was supported by team-based data analysis and external peer review. Confirmability was achieved through detailed documentation of the research process and analysis steps. Transferability was strengthened by including participants with diverse roles and experiences.\u003c/p\u003e\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n"},{"header":"Findings","content":"\u003cp\u003eParticipants included patients with MS, family caregivers, and healthcare providers. The age range of patients was 29–55 years (mean: 38.5), healthcare providers 24–56 years (mean: 41.46, with an average of 13 years’ experience), and caregivers 24–60 years (mean: 49). Data were analyzed using an inductive content analysis approach, resulting in two main categories, seven subcategories, and 24 sub-subcategories. The main categories were: (1) systemic and structural barriers in managing care services, and (2) challenges faced by patients and family caregivers in the care and treatment process of MS (See Table 4).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e(1) Structural and Professional Barriers in the Management of Care Services for MS Patients\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThis category encompasses a range of infrastructural, managerial, and professional challenges within the health system that hinder the effective and integrated delivery of care to patients with multiple sclerosis. These barriers manifest across policy, human resources, service structure, and clinical processes. Identifying these issues is essential for informing structural reforms and improving care quality. This category includes three subcategories.\u003c/p\u003e\u003cp\u003eSubcategory 1: Shortages in Health System Resources and Infrastructure\u003c/p\u003e\u003cp\u003eThis subcategory addresses infrastructural limitations and deficiencies in human, financial, physical, and service-related resources that hinder comprehensive MS care. It includes seven sub-subcategories:\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e1.1 Structural Issues in Financial and Insurance Policies\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThis sub-subcategory highlights the weaknesses and inconsistencies in financial and insurance policymaking related to MS care. Findings revealed that inefficient insurance coverage, fragmented systems, and a lack of incentives for healthcare centers to collaborate with insurers significantly disrupt patients’ equitable and continuous access to care and rehabilitation. These challenges not only increase financial burdens but also lead to dissatisfaction and interruptions in treatment.\u003c/p\u003e\u003cp\u003eAs noted by an MS Disease expert:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"One of the main problems is access to services. For instance, rehabilitation and dental schools, which are run by medical universities, ironically resist contracting with insurance providers the most. They charge patients directly, and many patients simply can't afford to pay.\" (Participant No. 42)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e2.1 Shortage of Trained and Specialized Healthcare Personnel\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThis sub-subcategory highlights the lack of adequately trained professionals in MS care. The findings show that many treatment centers, particularly public ones, face a shortage of specialists familiar with the complex needs of MS patients. This shortage leads to increased workloads for existing staff, diminished quality of care, and patient dissatisfaction. Inadequate specialized training and the involvement of unqualified personnel further exacerbate treatment challenges.\u003c/p\u003e\u003cp\u003eA plasma exchange nurse explained:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I cover three hospitals, and there’s no staff. Plasmapheresis is a specialized task—it takes a long time to learn. The patient's blood—around 700cc—is in the machine. If the nurse isn’t trained and the patient goes into hypovolemic shock, they could die. I received three months of training before getting certified.\" (Participant No. 18)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e3.1. Limited Home Care and Support Services\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThis subcategory highlights the lack of structured systems for delivering out-of-hospital care and support to MS patients. Findings revealed that home care services, especially for advanced-stage patients, are either unavailable or extremely limited. The absence of multidisciplinary home care teams and supportive services—such as spiritual care and rehabilitation—disrupts continuity of care and places a heavy burden on families.\u003c/p\u003e\u003cp\u003eA spiritual care provider noted:\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"The biggest challenge in spiritual care is structural. There’s no official organizational unit for spiritual care—neither in the Ministry, nor in universities, nor in hospitals. There’s no faculty, department, or clinic dedicated to it, not even in MS centers.\" (Participant No. 37)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA patient added:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026nbsp;\"I wish there were supportive agencies that came to homes, especially for patients with mobility issues who use walkers or similar aids. In-home physiotherapy at an affordable cost would help.\" (Participant No. 1)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e4.1. Inadequate Supportive and Regulatory Infrastructure\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThis subcategory addresses the absence of essential supportive and supervisory structures needed for effective MS care. Key issues include a lack of counseling services, the absence of caregiver support systems, insufficient oversight of non-specialized interventions, and financial competition among care centers.\u003c/p\u003e\u003cp\u003eA social worker noted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"We have many bedridden patients, but there are no dedicated support services for their caregivers.\" (Participant No. 39)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e5.1 Deficiencies in Professional Health Education Systems\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThis subcategory reflects gaps in the education and training of healthcare professionals. These include limited awareness of MS symptoms, lack of training on comprehensive and interdisciplinary care, and neglect of patients’ psychological and spiritual needs. Such gaps hinder the provision of holistic care.\u003c/p\u003e\u003cp\u003eA psychiatrist remarked:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"A major factor is lack of awareness. Physicians and nurses treating MS patients often fail to recognize mental symptoms or understand the importance of addressing them alongside physical symptoms.\" (Participant No. 34)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e6.1. Lack of Physical and Equipment Infrastructure\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eDeficiencies in physical and medical infrastructure—such as limited hospital beds, inadequate equipment, and constrained clinical space—have imposed additional pressure on healthcare staff and negatively affected care quality. These shortages create widespread operational and managerial challenges in the treatment process.\u003c/p\u003e\u003cp\u003eA nurse shared:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Since MS patients often need regular infusions, we have far fewer beds than required. Thousands of patients are under treatment, but the outpatient clinic has very limited infusion beds, leading to delays in timely drug administration.\" (Participant No. 22)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e7.1. Gap Between Services Provided and Patient Expectations\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe mismatch between available services and patient expectations negatively affects patient experience and satisfaction. Limited time for doctor–patient interaction, inadequate communication, and unmet expectations contribute to dissatisfaction and reduced care quality.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOne patient explained:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"My doctor doesn’t spend enough time with me—just a quick one-minute visit. I can’t fully express my problems. There’s pressure to rush through appointments, and I end up forgetting important things. I expect better care than this.\" (Participant No. 6)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSubcategory 2: Organizational and Managerial Challenges in the Care Process\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThis subcategory highlights managerial and structural barriers such as the lack of an effective referral system, neglect of a holistic care approach, poor interdepartmental coordination, weak teamwork, limited insurance coverage, and time-consuming administrative processes. These factors disrupt the continuity and effectiveness of care for MS patients and hinder timely and integrated service delivery.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e1.2. Structural Deficiencies in Referral and Follow-Up Processes\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eFindings revealed that the lack of an integrated system for identifying, referring, and following up with MS patients leads to confusion and discontinuity in care. Inadequate referrals to specialized services and the absence of follow-up mechanisms, such as nurse coordinators or medical record tracking, significantly disrupt the continuity and quality of care.\u003c/p\u003e\u003cp\u003eA nurse noted:\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cem\u003e“We don’t have a follow-up nurse to coordinate treatment and care activities” (Participant 21).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eSimilarly, a speech therapist stated: “The main reason patients don’t come to speech therapy is that doctors don’t refer them—they’re not even aware we can help” (Participant 29).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e2.2. Neglect of a Holistic Approach in Service Design\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe healthcare system's focus on medical interventions has led to the neglect of essential components such as nutrition, optometry, spiritual care, and complementary medicine in MS management. The absence of integrated care centers offering multidisciplinary services has reduced both care effectiveness and patient satisfaction.\u003c/p\u003e\u003cp\u003eA physiotherapist explained:\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cem\u003e“In MS, nutritional status is critical, but often ignored. Everyone focuses only on medication or rehab. If nutrition and psychological support are strong, I can get much better outcomes from physiotherapy” (Participant 25).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e3.2. Lack of Interprofessional Coordination and Teamwork\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eData revealed that the absence of an integrated care team and poor interprofessional collaboration among healthcare providers lead to fragmented services and reduce the effectiveness of multidisciplinary MS care.\u003c/p\u003e\u003cp\u003eAn occupational therapist explained:\u003c/p\u003e\u003cp\u003e\u003cem\u003e“Without a treatment team, patients receive poor care. If nurses, doctors, physiotherapists, and others coordinated, we could avoid unnecessary treatments and equipment. But now everyone works separately” (Participant 28).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e4.2. Inadequate Insurance Coverage for Medications and Rehabilitation Services\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eLimited insurance support for rehabilitation, supplementary medications, and assistive devices imposes a significant financial burden on patients, disrupting continuity of care.\u003c/p\u003e\u003cp\u003eAn ophthalmologist noted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026nbsp;“Insurance doesn’t cover the high cost of low vision aids, including visits and devices” (Participant 31).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA health insurance specialist added:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026nbsp;“Rehabilitation services like occupational therapy are not covered” (Participant 44).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e5.2. Delays in Accessing Care Services\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eInefficient appointment systems and long waiting times, especially in public centers, were reported to hinder the treatment process, causing frustration, dissatisfaction, and in some cases, treatment discontinuation.\u003c/p\u003e\u003cp\u003eA chronic disease coordinator remarked:\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cem\u003e“Public centers offering rehabilitation services are overcrowded, and MS patients face long waits” (Participant 42).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSubcategory 3: Operational Gaps in the Delivery and Provision of Care Services\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThis subcategory highlights executive challenges in the supply of medications, equipment, and the effective delivery of care services. Findings showed that instability in drug availability, poor resource management, and disorganized service provision—especially in public centers—led to delays in treatment, patient dissatisfaction, and reduced care effectiveness.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e1.3. Medication and Equipment Supply Issues\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eParticipants reported shortages of essential medications, difficulty accessing certain drugs, delays in hospital pharmacy supply, and problems with home delivery. These issues disrupted treatment continuity and imposed psychological and financial stress on patients.\u003c/p\u003e\u003cp\u003eA nurse noted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026nbsp;“Sometimes getting medication is very difficult, and patients wait for months” (Participant 20).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e2.3. Managerial and Operational Failures in Service Delivery\u003c/strong\u003e\u003c/p\u003e\u003cp\u003ePatients faced confusion during service navigation, a lack of guidance, and inefficient resource allocation. Poor distribution of equipment, limited clinical space, inadequate hospital capacity management, and unclear task distribution among staff were cited as barriers to consistent and quality care.\u003c/p\u003e\u003cp\u003eA dietitian stated:\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cem\u003e“There are very few centers focused on MS nutrition; in fact, we lack professionals who understand and provide specific dietary recommendations for MS. That’s our biggest gap” (Participant 35).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e2) Challenges Faced by Patients and Family Caregivers in the MS Care Process\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThis category highlights the difficulties experienced by patients with multiple sclerosis and their family caregivers during the care process. Psychological, financial, informational, and support-related pressures—as well as limited access to services—have reduced their ability to manage the disease effectively. These challenges have also disrupted treatment adherence and negatively impacted their quality of life. This category includes four subcategories.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSubcategory 1: Economic Burdens in the Treatment and Rehabilitation Pathway\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThis subcategory refers to financial barriers that hinder the treatment and rehabilitation of MS patients. Findings revealed that high and ongoing costs have led to treatment delays, interrupted rehabilitation, and, in some cases, withdrawal from care services. These financial strains have also been associated with stress, social isolation, and reduced quality of life.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e1-1. Economic Burden of Treatment and Rehabilitation Services\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe findings revealed that high costs related to medical care, rehabilitation sessions, and diagnostic and assistive equipment impose a substantial financial burden on patients and their families. Inadequate insurance coverage further exacerbates this issue, often resulting in treatment delays and reduced access to effective care.\u003c/p\u003e\u003cp\u003eA family caregiver shared:\u003c/p\u003e\u003cp\u003e\u0026nbsp;\u003cem\u003e“They told me to get a respiratory support device, but it was expensive. Even renting it was costly.” (Participant 47)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e2-1. Financial Barriers to Continuity of Care\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eData indicated that low income and financial stress—often due to unemployment or reduced earnings—led to interruptions in treatment, withdrawal from rehabilitation, and choices driven by affordability rather than clinical need. These limitations compromise the continuity and effectiveness of care.\u003c/p\u003e\u003cp\u003eA neurologist explained:\u003c/p\u003e\u003cp\u003e\u0026nbsp;\u003cem\u003e“Many patients have serious financial difficulties, which prevent them from receiving necessary treatment.” (Participant 13)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSubcategory 2: Psychosocial Stressors Experienced by Patients and Caregivers\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eData revealed that anxiety, stress, burnout, and financial and social concerns are common among patients and caregivers. Prolonged caregiving without adequate support often leads to emotional exhaustion, diminished quality of life, and strained family dynamics, social interactions, and treatment adherence.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e1-2. Distrust and Negative Perceptions Toward Treatment\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eParticipants cited prior unsuccessful experiences, uncertainty about treatment outcomes, and delayed therapeutic responses as key reasons for distrust. This skepticism sometimes led to treatment discontinuation, disregard for professional advice, and neglect of complementary care.\u003c/p\u003e\u003cp\u003eA vision specialist stated:\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cem\u003e“Part of the problem is a lack of trust in the medical team—patients aren’t sure whether paying for care will help.” (Participant 32)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e2-2. Caregiver Burnout and Role-Related Stress\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eCaregivers reported persistent fatigue, repetitive responsibilities, conflict between personal and caregiving needs, and high emotional strain. These challenges gradually undermined their mental well-being and reduced the quality of care provided.\u003c/p\u003e\u003cp\u003eA family caregiver shared:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026nbsp;“My husband was hospitalized and I stayed with him all the time. I was so exhausted that I could barely walk, and my family was worried about me too.” (Participant 48)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e3-2. Emotional and Social Conflicts Faced by Family Caregivers\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eConcerns about the patient's financial future, social acceptance, marriage prospects, and balancing caregiving with personal life caused emotional distress and mental health strain among caregivers.\u003c/p\u003e\u003cp\u003eOne caregiver noted:\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cem\u003e“No one knows what will happen to my daughter in the future. I’m very worried.” (Participant 46)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSubcategory 3: Psychological and Cultural Barriers to Care Access\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe findings revealed that misconceptions about treatment, fear of stigma or side effects, and lack of information significantly restrict access to care. These barriers stem from inadequate patient education, negative attitudes toward chronic illness, and low cultural readiness for multidisciplinary services.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e1-3. Patient and Family Misbeliefs Regarding Treatment\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eSome participants held erroneous beliefs—such as fearing addiction to psychiatric medications, thinking treatment is unnecessary during pregnancy or breastfeeding, or doubting the efficacy of rehabilitation—which led to delays, discontinuation, or resistance toward comprehensive care.\u003c/p\u003e\u003cp\u003eOne speech therapist remarked:\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cem\u003e“Patients often expect medication rather than therapy; when speech therapy exercises begin, they resist because it’s not a pill they can take.” (Participant 30)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e2-3. Fear of Stigma and Shame\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eFear of judgment, shame, and concern over being labeled mentally ill prevented some patients and caregivers from seeking psychological services. These hidden barriers limit access to critical mental health care.\u003c/p\u003e\u003cp\u003eA psychologist stated:\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cem\u003e“Patients feel embarrassed to see a psychologist; they worry others will think they are mentally unwell, so they avoid seeking help.” (Participant 33)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e3-3. Lack of Awareness About the Importance of Care and Available Services\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eParticipants reported that patients and families often lack awareness of psychological symptoms, the role of mental health in physical recovery, and the availability of supportive services like spiritual care, psychotherapy, and rehabilitation. This gap in awareness undermines comprehensive, effective care.\u003c/p\u003e\u003cp\u003eA spiritual caregiver explained:\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cem\u003e“The problem is that patients are unfamiliar with spiritual care and unaware of its benefits.” (Participant 38)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSubcategory 4: Physical and Operational Barriers to Healthcare Access\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eFindings indicated that a lack of adequate transportation facilities, mobility limitations, and challenges accessing medical centers significantly hinder patients’ ability to attend appointments. These barriers reduce treatment adherence and heighten patients’ feelings of isolation.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e1-4. Transportation Issues and Mobility Challenges\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eParticipants reported difficulties in transporting physically disabled patients due to the lack of appropriate vehicles and limited family support. These issues, particularly in advanced disease stages, often led to missed appointments and reduced motivation to continue care.\u003c/p\u003e\u003cp\u003eA caregiver shared:\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cem\u003e“Getting the patient to the hospital or doctor’s office is very hard. Sometimes, we don’t even take them because it’s just too difficult.” (Participant 49)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore the challenges of MS care management from the perspectives of patients, family caregivers, and healthcare providers. One of the main categories identified was \u0026ldquo;structural and professional barriers in the management of care services,\u0026rdquo; which included policy gaps, workforce shortages, inadequate infrastructure, and weak implementation processes. Issues such as the lack of home-based services, limited medical equipment, and poorly designed clinical environments were also found to hinder the quality and accessibility of care. These findings highlight a significant mismatch between the complex needs of MS patients and the current structure of the healthcare system. To enhance care quality, health policies must prioritize system reform, resource strengthening, and the development of integrated and continuous care services[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOne of the key findings of this study was that insufficient resources and infrastructure within the healthcare system hinder the delivery of continuous and effective care for MS patients. Participants identified shortcomings in financial and insurance policies, workforce shortages\u0026mdash;particularly in rehabilitation, mental health, and nursing\u0026mdash;limited home-based and psychosocial support services, inadequate professional training, lack of necessary equipment, and a mismatch between patient needs and available services. In the financial domain, inadequate insurance coverage for rehabilitation, medications, and assistive devices imposes a heavy burden, a challenge affecting over 54% of MS patients in Iran, as reported by Gharibi et al. (2021)[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Similarly, Jahromi et al. (2023) emphasized workforce shortages as a major barrier to comprehensive care. Weak home care structures and psychosocial supports exacerbate family stress and disrupt treatment continuity, while insufficient professional preparation leaves many care providers unready[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Additionally, the lack of physical and rehabilitative infrastructure\u0026mdash;especially in underserved regions\u0026mdash;diminishes patients\u0026rsquo; motivation to pursue treatment. Finally, the gap between patient expectations and available services reflects insufficient stakeholder engagement in service design, an issue highlighted by Hosseini et al. (2022)[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Collectively, these findings underscore the urgent need for insurance reform, multidisciplinary workforce development, expansion of home-based care, infrastructure strengthening, and inclusive, patient-centered service planning.\u003c/p\u003e\u003cp\u003eThis study revealed that organizational and managerial deficiencies, alongside structural barriers, play a crucial role in undermining the effectiveness of MS care. Deficiencies in referral and follow-up systems, the absence of integrated care services, and poor interprofessional coordination disrupted treatment continuity and created confusion for patients, an issue also highlighted by Madani et al. (2025) as a primary barrier to sustained care [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Additionally, weak collaboration among care team members and insufficient attention to psychological and social dimensions of the disease impeded comprehensive care, findings that align with systematic review results [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Furthermore, inadequate insurance coverage for medications and rehabilitation services[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], combined with lengthy appointment scheduling processes, decreased patient motivation, and increased financial strain, is another challenge emphasized by Madani et al. (2025) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Addressing these challenges requires the establishment of coordinated care frameworks, the development of integrated treatment models, and a comprehensive review of insurance policies.\u003c/p\u003e\u003cp\u003e The study\u0026rsquo;s findings indicate that operational shortcomings in securing medications and equipment, coupled with managerial inefficiencies in service distribution, directly undermine the quality of care for MS patients. Participants reported shortages of essential drugs, price volatility, and restricted access to specialized equipment\u0026mdash;issues consistent with documented supply chain disruptions in Iran. Additionally, inadequate planning for specific services, such as periodic infusions, imposed additional burdens on patients and families. This challenge mirrors the conclusions of Chungyi Chiu (2017), who identified resource distribution failures as a primary contributor to care discontinuity[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These findings underscore an urgent need to reform operational structures, strengthen oversight systems, and implement effective resource management to enhance care continuity and quality.\u003c/p\u003e\u003cp\u003eThe findings of this study indicate that individuals with MS and their family caregivers confront a spectrum of economic, psychosocial, cultural, and logistical barriers in accessing care, beyond the clinical challenges of the disease. These obstacles\u0026mdash;represented in subthemes such as psychosocial stress, financial strain, misconceptions, and physical access limitations\u0026mdash;have led to fragmented treatment, increased emotional burden, and diminished quality of life for both patients and caregivers. These results underscore the need for holistic, interdisciplinary, and cross-sector interventions in MS care planning.\u003c/p\u003e\u003cp\u003eA particularly critical dimension is the financial burden associated with treatment and rehabilitation. Our data show that, without sufficient insurance support, high out-of-pocket costs often lead to treatment interruptions and reliance on less effective alternatives. Consistent with Rezaee et al. (2022), who reported that medications account for up to 80% of total MS treatment costs[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and Soltani et al. (2024), which found that approximately 72% of individuals below the poverty line cannot afford rehabilitation expenses[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], financial hardship has also been linked to \u0026ldquo;treatment poverty\u0026rdquo;\u0026mdash;driven by debt or prioritizing medical costs over basic needs\u0026mdash;particularly in low-income families. Jahromi et al. (2023) further revealed that Iranian MS patients spend, on average, more than 40% of their household income on care. This economic stress not only hinders treatment continuity but also impacts the mental health of both patients and caregivers[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Therefore, enhancing insurance coverage, expanding public rehabilitation services, and implementing targeted financial support are essential strategies to alleviate this burden.\u003c/p\u003e\u003cp\u003ePsychosocial stressors emerged as one of the key factors undermining the care process for individuals with multiple sclerosis. The findings of this study revealed that negative attitudes toward treatment\u0026mdash;often stemming from prior unsuccessful experiences or cultural beliefs\u0026mdash;led to mistrust and discontinuation of care[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Family caregivers were particularly vulnerable to emotional exhaustion due to continuous responsibilities, emotional strain, and role conflicts. This aligns with findings from qualitative studies conducted in Ahvaz[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], which also reported anxiety about the patient\u0026rsquo;s future and the impact of caregiving on caregivers\u0026rsquo; personal and professional lives[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. These concerns created an additional psychological burden, negatively affecting the quality of life of both patients and caregivers[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. This psychological stress cycle was found to contribute to disrupted treatment adherence and increased caregiver strain. These findings highlight the urgent need for targeted interventions such as psychosocial support, caregiver training programs, and awareness-raising initiatives for patients and families to strengthen care continuity and improve overall well-being[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe findings of this study revealed that misconceptions, stigma-related fears, and lack of awareness among patients with multiple sclerosis (MS) and their families are significant barriers to effective care. Misbeliefs\u0026mdash;such as the addictive nature of psychiatric medications or the ineffectiveness of rehabilitation\u0026mdash;have, in some cases, led to treatment discontinuation, as also reported by Pourhaji et al. (2023)[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Additionally, fear of social labeling has discouraged patients and caregivers from seeking psychological and spiritual care, a phenomenon consistent with the findings of Masoudi et al. (2014)[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Furthermore, limited awareness of the importance of treatment and available services has contributed to delayed initiation of care and a tendency toward unscientific methods. Hosseini et al. (2022) also emphasized that inadequate health literacy significantly compromises the quality of care[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese results underscore the urgent need to improve health literacy, promote public education, and foster a supportive cultural environment to enhance the accessibility and effectiveness of MS care.\u003c/p\u003e\u003cp\u003eThis study identified transportation-related challenges as one of the major barriers in the care pathway for patients with multiple sclerosis (MS), particularly those with physical disabilities. Limited mobility, high transportation costs, lack of suitable transport services, and long distances to treatment centers were key factors contributing to missed appointments and interruptions in care continuity. Similar findings were reported in a qualitative study conducted in Tehran, where the absence of home-based care services was cited as a primary cause of treatment disruption[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA review of the literature also indicates that 5\u0026ndash;67% of MS patients experience transportation-related barriers, which are associated with treatment delays, increased psychological stress, and reduced motivation for ongoing care[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Additionally, the absence of an efficient appointment system, difficulty coordinating caregiver support, and inadequate clinical environments were noted as factors contributing to treatment discontinuation in some cases. To address these challenges, the expansion of home care services, the development of specialized transportation systems, and the integration of telemedicine are recommended. The effectiveness of such interventions in enhancing treatment adherence and reducing healthcare costs has been supported by El-khalik Ahmed (2023)[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and Limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study explored the experiences of patients with multiple sclerosis, family caregivers, and healthcare providers, identifying key challenges and barriers in the management of MS care. A major strength of the study was its focus on first-hand narratives from individuals directly involved in the care process, offering rich and practical insights into the complexities and multidimensional needs associated with living with and managing MS. However One limitation of this study was the potential influence of participants\u0026rsquo; psychological, emotional, and environmental conditions during interviews, which could have affected how experiences were expressed and the quality of the data. To mitigate this, interviews were conducted in calm and familiar settings, and the interviewer created a trusting atmosphere to encourage open and honest sharing.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe present study revealed that the structural, economic, psychological, and operational challenges within the care system for patients with multiple sclerosis (MS) are highly complex and interwoven. Therefore, policymaking in the field of MS must increasingly adopt a holistic, multidisciplinary, and team-based approach. Enhancing insurance coverage, expanding supportive services, improving access to specialized facilities, and promoting education, public awareness, and efficient resource management can significantly facilitate the optimization of care delivery for individuals living with MS.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMS: multiple sclerosis, RRMS: relapsing-remitting, HC: Home Care\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors extend their sincere gratitude to Isfahan University of Medical Sciences for its support in conducting this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSomayeh Azimpour: Conceptual design of the study, conducting interviews, data analysis, and drafting the initial manuscript.\u003c/p\u003e\n\u003cp\u003eNasrollah Alimohammadi:* Study design, participation in data analysis, scientific and editorial revision of the manuscript, project management, and overall supervision.\u003c/p\u003e\n\u003cp\u003eFatemeh Nazari: Contribution to data analysis and revision of manuscript drafts.\u003c/p\u003e\n\u003cp\u003eFereshteh Ashtari: Oversight of the research process, final revision of the manuscript, and scientific guidance throughout the writing stages.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was financially supported by Isfahan University of Medical Sciences under grant number 3403443.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Statement and Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki [https://www.wma.net/policies-post/wma-declaration-of-helsinki/].\u0026nbsp;Ethical approval was obtained from the Research Ethics Committee of Isfahan University of Medical Sciences, under the approval number IR.MUI.MED.REC.1403.259.\u003c/p\u003e\n\u003cp\u003eBefore participation, all individuals received detailed information about the study objectives, the process of audio recording, the use of data, and their rights as participants. Written informed consent was obtained from each participant. Confidentiality, anonymity, and the right to withdraw from the study at any stage were guaranteed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data are provided within the manuscript or as supplementary files. All data are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYamout B: \u003cstrong\u003eUpdate in multiple sclerosis\u003c/strong\u003e. \u003cem\u003eeNeurologicalSci \u003c/em\u003e2025, \u003cstrong\u003e38\u003c/strong\u003e:100553.\u003c/li\u003e\n\u003cli\u003eWitzig-Br\u0026auml;ndli V, Zech L, Lange C, Adlbrecht L, Gschwend S, Mayer H, Kohler M: \u003cstrong\u003eA self-management intervention for people with multiple sclerosis: The development of a programme theory in the field of rehabilitation nursing\u003c/strong\u003e. \u003cem\u003eEvaluation and program planning \u003c/em\u003e2023, \u003cstrong\u003e99\u003c/strong\u003e:102302.\u003c/li\u003e\n\u003cli\u003eKarimi S, Derakhshan M, Tondro A: \u003cstrong\u003eFrequency 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\u003cstrong\u003e19\u003c/strong\u003e(4):416-423.\u003c/li\u003e\n\u003cli\u003eHosseini Z, Homayuni A, Etemadifar M: \u003cstrong\u003eBarriers to quality of life in patients with multiple sclerosis: a qualitative study\u003c/strong\u003e. \u003cem\u003eBMC neurology \u003c/em\u003e2022, \u003cstrong\u003e22\u003c/strong\u003e(1):174.\u003c/li\u003e\n\u003cli\u003eSaadati Qamsari A, Noorizadeh Dehkordi S, Dadgoo M: \u003cstrong\u003eMobility barriers for people with multiple sclerosis: A qualitative study\u003c/strong\u003e. \u003cem\u003eFunction and Disability Journal \u003c/em\u003e2018, \u003cstrong\u003e1\u003c/strong\u003e(4):18-27.\u003c/li\u003e\n\u003cli\u003eSyed ST, Gerber BS, Sharp LK: \u003cstrong\u003eTraveling towards disease: transportation barriers to health care access\u003c/strong\u003e. \u003cem\u003eJournal of community health \u003c/em\u003e2013, \u003cstrong\u003e38\u003c/strong\u003e:976-993.\u003c/li\u003e\n\u003cli\u003eAhmed MAE-k, Zakaria MF, Elaziz AAEA, Fouad MM, Elbokl AM, Swelam MS: \u003cstrong\u003eAssessment of the role of telemedicine in the outcome of multiple sclerosis patients\u003c/strong\u003e. \u003cem\u003eThe Egyptian Journal of Neurology, Psychiatry and Neurosurgery \u003c/em\u003e2023, \u003cstrong\u003e59\u003c/strong\u003e(1):99.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Demographic Characteristics of Patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant Code \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eDisease Duration (Years)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;P.No 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;P.No 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;P.No 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMarried\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;P.No 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;P.No 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;P.No 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMale \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;P.No 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMale \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eP.No8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMale \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eP.No 9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 49 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMale \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp; P.No 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMale \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp; P.No 11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMale \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp; P.No 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Demographic Characteristics of Family Caregivers\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eParticipant Code\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMarital Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eYears of Caregiving Experience\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eP.No 45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eP.No 46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eP.No 47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eP.No 48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eP.No 49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eP.No 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Demographic Characteristics of MS Care Providers\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant Code\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eField of Study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWork Experience (Years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eMedicine (MS Fellow)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eFellowship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eMedicine (MS Fellow)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eFellowship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eNeurology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eSpecialty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eBSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eBSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eBSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eMSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eMSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003ePhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 22 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eBSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eBSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003ePhysiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003ePhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003ePhysiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003ePhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003ePhysiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003ePhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eOccupational Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eBSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 28 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eOccupational Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003ePhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 29 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eSpeech Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eBSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No30 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eSpeech Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003ePhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eOphthalmology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eSpecialty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eOptometry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eBSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003ePsychology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003ePhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003ePsychiatry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eSpecialty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eNutrition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003ePhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eNutrition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003ePhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eSpiritual Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003ePhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 38 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eSpiritual Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003ePhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eSocial Work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eBSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eSocial Work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eBSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eBSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No \u0026nbsp; \u0026nbsp; 43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eGeneral Medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eGP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eP.No 44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eInsurance Services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003ePhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Main Categories, Subcategories, and Sub-subcategories\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"737\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain Category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubcategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSub-subcategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"9\" valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eChallenges Faced by Patients and Family Caregivers in the MS Care Process\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eFinancial and Economic Barriers in Treatment and Rehabilitation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eEconomic burden of treatment and rehabilitation services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eFinancial constraints affecting the continuity of care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePsychosocial Pressures on Patients and Caregivers\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eMistrust and negative attitudes toward the effectiveness of care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eBurnout and stress from caregiving roles\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003ePsychological and social conflicts among family caregivers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePsychological and Cultural Barriers to Accessing Care\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eMisconceptions about treatment and care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eShame or reluctance to seek help\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eLack of awareness about the necessity of treatment and available services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ePhysical and Logistical Barriers to Accessing Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eTransportation challenges and mobility issues for patients with disabilities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"15\" valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStructural and Professional Barriers in the Management of MS Care Services\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of Resources and Infrastructure in the Health System\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eStructural problems in financial and insurance policies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eShortage of trained and specialized human resources\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eWeaknesses in home care and supportive services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eInadequate supportive and supervisory infrastructure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eDeficiencies in professional education systems\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eInadequate physical infrastructure and medical\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEquipment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eDiscrepancies between provided services and patient expectations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eOrganizational and Professional Issues in Care Pathway\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eStructural shortcomings in referral and follow-up processes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eNeglect of a holistic approach in service design\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eFragmentation and poor coordination among healthcare and support units\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eLack of interprofessional coordination and teamwork\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eInefficient insurance coverage for medication and rehabilitation services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eTime-consuming access to medical and care services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eOperational Challenges in Service Provision and Delivery\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eIssues in the supply of medications and medical equipment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 360px;\"\u003e\n \u003cp\u003eManagerial and operational inefficiencies in service distribution\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Multiple Sclerosis (MS), Treatment, Challenges, Care, Management, Caregivers, Healthcare Providers","lastPublishedDoi":"10.21203/rs.3.rs-7105887/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7105887/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Multiple sclerosis (MS) is a chronic, progressive, and disabling autoimmune disease of the central nervous system that requires continuous, coordinated, and multidimensional care. Despite advancements in medical science, patients still face numerous barriers in accessing effective care. This study aimed to identify the challenges of MS care management from the perspectives of patients, family caregivers, and healthcare providers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This descriptive qualitative study was conducted in Iran from 2024 to 2025 using purposive sampling. Data were collected through 50 semi-structured interviews with patients diagnosed with MS, family caregivers, and healthcare professionals. Data were analyzed using the Lundman and Graneheim content analysis approach, supported by MAXQDA 2020 software.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Inductive analysis yielded two main categories, seven subcategories, and 24 sub-subcategories. The two main categories were: (1) structural and professional barriers in the management of care services, and (2) Challenges faced by patients and family caregivers in the care process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The findings revealed that MS care is hindered by various structural, professional, and managerial barriers within the healthcare system, including a Shortage of specialized human resources, inadequate infrastructure, poor insurance coverage, poor interprofessional coordination, and fragmented referral and follow-up systems. In addition, psychologicalburden on patients and caregivers, misconceptions, social stigma, and physical barriers such as transportation difficulties negatively impact continuity of care and quality of life. These results highlight the need for policy reforms, interdisciplinary team training, home-based care expansion, insurance improvements, and patients and their families to enhance care quality and reduce the psychological and financial burden on patients and families.\u003c/p\u003e","manuscriptTitle":"Challenges in the Management of Care for Patients with Multiple Sclerosis: A Qualitative Study from the Perspectives of Patients, Family Caregivers, and Healthcare Providers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-21 16:41:58","doi":"10.21203/rs.3.rs-7105887/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d85ae3c9-5ee3-4ae8-bb4f-6b8608fbfb59","owner":[],"postedDate":"August 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T04:53:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-21 16:41:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7105887","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7105887","identity":"rs-7105887","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}