In this study, we explored the impact of several gender dimensions on the health technology self-efficacy (HTSE) and intention for uptake of digital health technologies (DHT) among men and women with PD. We found that gender role orientation was a stronger predictor of HTSE and intention to use DHT compared to the dimension of gender identity and gender relations. Particularly, an androgynous gender role orientation was associated with higher general self-efficacy (GSE), health technology self-efficacy (HTSE) and more positive attitude toward health technology (HTA), meaning that men and women with PD who endorse both Western stereotypical masculine and feminine (non-binary) gender role orientations, as opposed to those that orient toward either a masculine or feminine (binary) gender role orientation, are therefore more likely to adopt health technologies to monitor their health and treat their medical condition.

The impact of gender-related roles and norms on health inequalities have been emphasized in previous publications [28,29,30,31,32]. Disentangling dimensions of gender identity and normative gender roles enables a more complex investigation into the influence of gender-related norms, roles and stereotypes in access to and interactions with health technology for people with PD of similar and different socio-demographical backgrounds. This approach to gender in relation to digital healthcare technology uptake and use focuses on the way how people are culturally ‘doing gender’ (gender as a behavioral construct) in relation to health technology, rather than assuming gendered patterns of health technology use among people with PD solely based on their gender identity, which can lead to false negative findings [33, 34]. The findings of our study endorse the calls of previous papers that emphasized the critical need for considering more behavioral and relational focused gender-sensitive analyses when examining differences and similarities between women, men and non-binary people in the context of (non)digital health technology use [16, 35,36,37,38]. We therefore highlight the need to move beyond the simplistic gender identity binary in gender-sensitive analyses of health technology evaluations.

The relationship between gender roles, norms and relations and health technology is highly contextual and can be influenced by intersecting social demographics, such as education type, relative income, sexual orientation, (dis)ability, generation/age, social class/caste, (multi)ethnicity and racialization [1, 37]. Gendered experiences in self-efficacy, attitude toward and uptake of health technologies can therefore vary significantly between and within gender identity categories when multiple intersecting social demographics or clinical outcomes are considered. Therefore, we showcased a novel exploratory intersectional gender analysis to examine how gender identity, roles and relations, intersect with education, employment, disease duration and disease severity and affect health technology self-efficacy (HTSE) and health technology attitude (HTA) among people with PD. To our knowledge, this is a first intersectional gender analysis applied in the context of health technology and PD. We emphasize that the sample sizes for this exploratory analysis may not have provided adequate statistical power for robust intersectional conclusions and that the results should therefore be interpreted with caution. We accentuate the exploratory intention for this analysis to demonstrate an intersectional gender approach that could be replicable in more detailed (case) studies with more extensive study populations.

Our exploratory intersectional gender analysis suggested that an androgynous gender role, compounded with higher education, unemployment, or lower disease severity appeared to be related to better HTSE, whereas an undifferentiated gender role, compounded with a lower education level, unemployment, and relatively higher disease duration predicted related to worse HTSE. Additionally, an androgynous gender role, compounded by higher education, unemployment, or a relatively shorter disease duration, predicted more positive HTA, whereas an undifferentiated gender role, compounded with a lower education level, unemployment, a relatively shorter disease duration, or more severe disease severity predicted more negative HTA. These results indicate, cautiously, that the impact of normative gender roles on HTSE and HTA can be moderated by these sociodemographic and clinical factors and are therefore potentially relevant to consider in conjunction with gender dimensions through intersectional analyses. The observed effect sizes for HTSE and HTA ranged from small to medium, with some reaching medium to large, highlighting the importance of considering the nuances and contexts of these effects in further research and practical applications.

Digital health technologies are often presented as having the potential to boost efficiency, increase personalization of PD care and provide more equitable access to PD healthcare services [1, 39]. However, DHT that are supposed to lessen disparities can also potentially exacerbate them for particular sub-populations of people with PD when social determinants, such as gender, are looked at as single factors rather than as factors that are moderated in the presence or absence of other intersecting social or disease-specific factors, resulting in compounded advantages or disadvantages in uptake and use of these DHT [40]. Intersectionality theory applied to DHT suggests that each individual’s identity and lived experience is multifaceted and that individuals will use (or will not use) digital health services based on their own unique circumstances, rather than as members of a single social category (Man/Woman, Higher/Lower Educated, Younger/Older, Higher/Lower Disease Severity, etc.). With a growing interest in assessing and monitoring PD symptoms with digital and mobile health technologies, it is simultaneously important to consider these intersectional factors in detailed case studies to better understand how different aspects of (dis)advantages interact with individual lives of people with PD. Ultimately, this should support more successful adoption of health technologies into PD care while reduce the risk of, unintentionally, causing or increasing digital health disparities between different social groups of men and women with PD [39, 40].

To capture multiple gender dimensions in our survey, we used a gender assessment including state-of-the-art options for operationalizing the gender dimensions as applied to this study. Currently, there is no golden standard for the operationalization of these gender dimensions in medical research. Therefore, it remains critical to clearly define the underlying classifications to support reproducibility. Although the BSRI is still widely used as a measure for gender roles, it has encountered valid criticism regarding the categorization of masculine and feminine traits and the cultural and time sensitivity of gender stereotypes [41, 42]. Furthermore, we operationalized gender relations through involvement in household tasks and relative income using self-reported responses from the participants only. For more robust data interpretation, the recording of the responses of both the participants and their partners/spouses to these items would be preferred.

Also, the HTSE questionnaire was not specifically designed to detect HTSE among people with PD. While using a generic HTSE measure allows for comparison between individuals with PD and people with other chronic diseases, disease-specific factors may affect the ease and confidence with which people with PD use health technologies. Our exploratory intersectional gender analysis showed that disease-specific factors, such as disease duration and disease severity, can potentially affect HTSE and HTA but only on the behavioral dimension of gender role orientation, indicating their intersection with social gender norms and stereotypical roles.

The finding that individuals with androgynous gender roles exhibited better HTSE and HTA was based on our initial hypothesis, thus rejecting the null hypothesis. Specifically, androgynous gender roles were associated with higher HTSE and more positive attitudes toward health technology with medium effect sizes. This effect size, while indicative of meaningful associations, also highlight a limitation in terms of the strength, emphasizing the need for further research with larger sample sizes to confirm these findings.

We also reported preliminary findings of our intersectional gender analysis intended for replication due to limitations on statistical power. Replicating these results in future studies is essential to validate the observed trends and to further investigate the complex interactions between gender roles, social factors, and disease-specific factors in influencing HTSE and HTA.