Abstract
Purpose:
This cross-sectional descriptive study describes available pelvic floor physiotherapy (PT) services for older women with urinary incontinence (UI) in Quebec, Canada, and identifies possible affordability barriers.
Methods:
From September to December 2019, Quebec physiotherapists practising pelvic floor PT were invited to complete a survey on their clinical practice and perceptions of the affordability of UI treatment for older women.
Results:
Eighty-four of the 225 registered pelvic floor physiotherapists (37.3%) filled out the online survey. They worked a median of 32 hours/week in PT, with 15 of those hours (46.9%) in pelvic floor PT and three hours (9.8%) treating UI in older women. Only 13.0% of them offered group treatment, while 84.3% were interested in it. Most of the physiotherapists (92.2%) had met older women in their practice who had reported financial barriers to completing their pelvic floor PT treatment.
Conclusions:
The accessibility of UI care in Quebec appears hampered by the limited availability of pelvic floor PT treatments, mainly in public settings, and potential financial constraints. Providing pelvic floor PT to groups could constitute a promising avenue to tackle both issues. Future studies should look at ways of implementing this option.
Key Words: aged, health care surveys, health services accessibility, rehabilitation, urinary incontinence
Résumé
Objectif :
Cette étude transversale décrit les services de physiothérapie du plancher pelvien (PPP) disponibles aux femmes âgées qui présentent de l’incontinence urinaire (IU) au Québec, Canada et en identifie les possibles barrières financières.
Méthodologie :
De septembre à décembre 2019, les physiothérapeutes du Québec pratiquant la PPP ont été invités à compléter un sondage sur leur pratique clinique et leurs perceptions quant à l’accessibilité financière du traitement de l’IU pour les femmes âgées.
Résultats :
Quatre-vingt-quatre des 225 physiothérapeutes en PPP du Québec (37,3%) ont complété le sondage. Leur semaine de travail médiane était de 32 heures/semaine en physiothérapie, dont 15 heures (46,9%) en PPP et trois heures (9,8%) pour le traitement de l’IU auprès de femmes âgées. Seulement 13,0% des physiothérapeutes offraient des traitements en groupe, bien que 84,3% avaient de l’intérêt pour ce format. La plupart (92,2%) avaient rencontré des femmes âgées avec des barrières financières limitant la poursuite de leur traitement en PPP.
Conclusions :
L’accessibilité des soins de continence au Québec apparaît limitée par la disponibilité restreinte des traitements de PPP, principalement dans le système public, et de possibles contraintes financières. La PPP en groupe pourrait constituer une avenue intéressante. D’autres études devront s’interroger sur l’implantation de telles options.
Mots-clés : accessibilité des services de santé, incontinence urinaire, population âgée, réadaptation, sondage sur les soins de santé
Urinary incontinence (UI) is a highly prevalent condition affecting 25% of adult women.1 Prevalence increases with age, and one in three women is affected after age 65.2,3 UI in women is a major public health issue, not only in terms of prevalence but also because of its negative impact on quality of life, body image, sexual intimacy, and social participation.4,5 Older women are particularly affected and often reduce their physical and social activities to avoid leakage. Consequently, they commonly experience isolation, stigma, and reduced self-confidence due to their symptoms.2,6
Conservative management interventions including pelvic floor PT, lifestyle interventions, and bladder retraining are recognized as effective treatment options for UI.7,8They are recommended as a first-line treatment in national and international clinical practice guidelines (recommendation grade: A).7,9 Pelvic floor PT is considered an effective treatment option for all young, middle-aged, and older women with stress or mixed UI.8
The accessibility of service encompasses multiple concepts: acceptability (whether the attitudes, beliefs, and expectations of the service users and providers foster appropriate care); availability (whether appropriate care can be provided in the needed time and place); and affordability (whether the service users have the ability to pay for the full cost of their care).10
Pelvic floor PT’s acceptability is supported by strong clinical recommendations.7,9 Despite these recommendations and the evidence supporting the negative long-term impacts of untreated UI, treatment availability remains problematic as more than half of incontinent women in North America and Europe are not receiving any treatment.11,12 In a briefing document for policy-makers, the Canadian Continence Foundation highlighted delays in accessing appropriate care and one-year wait-lists for a consultation with a UI specialist.13 Quebec’s wait times for publicly funded general or musculoskeletal PT services often reaches several months.14,15 However, there is no data describing the availability of pelvic floor PT in the province of Quebec.
The issue of the affordability of pelvic floor PT has been identified as a barrier to receiving services in other Canadian provinces and could discourage potential patients from consulting a specialist.16 Considering the long wait times for publicly funded PT services in Quebec, patients are commonly directed toward privately funded ser-vices.14 However, private health insurance offers limited coverage of PT in the province. Quebec’s federation of private PT clinics (Fédération des cliniques de physiothérapie du Québec [FCPQ]) reported that patients were typically unwilling or unable to cover the costs out of pocket.17 No statistics specific to pelvic floor PT are currently available.
To date, no study has assessed the accessibility of pelvic floor PT in the Quebec health care system for women and particularly for older women, who have a higher risk of UI. The objective of this study was to describe available pelvic floor PT services for older women with UI in Quebec and identify possible affordability barriers.
Methods
Research design and study sample
In this cross-sectional descriptive study, we invited all physiotherapists practising pelvic floor PT in Quebec to complete an online survey. We contacted potential participants by email through the newsletter of the Quebec physiotherapists’ professional order, the Ordre professionnel de la physiothérapie du Québec (OPPQ) and the list of graduates from Université de Montréal’s postgraduate pelvic floor PT program. We also contacted potential participants through social media platforms and pelvic floor PT-specific Facebook groups and pages. The survey was available online in French and English from September to December 2019.
The Ethics Committee Board of the Montreal Geriatric University Institute Research Centre approved this study (CER VN 18-19-37). Participants provided informed consent online before accessing the 10-minute survey. We avoided collecting any identifying information, and all of the participants filled out the survey anonymously.
Survey instrument
We created the survey using FourEyes servers, which are hosted in a secure location in Seattle, protected by high-performance monitored firewalls and which encrypt all data via Transport Layer Security. The survey collected: (1) the physiotherapists’ socio-demographic data (preferred language, gender, public/private setting, rural/ urban community, training in pelvic floor PT, age, y of practice); (2) data on available PT services and the physiotherapists’ clinical practice (weekly h, current practices, wait-lists); and (3) the physiotherapists’ perceptions of the affordability of treatment for older women (costs associated with evaluation and treatment, financial security of their served population, barriers seen in their practice). The research team created the survey questions by considering both the availability and affordability dimensions of accessibility, as defined by McIntyre and colleagues.10 This definition is frequently cited and used in multiple reviews on the accessibility of care world-wide.18–20 We also considered pragmatic concerns related to the online format of the survey and the busy schedules of physiotherapists. The survey is available in Appendix 1.
Statistical analyses
The survey responses provided both quantitative and qualitative data. We reported quantitative data in a descriptive manner using frequencies and percentages, means, and standard deviations or medians, and 25th and 75th percentiles, when appropriate. We analyzed all of the data with IBM SPSS Statistics, version 23.0.0.2 (IBM Corporation, Amonk, NY). Additionally, because the accessibility concerns of public and private health care services21–23 and rural and urban areas24–26 might differ, we contrasted narratively the answers from the different sub-groups of public/private practice settings and rural/ urban work areas. We used qualitative data to understand the status of Quebec’s pelvic floor PT services. Respondents’ free text answers were grouped and summarized or categorized, when applicable. When relevant, we reported these answers narratively.
Results
Socio-demographic data
Among the 225 physiotherapists registered as pelvic floor physiotherapists in 2019,29 84 (37.3%) answered the online survey. All respondents were women (n = 84), and the vast majority were French-speaking (n = 79; 94.0%), working exclusively in the private sector (n = 70; 83.3%), and working in an urban area (n = 76; 90.5%). Of note, all physiotherapists practising in rural settings (n = 8; 9.5%) worked in the private sector. Respondents were aged 23–60 years and had a median pelvic floor PT practice experience of 4.3 years. Almost two-thirds of respondents (n = 54; 64.3%) were either enrolled in or had already completed a postgraduate university program in pelvic floor PT. Complete socio-demographic data are summarized in Table 1.
Table 1.
Socio-Demographic Data of Survey Participants
| No. (%) of respondents or median (25th–75th percentile) | ||
|---|---|---|
| Preferred language | French | 79 (94.0) |
| English | 5 (6.0) | |
| Gender | Women | 83 (98.8) |
| Men | 0 (0.0) | |
| Not answered | 1 (1.2) | |
| Work sector | Public | 7 (8.3) |
| Private | 70 (83.3) | |
| Public/Private | 7 (8.3) | |
| Practice setting | Urban | 74 (88.1) |
| Rural | 8 (9.5) | |
| Mixed | 2 (2.4) | |
| Training in pelvic floor PT* | Postgraduate university program in pelvic floor PT | 54 (64.3) |
| Entry-level university course in pelvic floor PT (with hands-on practice) | 19 (22.6) | |
| Entry-level university course in pelvic floor PT (without hands-on practice) | 6 (7.1) | |
| Continuing education training† | 40 (47.6) | |
| No answer | 2 (2.4) | |
| Age (y) | 32.2 (29.0-36.0) | |
| PT practice experience (y) | 8.0 (4.0–12.3) | |
| Pelvic floor PT practice experience (y) | 4.3 (2.0–9.0) |
Respondents could choose more than one answer.
The continuing education training listed by the respondents included OPPQ continuing education courses (with and without hands-on practice); formal courses from private organizations; out-of-province experts; European classes; rehabilitation institutes in the United States; and mentoring from other physiotherapists, either through clinical placements or from senior colleagues.
Available services and clinical practice
Weekly hours
The surveyed physiotherapists reported working a median of 32 hours per week in PT, with 15 (46.9%) of those hours dedicated to pelvic floor PT and three hours (9.8%) devoted to treating UI in women over age 60 (Table 2).
Table 2.
Available Pelvic Floor PT Services and Clinical Practice Data in Public and Private Settings
| Public only | Private only | All respondents | |
|---|---|---|---|
| n = 7* | n = 70* | n = 84*† | |
| Weekly h worked in PT (median, 25th–75th percentile) | 28.0 (25.0–36.0) | 32.0 (25.8–35.0) | 32.0 (25.0–35.0) |
| n = 7 | n = 66 | n = 80 | |
| Weekly h worked in pelvic floor PT (median, 25th–75th percentile) | 7.0(4.0–16.5) | 15.5 (7.3–24.5) | 15.0 (6.0–23.5) |
| n = 7 | n = 66 | n = 80 | |
| Weekly h worked in pelvic floor PT treating women aged 60+ y with UI (median,25th-75th percentile) | 4.0 (2.5–8.5) | 3.0 (2.0–5.5) | 3.0 (2.0–6.0) |
| n = 7 | n = 65 | n = 77 | |
| Duration of a pelvic floor PT evaluation in min (median, 25th–75th percentile) | 90.0 (75.0–90.0) | 60.0(60.0–71.3) | 60.0 (60.0–75.0) |
| n = 4 | n = 63 | n = 73 | |
| Duration of a pelvic floor PT treatment in min (median, 25th–75th percentile) | 60.0 (60.0–60.0) | 60.0 (60.0–60.0) | 60.0 (60.0–60.0) |
| n = 4 | n = 63 | n = 73 | |
| Number of pelvic floor PT sessions routinely scheduled to treat women aged 60+ y with UI (median, 25th-75th percentile) | 6.0 (4.5-7.0) | 5.0 (4.0-5.6) | 5.0 (4.0–6.0) |
| n = 4 | n = 62 | n = 68 | |
| Reported being the only pelvic floor physiotherapist at their workplace (n, %) | 2 (40.0%) | 39 (58.2%) | 41 (56.2%) |
| n = 5 | n = 67 | n = 73 | |
| Currently offering a group treatment approach (n, %) | 1 (25.0%) | 7(11.1%) | 9 (13.0%) |
| n = 4 | n = 63 | n = 69 | |
| Open to offering a group treatment approach (n, %) | 3 (100.0%) | 51 (83.6%) | 59 (84.3%) |
| n = 3 | n = 61 | n = 70 | |
| Wait-list in number of wk (median, 25"th-75th percentile) | 5.9(4.0–12.0) | 2.0(3.5–1.0) | 2.0 (1.4–4.0) |
| n = 4 | n = 62 | n = 69 |
As response rates varied between questions, the table reports the number of respondents for each question (n).
Seven respondents had a mixed practice of both public and private sectors: their data is only reported in the “All respondents” column.
Current practices in pelvic floor PT
In their pelvic floor PT practice, respondents typically scheduled a 60-minute initial evaluation session and 60-minute treatment sessions. When treating UI in women over the age of 60 years, physiotherapists planned a median of five treatment sessions. The majority of the respondents (56.2%) were the only physiotherapist in their workplace to offer pelvic floor PT. Overall, only a few of the surveyed physiotherapists offered a group treatment approach in their practice (13.0%), while many were interested in the idea (84.3%).
Wait-lists
Respondents estimated that new patients would have to wait a median of two weeks before receiving pelvic floor PT in their setting. This wait time refers only to the time between a contact with the physiotherapists’ setting and an appointment availability. It does not include any wait time for a physician appointment to obtain a referral. Yet, such referrals were needed for a few of the respondents with a public practice (6/14, 42.9%), possibly adding to the wait times.
Perceived affordability of treatment in private practice
Costs associated with evaluation and treatment
In their pelvic floor PT practice, private-sector physiotherapists charged a median fee of $105 for an evaluation session and $95 for a treatment session (Table 3). Almost all of the respondents (n = 26/27; 96.3%) mentioned that occasional fees could be added during the course of the treatment. The most frequently reported additional costs pertained to vaginal or anal probes, which cost from $20 to $60, and dilators, which cost from $20 to $70.
Table 3.
Perceived Affordability of Pelvic Floor PT Among Private-Practice Respondents
| All respondents with a private practice n = 77*† | |||
|---|---|---|---|
| Cost of a pelvic floor PT evaluation session, in $CAD (median, 25th–75th percentile) | 105.0(95.0–110.5) n = 63 | ||
| Cost of a pelvic floor PT treatment session, in $CAD (median, 25th–75th percentile) | 95.0(95.0–100.0) n = 63 | ||
| Possibility of occasional additional fees during the treatment course (n, %) | 26 (96.3%) n = 27 | ||
| Respondents declaring that women aged 60+ y seen in practice generally have insurance to cover treatment cost (n, %) | 21 (33.9%) n = 62 | ||
| Respondents declaring that women aged 60+ y seen in practice have reported financial limitations to complete treatment (n, %) | 59 (92.2%) n = 64 | ||
| Proportion of older women with | 0–25% | 34 (54.0%) | |
| financial limitations seen in | 26–50% | 15(23.8%) | n=63 |
| practice (n, %) | 51–75% | 9 (14.3%) | |
| 76–100% | 5 (7.9%) | ||
| Respondents declaring that older women seen in practice limited their number of treatment sessions for financial reasons (n, %) | 57 (90.5%) n = 63 | ||
| Respondents declaring that reducing the number of sessions due to financial constraints affected or limited impact of treatment (n, %) | 51 (91.1%) n = 56 | ||
Seven of these respondents had a mixed practice in both the public and private sectors.
As response rates varied between questions, the table reports the number of respondents for each question (n).
Financial security and financial barriers seen in practice
When answering the questions pertaining to afford-ability, physiotherapists shared their perceptions specifically related to the population of women over age 60 years with UI. To cover the previously mentioned expenditures, respondents estimated that, in their experience, only one in three older women had private health insurance. Most of the surveyed physiotherapists (n = 59/64; 92.2%) had met older women in their practice who had reported that financial barriers limited their completion of pelvic floor PT treatment. For almost half of respondents (n = 29/63; 46.0%), the situation arose at least in one in four older women. As a consequence, most physiotherapists (n = 57/63; 90.5%) reported having observed older women limiting their number of treatment sessions due to financial reasons. The majority of respondents (n = 51/56; 91.1%) considered that this reduction in the number of treatment sessions limited the impact of pelvic floor PT on the symptoms of the consulting older women.
Sub-group comparison analyses
Public/private practice settings
The physiotherapists working exclusively in a public setting (n = 7) reported slightly fewer work hours compared to their colleagues in private settings with a median of 28 hours versus 32 hours of PT, respectively. Public- and private -sector physiotherapists reported a median of seven hours (25% of caseload) versus 15.5 hours (48% of caseload) of pelvic floor PT, respectively, but a median of four hours (14.3% of caseload) versus three hours (9% of caseload) of treating older women with UI (Table 2).
Physiotherapists working in a public setting scheduled longer evaluation sessions than their private-setting colleagues (90 vs. 60 min) and planned a slightly higher median number of treatment sessions (6.0 vs. 5.0). In addition, professionals in public settings described longer wait times with a median of almost six weeks, compared to only two weeks in private settings. Again, these times did not include any wait time for a physician appointment to obtain a referral, possibly adding more weeks to the public settings wait times.
Rural/urban areas
Compared to their urban counterparts, physiotherapists working in a rural area (n = 8) reported similar work hours and scheduled similar durations for both evaluation and treatment sessions. More physiotherapists working in rural areas were offering group treatments compared to their urban colleagues (22.2% vs. 10.0%), while all were interested in the approach (100% in rural areas vs. 81.0% in urban areas). In addition, physiotherapists practising in rural areas reported median wait times of three weeks, compared to only two weeks in urban areas.
In rural areas, physiotherapists charged a median fee of $96 for an evaluation and $88.50 for a treatment session, compared to $105 and $99 in urban areas. All physiotherapists working in rural areas mentioned that occasional fees could be added (100% in rural areas vs. 95.2% in urban areas), describing similar costs and reasons for these fees. Yet, physiotherapists working in rural areas estimated that only 16.7% of the older women seen in their practice had private health insurance to cover these fees, compared to 37.0% in urban areas. The vast majority of physiotherapists in both rural and urban areas had met women over age 60 years in their practice who reported financial barriers limiting their completion of pelvic floor PT treatment (100% in rural areas vs. 91.1% in urban areas). As a consequence, most had observed older women limiting their number of treatment sessions for financial reasons (100% vs. 89.1%) and considered that this reduction had limited the impact of their treatment (100% vs. 89.6%).
Discussion
This survey investigated two major determinants of accessibility of care among Quebec’s pelvic floor physiotherapists: availability and affordability. Considering availability, 84 physiotherapists reported dedicating, on average, less than half of their caseload to pelvic floor PT, and only 9.8% to 16.1% of their work time was spent treating UI in older women. Very few physiotherapists offered group treatments in their clinical practice but most were interested in this treatment approach. Considering affordability, the median cost associated with treatment in private practice was $95 per hour, and this cost was often combined with additional fees, mainly to cover materials such as vaginal or anal probes. Looking specifically at the population of older women with UI, most of Quebec’s pelvic floor physiotherapists had met older women in their practice who had limited their number of treatment sessions for financial reasons.
Availability of pelvic floor PT
Based on this survey’s findings, the availability of pelvic floor PT treatments appears limited in Quebec, and human resources are also constrained, considering how few clinical hours are dedicated to pelvic floor PT. In addition, the majority of respondents stated that they were the only pelvic floor physiotherapist in their workplace. Similarly, over two-thirds of physiotherapists practising in women’s health in Canada reported that they dedicated less than 50% of their hours to treating specific women’s health issues.28
Furthermore, our sample of respondents highlighted that publicly funded pelvic floor PT services are much less common than privately funded pelvic floor PT services in Quebec. Overall, recent estimates suggest that more than two in five clinicians practising general PT work in private settings in Quebec,17 with a continuous increase during the past 20 years.29 This portrait appears exacerbated for more specialized approaches, such as pelvic floor PT. In line with these numbers, Deslauriers and colleagues reported that as few as 12% of public hospitals offered this type of treatment.15 Canada wide, only 20% of physiotherapists practising in women’s health worked in the public sector. 28
This paucity of pelvic floor PT positions in Quebec’s public sector may be partially due to specific organizational challenges, which often lead to greater wait times to access publicly funded health care. Recent studies have highlighted these long wait times and related issues, particularly for publicly funded PT services in Quebec.14,15,30 A provincial survey estimated that 59% of public hospitals providing general PT had wait-lists of over three months.15 Our numbers were slightly lower, with a median of six weeks, but could go as high as six or eight months for some respondents and only accounted for urban areas. Our findings for wait-lists were higher overall compared to publicly funded general PT in Ontario, where patients generally wait one month.31
Only 9.5% of our respondents worked in rural areas, which demonstrates even more severe accessibility issues. Furthermore, none of our rural respondents worked in the public sector, which shows even scarcer resources for Quebecers living outside urban areas. Similarly, a survey by Francis and colleagues found that only 11% of Canadian physiotherapists practising in women’s health worked in rural settings.28
This limited availability could have long-term consequences. Difficulty accessing publicly funded PT services reduces patient options; their only choice may be to pay for private services or not receive treatment.14 Earlier studies in Ontario have shown that patients with more chronic conditions had the longest wait times for PT.31 No specific statistics were available on the profile of patients currently waiting for pelvic floor PT treatment in Quebec. However, this could potentially translate to more complex cases or more vulnerable patients facing additional barriers to care. Left untreated due to unavailability of services in their region, UI could lead to other medical conditions such as urinary infections, dermatitis, and depression. Older women with untreated UI could also face stigma, increased risks of isolation, and a higher risk of falls and institutionalization.2,4-6
Affordability of pelvic floor PT
The accessibility of UI care in Quebec could be further hampered by financial constraints. According to our findings, older women with UI are usually charged around $600 to address their symptoms in private practice with a median of five treatments following their initial evaluation. Our respondents also estimated that from their experience, only one in three older women were covered by private health insurance. As a result, most had encountered older women in their practice with financial barriers, who limited their number of treatment sessions for this reason. In line with these numbers, many authors have previously expressed their concerns about PT being “financially impossible for many women.”32 In response, the Canadian Continence Foundation recommended increased funding to enhance access to conservative treatments.13
In addition, Canadian women with UI spend $360 to $1,750 annually to manage their symptoms, notably on absorbent products, additional laundry, and personal hygiene items.13,33 Considering that older women have the lowest annual incomes of all Canadians34 and often lack health insurance coverage in retirement,35 these expenditures increase their vulnerability to financial limitations, which in turn affects their access to pelvic floor PT. In these circumstances, many older women are limiting their treatment and therefore their potential for recovering from UI symptoms.
Potential solutions to improve accessibility
In addition to highlighting these important issues, this survey may also provide some possible solutions to improve the current situation. Among our respondents, only 13% offered a group treatment approach. Yet, the vast majority of respondents were interested in and open to the idea.
A group approach is already offered in musculoskele-tal PT in the form of information and exercise classes for back pain or osteoarthritic knee pain for example. Group treatment approaches represent a wait-list management strategy in 39% of Quebec’s public hospitals15 and in 45% of outpatient and community PT programs in Ontario.3 6 The group approach was recognized as “very effective” in reducing wait times by more than half of the managers of rehabilitation services in the Passalent and colleagues’ survey.36 Therefore, it could constitute an option to enhance the availability of pelvic floor PT in Quebec.
Group treatment approaches could also lower the costs associated with the treatment by distributing some of the expenditures over a higher number of patients. Estimating the potential savings of a group approach using Quebec’s pelvic floor PT costs, researchers recently reported that treatment in groups of six to eight older women could divide the costs by 2.7 to 3.5 for patients and 2.6 to 2.7 for providers.33,37 The efficacy of the group approach was found to be the same as for individual treatment.38 This approach could help enhance the affordability of pelvic floor PT in Quebec without compromising treatment efficacy.
An additional solution to improve the availability of pelvic floor PT could be telerehabilitation, which was particularly popular in Quebec during the COVID-19 pandemic.39
PT treatments provided remotely could further help fill the gap in services between rural and urban regions.40 For the unique context of pelvic floor PT, a hybrid model allowing for an in-person evaluation followed by telerehabili-tation treatments may be a promising avenue to explore. This option would possibly combine the benefits of an in-person evaluation to gain information on the patient’s situation, often best obtained through palpation,41 with the benefits of telerehabilitation with its increased flexibility and reduced need for transportation.40 Other promising solutions that experts report include the implementation of additional prioritization process and triage tools, and the determination of clear, specific wait time goals.15 Some researchers also suggested the possibility of targeting the distribution of physiotherapists across Canada, notably by increasing the funding for community-based and publicly funded clinics.42
Our study presents some limitations. This online survey attained a response rate of 37.3% out of 255 Quebec physiotherapists, who officially registered pelvic floor PT as one of their clinical disciplines in 2019. While appearing low, this percentage is similar to other online surveys targeting physiotherapists;28,43,44 and exceeds the 20% response rate expected with anonymous surveys of health care professionals without associated compensation or reward.45,46 The composition of our sample of respondents also reflected Quebec’s situation, with pelvic floor PT being offered mainly by women physiotherapists47 with a vast majority practising in private practice, particularly for treating UI cases.48 This composition also echoes national surveys on the practice.28 Therefore, despite this relatively low response rate, this survey depicts a realistic portrait of available services and possible barriers to care in pelvic floor PT in Quebec.
As well, surveying physiotherapists was a strategic choice, enabling us to target the provision of pelvic floor PT by using established networks of professionals. Yet, since only physiotherapists were surveyed, all data were reported from the provider’s perspective. Accessibility issues may yet extend beyond these findings, by preventing older women from seeking treatment in the first place.15,49 The estimates reported here therefore constitute a conservative assessment of accessibility barriers. To complement our findings, future research could investigate the perspective of women and older women seeking care. Furthermore, not all women who would benefit from pelvic floor PT are seeking care.49 Awareness might therefore be an additional issue to explore in promoting optimal accessibility to pelvic floor PT.
Lastly, accessibility is a complex construct. In addition to availability, and affordability, which were included in our survey and to acceptability, as per McIntyre and colleagues’ framework,10 recent research added two more concepts to more thoroughly grasp all of its facets. Levesque and colleagues introduced approachability (whether persons facing specific health needs are aware that services exist and can be reached); and appropriateness (whether there is an adequate fit between the provided services and the population needs).50 Approachability echoes the importance of exploring women and older women’s awareness of pelvic floor PT, as previously suggested. Appropriateness would require a formal evaluation of needs to ensure that the current service provision adequately answers the needs of various populations.
Conclusion
By describing the available services in pelvic floor PT in Quebec, our survey identified potentially important barriers in both the availability and affordability of care, particularly for older women with UI. Since limited services are offered in the public sector, the private sector appears to have become the main provider, with little support from publicly funded organizations. Delivering pelvic floor PT treatment to groups of older women could constitute a promising avenue to increase the accessibility of care in public health care, allowing for a more balanced repartition of service provision in both sectors. Clinicians generally endorsed this solution. Future studies should look at organizational perspectives and ways of successfully implementing this option.
Key Messages
What is already known on this topic
Urinary incontinence (UI) is a highly prevalent condition affecting 25% of adult women. Its prevalence increases with age, and one in three women is affected after age 65. Pelvic floor physiotherapy is considered an effective treatment option for all young, middle-aged, and older women with stress or mixed UI and is recommended as a first-line treatment in clinical practice guidelines. To date, no study has assessed the accessibility of pelvic floor PT in the Quebec health care system for women.
What this study adds
Since limited services are offered in the public sector, the private sector appears to have become the main provider. The accessibility of UI care in Quebec thus appears hampered by the limited availability of pelvic floor PT treatments, mainly in public settings, and potential financial constraints. Providing pelvic floor PT to groups could constitute a promising avenue to tackle both issues.
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