Supervised pelvic floor muscle training is recommended by clinical practice guidelines as the first-line treatment for several pelvic floor disorders[1]. However, it is unclear whether the pelvic health physiotherapy workforce available is adequate to address population demand. The purpose of this study was to describe the extent to which the distribution of pelvic health physiotherapists across Ontario, Canada aligns with the potential needs of the female population residing in various geographic areas. Two primary objectives were addressed: (1) to measure the potential geographic accessibility to pelvic health physiotherapy services for the female population in Ontario, Canada and (2) to explore its variations in the geographic accessibility across an urban-rural gradient.

A geographic information system-based observational study was conducted. To assess and gauge potential geographic accessibility to healthcare, three key elements were identified: healthcare capacity, population demand, and geographic impedance. 
Physiotherapists’ practice locations (healthcare capacity) were obtained from the College of Physiotherapists of Ontario registrant pelvic health roster. Population count by dissemination area (demand) was calculated based on the most recent (2021) Statistics Canada census data available for females in Ontario above 15 years of age. Additional information about geographic boundaries (i.e., provincial, census subdivisions, dissemination area) was extracted for mapping purposes. The 'distance' between service locations and population demand (dissemination area centroids) that can influence accessibility (geographic impedance) was set as a 30-kilometer catchment area using a Gaussian decay factor of bandwidth 50. Locations were geocoded, mapped and an accessibility score was computed using an enhanced 2-step floating catchment area method using ArcMap[2]. A choropleth mapping approach with a mean ±0.5 standard deviation classification scheme was generated. The geographic accessibility scores were converted into eleven categories based on the overall distribution and the mean value. Results were then stratified using an urban-rural gradient.

Geographic locations of 1172 pelvic health physiotherapists (PHPTs) across Ontario were retrieved as of October 2023 (Figure 1). At that time, 1115 PHPTs (95.1%) worked within a metropolitan area and agglomeration centre. Geographic accessibility maps are presented in Figure 2. The provincial average accessibility score was 1.84 PHPTs per 10,000 females (min, max= 0, 26.27). Geographic access to PHPTs was more limited in rural areas and municipalities with weak to no metropolitan influence and was higher in census metropolitan areas and larger urban centres (Figure 2). Mean accessibility results stratified by urban-rural variables are presented in Table 2.

This geographic mapping and these descriptive analyses demonstrate an uneven distribution of PHPT resources in Ontario, with higher accessibility observed in large urban centres and lower access in rural and remote areas. Such disparities in access to health services may have adverse implications for effectively addressing population health needs. Limited supply and high demand for services compromises the provision of timely and effective patient-centered care. As such, limited availability of PHPT services in Ontario, and particularly in rural and remote areas, could detrimentally impact the quality of care available to females in Ontario, particularly since these services are repeatedly recommended as first-line treatments for various pelvic floor disorders by both national and international guidelines[1].  

The accessibility patterns illustrated in this study are not unique to PHPTs, as other studies examining access to various healthcare professionals in Canada have reported similar trends. 
It is important to exercise caution in interpreting differences in geographic accessibility observed in this study, as the large standard deviations indicate that accessibility scores are highly variable. Outliers were observed whereby some dissemination areas in remote areas had remarkably high accessibility scores which reflected the practice location of a single or two PHPTs offering services in that region. In remote areas, a single PHPT can substantially improve the geographic accessibility of multiple surrounding communities. Yet, this accessibility is highly susceptible to change, as it can plummet if the single PHPT provider leaves the region or ceases to practice. This finding supports the need for a mandate to support training in pelvic health physiotherapy assessment and management approaches for current physiotherapists (or other healthcare professionals such as nurses or nurse practitioners) who already have established practices in rural and remote areas. Telerehabilitation is another potential avenue to improve access; it has demonstrated promising outcomes in the management of pelvic floor disorders, showing effectiveness comparable to traditional treatment face-to-face models[3]. Nonetheless, access to a primary care provider for a thorough in-person assessment of pelvic floor disorders is important to direct management decisions, and thus geographical accessibility remains necessary for virtual care. 
Healthcare access is a multidimensional concept that involves accessibility, availability, affordability, acceptability, adequacy and awareness. To inform planning and policy, the next relevant step is to investigate the affordability (direct and indirect costs) of PHPT services and actual use (revealed accessibility), comparing the latter to geographic accessibility. In Ontario, no referral is required to access physiotherapy services. Nevertheless, PHPTs are predominantly available in the private sector, necessitating patients to personally bear the associated costs if they have no insurance coverage. Utilization of private-sector physiotherapy is closely tied to one's income and insurance coverage. Given that the median total income amongst Ontarians reported in the 2021 census was approximately $41,200 CAD and taking into account the current inflation crisis, the concept of affordability becomes critical. 

In light of our findings and recognizing the dynamic nature of accessibility, it is imperative to regularly monitor the distribution and accessibility of PHPTs to better plan service provision. A refined model that incorporates traffic data and public transportation networks for each census metropolitan area should be thoroughly explored for a more precise understanding, particularly in large urban centres where disparities between neighbourhoods may pose greater challenges. Further investigations into current accessibility patterns specifically addressing the PHPT needs of vulnerable populations are urgently needed to evaluate the inequality and inefficiency stemming from the lack of provincial coverage for pelvic health physiotherapy services. Thus, future studies should explore the socioeconomic determinants of health (such as income, education, immigration status, etc.) and their impact on the distribution and utilization of PHPTs.

This study highlights potential gaps in service delivery of pelvic health physiotherapy in Ontario, Canada due to geographic accessibility. It adds to the existing literature that rural and remote areas appear to be underserved. This study provides a baseline model and puts forth recommendations to enhance the investigation of geographic accessibility of pelvic health physiotherapy services as well as proposing potential solutions to mitigate poor access in remote areas.

Sussman RD, Syan R, Brucker BM. Guideline of guidelines: urinary incontinence in women. BJU Int. 2020;125(5):638-655.
McGrail MR. Spatial accessibility of primary health care utilising the two step floating catchment area method: an assessment of recent improvements. Int J Health Geogr. 2012;11:50.
Santiago M, Cardoso-Teixeira P, Pereira S, et al. A Hybrid-Telerehabilitation Versus a Conventional Program for Urinary Incontinence: a Randomized Trial during COVID-19 Pandemic. Int Urogynecol J. 2023;34(3):717-727.