A Qualitative Assessment of Pelvic Floor Physical Therapy Experiences for Women Veterans in VHA Care

Background Nearly 25% of women experience pelvic floor disorders, for which pelvic floor physical therapy (PFPT) is a first-line treatment. Within the Veterans Health Administration (VHA), only one-third of health care systems offer PFPT on site. Alternatives include receiving care from providers in the community (“Community Care”) or from VHA providers at a distant site via telehealth (“Clinical Resource Hub”). Little is known about Veterans’ experiences with these two PFPT care pathways.

To characterize women Veterans’ experiences with PFPT, including factors affecting access to and receipt of care. Design Using VHA data, we recruited and conducted semi-structured qualitative interviews with women Veterans who had received PFPT services within the last 6 months. Participants We recruited N = 20 women Veterans from five VHA health care systems. Participants from four health care systems went through the Community Care pathway (N = 12), while participants from the fifth went through the Clinical Resource Hub (N = 8). Approach We recorded and auto-transcribed semi-structured interviews. Using structured interview summaries, we completed a two-step analysis process, first using rapid, team-based matrix analysis, followed by thematic analysis. We identified key themes and domains into which we organized those themes. Key Results We identified themes in three domains: barriers getting care, experiences of care, and barriers extending care. Veterans described barriers to receiving care initially, including a lack of knowledge, stigma, providers dismissing concerns, and referral challenges. Participants were generally satisfied with their care and experienced quality of life improvements. Most desired some in-person care. Patients wanting more care after completing initially approved visits faced additional administrative barriers, leading to symptom recurrence.

Findings about patient access barriers suggest provider training and education (including awareness of PFPT’s clinical benefits, referral pathways, and trauma-informed care), patient education, hybrid care modalities, expansion of the PFPT provider workforce, and streamlining referrals may improve access to PFPT among Veterans. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-025-09645-w. KEY WORDS: women’s health, gender, veterans, pelvic floor physical therapy, health systems research, VA care

Women and gender-diverse Veterans are one of the fastest growing groups of Veterans Health Administration (VHA) health care users, nearly doubling in size from 317,000 in Fiscal Year (FY) 2010 to 556,000 in FY2020.1 Among this group, pelvic floor disorders — weakening or injury of the muscles, ligaments, or connective tissues of the pelvic area — are common: 12% have a urinary disorder, including urinary incontinence, and 18% have chronic pelvic pain.2,3 Approximately one in four women in the USA will experience a pelvic floor disorder in their lifetime, with many never receiving treatment.4,5 Military experiences, such as carrying heavy packs across long distances, prolonged holding of urine while on active duty, and sexual trauma (including military sexual trauma), may contribute to the prevalence of these conditions among Veterans in particular.6,7 A first-line treatment for pelvic floor disorders is pelvic floor physical therapy (PFPT) — a specialized form of physical therapy to improve the function of the pelvic floor muscles. Despite the prevalence of conditions treated by PFPT, only a third of VHA health care systems offer this treatment on site.2 When care is not accessible on site, patients can receive services at another VHA facility or through VHA-purchased care in the community (known as Community Care). In 2020, there were only 40 qualified pelvic floor physical therapists in VHA, a workforce insufficient to address the care needs of Veterans, and VHA invested in several care pathways to address the demand for PFPT services. To grow the PFPT workforce, the VHA Offices of Rural Health and Women’s Health funded initiatives to hire, train, and/or mentor qualified pelvic floor physical therapists, contributing to the more than 100 providers delivering PFPT in VA as of 2024. VHA has also developed the Clinical Resource Hub (CRH) program, through which Veterans can receive care, including PFPT, from VHA providers at distant sites via telehealth. Due to the demand for PFPT at CRH providers’ local sites, few patients from distant VHA facilities receive PFPT services through this pathway. Furthermore, the acceptability of telehealth PFPT among Veterans remains unknown, and data from non-Veteran samples suggest higher satisfaction with and a desire for at least some in-person care among patients initiating PFPT.8 Community Care is a common pathway for sex-specific care for women and gender-diverse Veterans when that care is not provided by VHA (e.g., maternity care) or is not accessible due to distance and wait times. However, the shortage of trained pelvic floor physical therapists evident within VHA is also mirrored in the community. As of June 2024, there were fewer than 900 board-certified physical therapists with specialization in women’s health compared to nearly 23,000 with specialization in orthopedics.9 Community provider shortages are likely more pronounced in rural areas, in which a quarter of Veterans reside.1 Numerous patient and provider challenges have been identified in accessing and coordinating Community Care generally for women Veterans, as well as for sex-specific services like mammograms, maternity care, and gynecologic cancer care.10–13 Together, this evidence suggests Community Care may not fully meet the needs of Veterans seeking PFPT services. Considering the high prevalence of pelvic floor disorders among women and gender-diverse Veterans, the limited supply of trained VHA and community PFPT providers, and VHA’s efforts to expand pathways for accessing PFPT care, we sought to characterize Veteran experiences with PFPT, including factors affecting access to and receipt of care. We focused on Community Care and CRH pathways and examined differences in experiences and acceptability between in-person and telehealth-delivered PFPT care. The underlying goal of this project was to inform efforts to improve access to and quality of PFPT for women and gender-diverse Veterans.

Recruitment and Study Population We identified women Veterans who had received PFPT within the past 6 months either through Community Care or a CRH (involving telehealth visits with a VA PFPT provider). For the Community Care pathway, pelvic floor physical therapy collaborators identified VHA health care systems without a pelvic floor physical therapist on-site. From this list, we selected four health care systems for targeted recruitment, ensuring rural and urban variability across sites. In the study timeframe, only one VHA health care system was providing PFPT via CRH, and therefore was included. For both pathway samples, we used VHA administrative and clinical reports from the VHA Support Services Center (VSSC) to generate lists of women Veterans from the selected health care systems with a completed PFPT consult within the past 6 months. We sent recruitment letters to randomly selected Veterans from our lists, stratified by care pathway. Study team members contacted Veterans by phone to assess/confirm self-reported eligibility, including receiving PFPT within the past 6 months and being born with a uterus (to identify sex assigned at birth). This project was considered quality improvement and, per VHA policy, did not require institutional review board approval or waiver. We obtained a non-research determination (per VHA Handbook 1058.05) from the VHA Office of Physical Medicine and Rehabilitation. Data Collection Between April and August 2023, two experienced qualitative researchers (JY and AM) conducted interviews using a semi-structured interview guide over Microsoft Teams (Appendix 1). The guide included questions about PFPT care, including reasons for seeking care, access, experiences (including satisfaction and outcomes), barriers and facilitators, telehealth care delivery (when applicable), and suggestions for improvement. We developed the interview guide using a purposeful approach developed in VA by Sayre and Young14 and in consultation with practicing VA pelvic floor physical therapists to ensure the clinical relevance of questions and topic areas. We reviewed the interview guide based on the first two interviews with patients. The co-author (JM), a VA pelvic floor physical therapist, participated in this review process with other team members (AM, JY, KG) to ensure the questions were meeting study aims and were salient to participants. Only minor wording revisions were made. Study staff audio recorded interviews with verbal informed consent and took detailed interview notes. We used Teams’ auto transcription feature and edited transcripts for accuracy. We completed structured post-interview summaries from transcripts and notes, which we used for data analysis. For descriptive purposes, we abstracted participant characteristics from the electronic medical record and VSSC reports (see Table 1). The team met regularly to discuss the interviews and interview guide and reflect on our own biases and experiences of the interviews. Table 1. | Interview length range (average) | 13–80 min (33 min) | | | Age | N | | | 20–29 | 3 | | | 30–39 | 7 | | | 40–49 | 2 | | | 50–59 | 6 | | | 60–69 | 2 | | | Provisional diagnosis from medical record | N | | | Incontinence (functional urinary, mixed, other specified, stress) | 6 | | | Pain (pelvic and perineal, deep dyspareunia, unspecified) | 8 | | | Pregnant state, incidental | 3 | | | Other (anal spasm, outlet dysfunction constipation, cystitis) | 3 | | | Location of care | Virtual | In-person | | Urban | 3 | 9 | | Rural | 4 | 3 | | Highly rural | 0 | 1 | Analysis We employed a two-phase analytic process. First, we conducted a rapid, team-based qualitative analytic approach using the process described by Hamilton et al.15,16 Three team members (JY, AM, and KG) independently reviewed all interview summaries, and two analysts (JY and AM) conducted a matrix analysis, organizing data in a single table 17 Matrix columns consisted of domains from the interview guide: patient history prior to receiving PFPT care, care received, care modality (in-person or telehealth), satisfaction, perceived impact, barriers and challenges, and suggestions. Two analysts sorted data from interview summaries and transcripts into these matrix domains, with one row for each participant, enabling us to summarize each participant’s experience and compare participant experiences within each domain. The analysts met regularly to review the summaries, discuss the analysis process, practice reflexivity, and resolve categorization disagreements through consensus building.18 We presented preliminary themes from the matrix analysis to operational partners. Subsequently, we conducted a targeted thematic analysis using ATLAS.ti 23 to gain a deeper understanding of initial themes and findings.19,20 One analyst (AM) coded transcripts using a codebook based on matrix domains and other domains identified from interview summaries. Analysts (AM, JY, KG) met once coding was completed to assess accuracy of coding, discuss patterns of shared meaning across participants, and synthesize findings.21 We conducted summative (across all participants) and comparative (telehealth vs. in-person care modality) analysis.

We interviewed N = 20 women Veterans who had received PFPT within the last 6 months (for a full description of participants, see Table 1). We organized key findings in three overarching domains related to the PFPT care pathway: (1) barriers to getting care, (2) experiences of care, and (3) barriers to extending care. Within each domain, we identified and developed themes that illuminate Veteran experiences with PFPT care through VHA. Domain 1: Barriers Getting Care Nearly every Veteran described challenges accessing PFPT at different stages of the care pathway. Challenges included those at the interpersonal level, like patient knowledge and willingness to disclose symptoms, and providers dismissing symptoms or offering no or limited treatment options; and system level, such as limited availability of qualified providers and challenging referral processes. These issues often led to long delays in receiving PFPT services. Interpersonal-Level Barriers Lack of Familiarity with and Knowledge of PFPT Most Veterans shared that they were unfamiliar with PFPT and unaware, prior to being referred, that it was a possible treatment option for pain, incontinence, and other signs of pelvic floor dysfunction. The few women who did report prior knowledge described hearing about it from a family member or a physical therapist they had been seeing for reasons unrelated to pelvic floor issues. I didn’t know there is a therapy out there, I just, I don’t know, my mind immediately just jumped to oh, they’re gonna put me on a pill, I don’t know what it’s going to do. But that’s just where my mind went. Pills. And Depends. I’m gonna have to buy Depends. But now that I know that I could just do these easy workouts that you could do all laying down, I’m a lot more happier about that, and they’re actually really easy to do. −33 years (age), Community Care (care pathway) This lack of awareness meant that Veterans had to rely on providers’ knowledge of PFPT as an appropriate treatment option, which often resulted in delays in getting referred to or starting PFPT. Stigma Inhibits Disclosing Symptoms Stigma served as a frequent barrier to care seeking. Women described embarrassment related to symptoms like incontinence, pelvic or lower back pain, and gastrointestinal discomfort and a reluctance to disclose “sensitive” or “private” health concerns to providers. It’s personal. It’s private. People are, you know, embarrassed to go to somebody and say I have pain in my vagina, like somebody stabbing me… you don’t know what’s going on, so you need extra sensitivity in this area… −53 years, Community Care One Veteran shared that she did not know how to bring up her bladder leakage with her primary care doctor and he never asked her about it, which meant it was not addressed. The Veteran suggested that the provider’s gender may have played a role in this: “Probably because it was a guy and nothing against him. It’s just not something they think about” (53 years, CRH). Providers Dismiss Symptoms and Concerns Veterans described substantial provider-related challenges to getting a referral to PFPT, which led some to deal with symptoms for months or years. After about 12 years of being misdiagnosed at the VHA for all sorts of things, from the GI Clinic who failed to refer me to an advanced specialist, and also the gynecology clinic missed it for years. – 49 years, Community Care Many participants described having their symptoms and concerns dismissed or doubted by providers, including those they saw during their military service. One Veteran recalled a provider during her military service reacting to her family history of cancer, abnormal pap smears, and current stomach pain. She was like, ‘I don’t know why you are here… you don’t need anything…we’re just both wasting our time’ −36 years, Community Care Many shared that these military experiences greatly impacted their trust in providers. Some shared being doubted by other providers, including VHA providers. …she’d [VA OB-GYN provider] also blown off my concerns when I brought up that I felt like I was excessively peeing and stuff like that – 30 years, CRH System-Level Barriers Providers Did Not Offer PFPT as a Treatment For some Veterans, their providers offered no treatment and told them they would have to “live with” their symptoms. I’ve been told by people, doctors at the VHA, ‘well, a lot of women just lived with undiagnosed pelvic pain.’ Like I'm supposed to just take that?—53 years, Community Care Other Veterans were only offered a limited set of treatment options, like medications or disposable underwear, but not PFPT. I told my primary care doctor. I told my OB, my primary care doctor… she just mailed me a box of underwear. Like Depends.—39 years, CRH Some Veterans described how PFPT did not come up in visits with their provider until after they had received several other treatment options, or the Veteran specifically brought up PFPT. when I brought up the request [for PFPT] she says… ‘that’s really highly recommended... maybe I should have recommended it to you’ - 36 years, Community Care Challenges Getting a Referral Many Veterans reported they were only referred to PFPT after seeing a specialist who was knowledgeable about pelvic floor dysfunction and treatment, such as a gastroenterologist or gynecologist, or after a life event like pregnancy. I was talking about it with my gynecologist for through the VA and was speaking to her about the pain that I was having and because it was causing pain with sex. And so she was suggesting that maybe I should try pelvic floor therapy or… steroidal shot. And I’m 25, so I don’t exactly want to take a steroidal shot at this age” - 25 years, CRH Once referred to PFPT, there were additional barriers to navigating the referral process. For some, the referral process was lengthy with several steps they needed to complete ahead of time: …to get someone to finally get the referral through so that actually took about a year to get it going just to get someone to put the referral in... there was something about trying to get a new therapy done that they were all just like, ‘oh, well, we need you to come in and do full lab panels and establish care with a new Doctor first because your doctor left.’ And I'm like, ‘OK,’ so I would try to set up an appointment, but then they'd have it so far out. – 38 years, CRH For others who went through Community Care, they were referred to providers without PFPT specialization, which led to delays in care because they had to get another referral to an appropriate provider. ‘We’re [VHA provider] going to put in one [a referral] for you for this physical therapist based on, but you know the criteria or the necessity that you require’…and the physical therapist there did an assessment and he’s like, ‘we don't have the specialist that you need.’ – 36 years, Community Care Others found that there were limited providers trained in PFPT in both VHA and the community, which led to long wait times for in-person and telehealth care. …there’s not in my area many if any, pelvic floor specialists and if they are, they were booked out for a few months. I mean the VA provider is also booked out usually three months in advance as well. – 25 years, CRH Domain 2: Experiences of Care Most Veterans experienced positive clinical and psychosocial benefits of PFPT, including improvement of symptoms and feeling supported and heard by their PFPT providers. However, not knowing what to expect from PFPT made them hesitant to receive treatment. Not Knowing What to Expect Once Veterans were referred to PFPT, some reported being unsure what to expect. Some thought PFPT was “just kegels” or only for people who had been pregnant. For some women, this was a deterrent to getting PFPT care, and they wanted more information about what PFPT entailed ahead of the visit. The vision I had or the understanding I had and even from Googling it and all that stuff, it had too much emphasis on pregnant women and kegel exercises and that turned me off completely because it needs to be, it needs to be understood or explained better than that. - 70 years, Community Care Among individuals with a history of trauma, including military sexual trauma (MST), not knowing what to expect was particularly challenging. Veterans were more comfortable engaging in treatment when providers were flexible with how care was delivered, took time to explain steps before they happened, and asked for consent throughout the process. I let her know that I did have PTSD. She described to me what the physical therapy would be and as soon as she described it, I was like hell no. No, because part of it is them putting their fingers… I’m still having trouble getting my pap smear because it causes a lot of anxiety. She was super sweet and she said, you know, we can come up with other exercises that don't involve that until you get to know me. - 52 years, Community Care Importance of Relationships with PFPT Providers Most respondents described the importance of their relationship with their PFPT provider, especially when Veterans perceived they were the first provider to listen to them and take their concerns seriously. This individual made me feel like, OK, this pain is not in my head. I'm not just feeling a little bit of pain and I’m not going overboard with it – 25 years, CRH it was good to, like start to somebody who had been in that situation, you know. And so then I didn’t feel completely like a weirdo that I’m not even 40 and I can’t control my pee. – 39 years, CRH PFPT providers also supported women Veterans with other health needs. For example, after seeing their PFPT provider, a Veteran felt more prepared to speak with other providers about getting evaluated for endometriosis. It’s hard to get into [VHA], to get seen, to communicate, to ask the questions, and so having the pelvic floor therapist, like I said, it's been a helpful tool and to have another professional to ask questions - 53 years, Community Care Improvements in Quality of Life By and large, Veterans described substantial benefits of PFPT. When asked about impacts of this care, some shared that receiving this care was “life changing.” One Veteran expressed that she can now laugh without worries of incontinence: I don’t pee every time I sneeze. I was working with someone at church and we cut up and laugh all the time and I didn't have an accident the whole time we were laughing. I mean, we were laughing hard. Yeah, and that used to be a problem. - 53 years, CRH Another Veteran said that she now feels comfortable leaving the house after years of worry: I don’t feel like I have to take extra clothes with me, and I don't have to plan my outings around where’s the closest bathroom - 30 years, CRH Lastly, some Veterans shared that PFPT addressed their pain. The biggest impact has been on my quality of life…I was in constant pain, I wasn’t sitting correctly, wasn’t walking correctly…I had extreme pain - 36 years, Community Care Mixed Preferences Around Care Modality Irrespective of whether participants received in-person or telehealth care, the majority preferred at least some in-person care, regardless of rural or urban location. Those who received telehealth described wanting in-person care for initial appointments so that providers could get a thorough understanding of their issues at baseline and give tailored treatment recommendations. I think that online pelvic floor therapy is, not that I think it’s stupid, but I do think it’s a waste of time. I think that someone should be checking it out physically, first going yeah definitely you need pelvic therapy or you know, hey you need this or whatever because like I said, I gave it the old college try, but there was nothing successful because I don’t even know if that’s really what I needed. - 39 years, CRH Among those that received in-person care, some perceived PFPT would not be amenable to telehealth, for example, biofeedback, which involves placing an internal pressure sensor to become aware of muscle contraction and relaxation. Many respondents felt that telehealth was not or, if they had received in-person care, would not be effective because they needed in-person instruction and feedback on exercises. I can’t imagine how that [telehealth] would be helpful. I wouldn’t imagine because a lot of times too you do an exercise and you need them to make sure that you’re doing it right, because otherwise you hurt yourself. - 53 years, Community Care However, a subset of Veterans preferred telehealth due to convenience, especially if they had caregiving responsibilities or lived very rurally and therefore farther away from in-person clinics. It was very convenient because I didn't have to go physically and drive… when we did have the appointments that were really flexible… They could actually do like 3 or 4pm, I believe, which was very convenient for me because that's the time that my husband was already home from work. So he was able to watch the baby while I had my own time with the physical therapist. – 24 years, CRH Some Veterans also preferred telehealth because they felt safer and more comfortable, especially if they had a history of trauma. Veterans described feeling safer because they could forego an internal physical exam. It feels a little bit safer…It’s just you and the doctor, and you're completely and totally in control of the situation - 53 years, CRH Domain 3: Barriers to Extending Care When Veterans are referred for Community Care services, the treatment authorization specifies the number of visits allowable over a specific period. Once visits or time elapses, updated referrals are required to ensure continued medical necessity and authorize additional visits. Because of the benefits of PFPT, many respondents wanted to continue treatment beyond their initial approval period. However, they described several barriers to getting another referral approved to continue care, leading to delays and recurrence of symptoms. Challenging Getting Additional Visits For some Veterans, they reached the maximum number of visits allowed by VHA and had difficulties getting additional visits approved, despite the chronicity of their conditions and the effectiveness of treatment. I had reached that maximum [approved visits] and they were saying like when you reach that maximum we can't really give you anymore for like the year and everything else. And I'm like, well, this is a very important service…I'm like you're literally taking something that's been very crucial in me… And the problem is that, well, endometriosis doesn't have a cure…it's like so kind of getting that message of like well you should only have so many of these a year and at a certain point you need to stop having a service and I'm like well like I said the only reason why I'm able to sit correctly now is because of the service. - 36 years, Community Care Getting “Back in Line” for Appointments As with getting initial appointments, wait times for care were long because of the limited number of qualified providers for both in-person and telehealth care, so having to “get back in line” for approval led to delays. So you have to make appointments way ahead in advance to make sure they stay consistent because there was like one time I had like a kind of like a break in [VHA] coverage… then when it got reapproved, I still had to wait like another month to get back with her because she was so booked up. - 36 years, Community Care Veterans described the burden of renewing necessary care, which required consistent following up and self-advocacy, sometimes with referral staff who were uninformed about the type of care they needed. Requires Additional Steps with Referring Provider Another challenge related to the continuation of care was that community providers were unable to request additional care directly, and some Veterans had to be seen by their referring VHA provider to get approval for more visits, leading to delays in care. I wasn’t done yet [when referral ran out]…still weak and having leaking…took two months for [VHA] to approve me and get started again…was frustrating and hurt my progress with my recovery. - 38 years, Community Care Infrequent visits with VHA referring specialists also made it challenging to get additional visits. One Veteran who met with her referring urogynecologist only every 12–18 months described feeling like she was “starting at ground zero” (75 years, Community Care) each time she had a break in treatment waiting for the referral. Lapses in Care Have Negative Impacts When Veterans had lapses in care, due to discontinuation or delays in getting another referral, they described a recurrence of symptoms, including pain, decreased quality of life, and increased stress and anguish. …[being denied additional PFPT] makes me upset because people feel hopeless and nobody's out there saying, well, I’ll help you… This is what drives people to want to end their lives at times, and I think it’s cruel. - 53 years, Community Care Veterans suggested that it should be simpler to get and continue this important care. As one Veteran stated: “Don’t make it so hard to get what you need and what your doctor thinks you need.” – 38 years, Community Care.

In this qualitative study, we explored women Veterans’ experiences getting to and receiving pelvic floor physical therapy services within VHA via telehealth and in the community. Almost universally, participants described challenges getting referred to PFPT initially and continuing care — including barriers at the individual, provider, and system levels — irrespective of whether Veterans received care in VHA or the community. However, participants highlighted important benefits of PFPT, such as improved quality of life, reduced pain, and less symptom interference with everyday life. Many respondents described a strong relationship with their PFPT provider and satisfaction with the care they received. Whether they received in-person, telehealth, or hybrid care, most participants expressed a desire for at least some in-person care. Despite PFPT being a frontline therapy for pelvic floor disorders,22,23 women Veterans faced significant obstacles getting referred to PFPT. Some challenges stemmed from individual-level factors, including patients’ lack of knowledge about treatment options, as well as shame and embarrassment, which inhibited disclosure to providers. These findings are consistent with other qualitative and quantitative studies exploring barriers and facilitators to care for pelvic health symptoms.24,25 Participants also almost universally highlighted provider-related barriers to accessing PFPT. Many Veterans described that providers in the military and in VHA did not take their symptoms seriously, a finding echoed in other work among women Veterans and civilians.25–28 In contrast, participants described a more patient-centered experience when working with their PFPT providers, including being listened to and validated, having their preferences accommodated, and receiving trauma-informed care. These findings highlight the importance of having an affirming and knowledgeable provider in accessing PFPT services. Once participants were referred to care, sometimes months or years after symptoms began, they encountered additional challenges. A protracted VHA referral process, referrals to providers in the community who did not specialize in PFPT, and a limited number of PFPT providers in VHA and the community led to delays in care. Similar systems-level challenges with the VHA referral process have been described for other sex-specific services.11,12 Participants described additional systems-level challenges when they sought additional care after completing their initially approved number of visits and had to navigate the referral process again. Nearly all participants described benefits from PFPT, including a reduction in symptoms and the ability to live life more fully, like being able to leave the house or laugh without fears of incontinence. Lapses in care when seeking approval for additional visits were distressing to some participants because their symptoms returned in the interim. Given the rise in telehealth over the last several years, including VHA expansion of telehealth PFPT, we explored patient preferences for care modality. Although our sample included individuals who received in-person, telehealth, and hybrid care, nearly all expressed a desire for at least some in-person care, consistent with prior studies among non-Veterans.8 However, notable exceptions to this included some Veterans with trauma histories and those with competing demands (e.g., caregiving) or living at a distance. Considering that 75% of women Veterans report military sexual trauma29 and 27% live in rural areas,1 telehealth PFPT may be the most feasible and acceptable care pathway for many women Veterans. Implications for Practice and Policy Findings from this work have important implications for practice and policy within and outside VHA. Considering the consistency of findings across studies that provider dismissal and trivializing of symptoms are barriers to care, VHA and other health care systems should consider widespread provider education regarding pelvic floor symptoms, treatment, and referral pathways. Given the prevalence of MST among women Veterans, provider training in trauma-informed care will continue to be important to ensure women Veterans feel safe disclosing and being treated for these stigmatized conditions. Recent research suggests that adults who experience pelvic floor dysfunction may have a higher prevalence of traumatic experiences; therefore, a trauma-informed approach may be especially important for delivering PFPT.30,31 Members of our research team, in collaboration with operational partners, are delivering education for providers to explore how training may facilitate access to PFPT services. These topics include (but are not limited to) the prevalence of and screening for pelvic floor dysfunctions, what populations and medical conditions would benefit from PFPT, understanding what normal bladder and digestive function look like, and information about the training received by PFPT providers. Patients may also benefit from education about PFPT, including the symptoms it can address and what treatment entails, which could also help mitigate stigma. Within VHA, this could include initial group PFPT visits for women Veterans; education and outreach campaigns; or women’s health navigators or coordinators, which exist for other services like maternity care and mammography.32 With projected increases in the women Veteran patient population, coupled with the limited number of trained providers within and outside VHA, continued efforts to grow the provider workforce are also needed. Over the last several years, the VHA Offices of Women’s Health and Rural Health have supported programs to hire and/or mentor PFPT providers, which has resulted in a large increase in the VHA workforce. Our findings also suggest that efforts are needed to improve the VHA referral and scheduling process, including reducing processing times, ensuring patients are referred to community providers with the right specialization, and making it easier to request additional care, which could be facilitated by navigators. Lastly, additional research is needed to determine who benefits from telehealth-delivered PFPT under what circumstances to guide decisions about care pathways in which VHA should invest. While hybrid (in-person plus telehealth) models of PFPT care are preferred by patients and could increase access to services,33 they would require a local workforce with sufficient training for initial assessment and evaluation. This may be feasible in some areas (for example, if local physical therapists can be trained in some basic PFPT skills) but it may not work in other areas and would highly depend on local context. Telehealth-delivered PFPT could be especially beneficial in rural areas where there are limited providers both within and outside VHA. Data from a descriptive cross-sectional study of the geographic distribution of PFPT providers found that the number of providers in many states is unlikely to meet clinical demand.34 Provider shortages may be mitigated through recruiting and training providers at more urban sites and telehealth could be used to connect patients in those underserved communities with providers at distal locations.35 Strengths and Limitations Findings from this study should be interpreted considering its strengths and limitations. We recruited women Veterans who had recently received PFPT care from two key care pathways and conducted in-depth interviews to explore their experiences. Qualitative interviews provide rich data that may not be captured in surveys or electronic health records. Limitations include that we interviewed a small number of women Veterans from only five VHA health care systems, potentially limiting generalizability to other settings. However, many of our findings echo those identified in prior research. Because we did not collect data about race or disability, our data cannot speak to barriers related to racisms and ableism. Future research is needed to explore how race, disability, and socioeconomic status influence access to PFPT. We also only interviewed participants who had received PFPT; women with pelvic floor symptoms who have not received PFPT may experience unique barriers. Future studies are necessary to compare experiences between those who sought but did not receive care to those who were able to access PFPT treatment to better understand missed opportunities for care.

Considering that only 37% of women with pelvic floor symptoms receive care for them,5 identifying factors affecting access to and receipt of treatment is needed to ensure women Veterans receive high-quality, patient-centered, timely care, consistent with VHA directives and priorities. We identified several important barriers and facilitators to care, which suggest provider training and education, patient education, hybrid care modalities, and expansion of the PFPT provider workforce may improve access. Supplementary Information Below is the link to the electronic supplementary material.

We thank the VA Office of Physical Medicine & Rehabilitation for their support of this project. We also thank Melanie Pomasko, PT, DPT, PRPC and Tejal Patel, PT, DPT, WCS, CLT-LANA for their work in developing this project. Author Contribution Ashley Mog: methodology; formal analysis; investigation; data curation; writing —original draft; writing —review and editing; visualization. Jessica Young: methodology; formal analysis; investigation; data curation; writing —original draft; writing — review and editing; visualization. Jordan Mamkherzi: conceptualization; resources; writing — original draft; writing — review and editing; supervision; funding acquisition. Caroline Merkel: investigation; data curation; writing — original draft; writing — review and editing; project administration. Kristen Gray: conceptualization; methodology; formal analysis; writing — original draft; writing — review and editing; supervision; funding acquisition. Funding This work was supported by operational funding from the U.S. Department of Veterans Affairs Veterans Rural Health Resource Center – Gainesville. Data Availability The United States Department of Veterans Affairs (VA) places legal restrictions on access to Veterans’ health care data, which includes both identifying data and sensitive patient information. This manuscript is the result of a VA internal operations project focused on the improvement of Veteran care. The Veteran data used for this project was authorized for internal VA use only. The analytic datasets used for this project are not permitted to leave the VA firewall. Declarations Consent to Publish The listed authors have authorized the submission of this manuscript and have approved all statements and declarations. Ethical Approval This project was considered quality improvement and, per VHA policy, did not require institutional review board approval or waiver. We obtained a non-research determination (per VHA Handbook 1058.05) from the VHA Office of Physical Medicine and Rehabilitation. Conflict of Interest The authors declare that they do not have a conflict of interest. Disclaimer The views expressed in this article are those of the authors and do not reflect the position or policy of the Department of Veterans Affairs or the United States Government. Footnotes Prior Presentations: This project was previously presented as a poster at the 2024 AcademyHealth Annual Research Meeting, with the same authors and titled, “‘Don’t Make it So Hard to Get What You Need’: A Qualitative Assessment of Pelvic Floor Physical Therapy in VA and Community Care.” Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Supplementary Materials Data Availability Statement The United States Department of Veterans Affairs (VA) places legal restrictions on access to Veterans’ health care data, which includes both identifying data and sensitive patient information. This manuscript is the result of a VA internal operations project focused on the improvement of Veteran care. The Veteran data used for this project was authorized for internal VA use only. The analytic datasets used for this project are not permitted to leave the VA firewall.