Accessing Insulin Pump Therapy by Adults with Type 1 Diabetes in Ireland. A Multiphase Mixed Methods Study.

The overarching aim of this thesis was to explore the determinants of uptake and access to continuous subcutaneous insulin infusion (CSII) for adults with type 1 diabetes (T1D) in Ireland through a mixed methods multiphase study. Methods: To explore this complex phenomenon in depth, the thesis consisted of 4 main objectives, 3 studies and 1 synthesis of all evidence. Study 1 was a quantitative secondary data analysis utilizing prescription-based data to estimate (1a) the epidemiology of T1D and (1b) uptake of CSII in adults with T1D. Study 2 investigated the availability of CSII in Irish adult diabetes centres through a national survey of diabetes clinics. Study 3 explored barriers and facilitators to accessing CSII by adults through semi-structured interviews with Health-Care Professionals (HCP) and other key stakeholders (OKS), and focus groups with People with type 1 Diabetes (PwD) from areas of low, medium and high uptake of CSII. Sampling was informed by the results of Studies 1 and 2. Qualitative data were analysed using the Reflexive Thematic Analysis approach. Finally, all evidence was synthesized within the Pillar Integration Process mixed methods synthesis. Results: Studies 1 and 2 confirmed that the uptake of CSII is low in adults, and that there is inequality in access to CSII. Both uptake and availability of CSII are geographically heterogeneous. Study 3 explained the reasons for the diverse availability and uptake of CSII, and the synthesis summarized the determinants of access. These are: the impact of individual factors (either HCP or PwD, including their interest and personal characteristics, beliefs and motivation); capacity (mainly resources and expertise); structure (i.e. of the health-service – referrals, standardised pathways); awareness of CSII and its benefits; dwelling location; availability of CSII in local diabetes clinic(s); distance from and choice of clinic(s); health-services planning, access to and lessons from paediatric care and data monitoring (i.e. diabetes registry).Conclusion: This PhD thesis provides evidence on the determinants of access to CSII and can inform policy-makers, health-services planners, HCP and PwD in Ireland on the complexity of access to CSII, and a current gap in Irish diabetes care delivery