Medication non-adherence is a major contributor to poor outcomes in diabetes. Previous research has shown an association between mail order pharmacy (MOP) and better medication adherence, but little is known about the barriers and facilitators to MOP use in diabetes patients. This qualitative study examined factors related to use of MOP vs. traditional pharmacies to obtain prescription medications. We conducted four 90-minute focus groups in 2016 among 28 diabetes patients in the Hawaii and Northern California regions of Kaiser Permanente, a large integrated health care delivery system. We queried participants on their preferred pharmacy use and perceptions of barriers and facilitators of MOP use. One researcher independently coded each focus group transcript, with two transcripts double-coded by an additional researcher to promote reliability. We employed thematic analysis guided by the Capability, Opportunity, Motivation, and Behavior (COM-B) framework using NVivo 11 software. The average age of participants was 64.1; 57% were female; 21% were Asian; 21% were black/African-American; 7% were Hispanic/Latino, and 14% were Native Hawaiian/Pacific Islander. Analysis uncovered 26 themes related to the decision to use MOP for dispensing medications. Most themes (18 out of 26) fell into the COM-B category of ’Opportunity.’ Barriers to MOP use included unpredictability of medication delivery date, concerns about mail security, and difficulty of coordinating refill orders for multiple prescriptions. In contrast, facilitators included greater access and convenience (e.g., no need to wait in line or arrange transportation) compared to traditional pharmacies. Receiving a MOP incentive of free one-month supply of prescriptions was a motivational facilitator to using MOP for delivering medications. These findings can be used to design interventions and quality improvement initiatives to increase MOP usage and improve medication adherence in diabetes patients across health care systems.


J. Schmittdiel: None. C. Marshall: None. D. Wiley: None. C.V. Chau: None. C.M. Trinacty: None. J.F. Wharam: None. O. Duru: None. A.J. Karter: None. K. Estacio: None. S. Brown: None.

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at