CHAPTER 1

Introduction

This chapter lays the foundational groundwork for the research project. It commences with an
exploration of the background of medication adherence, highlighting its global significance and
particular relevance within the Nigerian context. Following this, the chapter will identify the
study's target issues; namely, the challenges of ineffective adherence and communication failures
within current healthcare systems. The primary aim and specific objectives of the research will
then be outlined, followed by a justification for the study, detailing its potential benefits for
patients, clinicians, and the broader healthcare system. To provide a clear understanding of the
project's boundaries, the scope and inherent limitations of this research will be presented. The
chapter will also articulate key research questions that guide the investigation and conclude with
a definition of essential terms used throughout this report.

1.1 Background of the Study

Medication adherence refers to the extent to which the patient follows and strictly adheres to
medical instructions including the timing, dosage, and frequency of the medication. It also
includes patient compliance with disease or medication-related practices such as diet, exercise, or
lifestyle changes. Adherent patients are those who consistently take their dosage as
recommended by their healthcare provider and agreed to by the patient and this leads to the
effectiveness of treatment and improved health outcomes.

Globally, poor medication adherence remains a major public health challenge. According to
Rohatgi et al. (2021), approximately 50% of patients fail to take their medications as prescribed.
This widespread non-adherence contributes to increased disease complications, preventable
hospitalizations, rising healthcare costs, and, in some cases, the development of drug
resistance—particularly in chronic conditions like hypertension, diabetes, tuberculosis, and
HIV/AIDS. For some illnesses, such as HIV, adherence rates as high as 80–95% are required to
avoid resistance and treatment failure.

This global challenge is also evident in Nigeria, where an estimated 100 to 500 million
prescriptions are issued annually, and the cost of medications continues to rise. The American
Medical Association (2023) outlines key reasons for poor adherence, such as forgetfulness,
confusion about instructions, being overwhelmed by the number of medications, and fear of side
effects. Unsafe medication practices—including improper use and non-adherence—are estimated
to contribute to over 50% of deaths in the Nigerian healthcare sector (Aina, n.d.).

Generally, Technological tools, such as mobile phone applications (apps), have shown promise as
a tool to help patients adhere to medications(Peng et al., 2020). such as the Medisafe app a
commercially available medical adherence app that was rated as the top app for medication
adherence in a review that covered the app's strength and weaknesses(Sharma et al., 2022) this
app leverages sending reminders which is being sent through an SMS or via app notification to
patent on when to take the drugs and while this has been shown to improve adherence,
challenges remain—particularly in Nigeria, where the doctor-patient ratio stands at a staggering
1:9,083 far from the recommended 1:600 ratio Balogun et al. (2022) explained further . a critical
issue still remains

On the healthcare provider side, there’s no data to track whether patients are taking their
medication properly. For patients, there’s no real accountability to stay consistent—and delays in
detecting side effects make things worse.

As Egberts et al. (1996) points out, patients could help catch adverse reactions earlier by
reporting issues. But most don’t—either because they don’t realize the risks or worry about what
might happen. Without proactive care, these gaps lead to preventable complications.
But in a country that is estimated to have a mobile internet penetration rate of 38.94% as of 2029
Statista (2024) remote patient monitoring might be the prevalent solution.

1.2 Statement of the Problem

Ineffective adherence is a serious problem that affects not only the patient but also the health
care system, Consistent medication adherence is essential for treating chronic conditions such as
hypertension, diabetes, and HIV/AIDS, however suboptimal adherence remains a major barrier
to successful treatment in A study lead by Ejeliogu & Courage,(2020) of 194 children with
epilepsy found that nearly half struggled to take their seizure medications regularly. One of the
main reasons was forgetfulness and side effects. The outcome could be worsened disease
progression (e.g., uncontrolled blood pressure, diabetic complications, drug-resistant infections),
Increased hospitalizations and healthcare costs due to preventable complications, and Higher
mortality rates, particularly among patients with limited access to follow-up care.
Critical factors contributing to poor medication adherence include insufficient patient
monitoring, difficulties in timely identification and reporting of side effects delaying medical
intervention, limited patient accountability mechanisms, and challenges in proactively tracking
adherence patterns.

While various mobile applications exist to remind patients, a specific gap remains in solutions
that facilitate simple, automated reporting of patient-generated adherence and side-effect data
directly to clinicians, without requiring complex portal integrations.
This limits the clinician's ability to gain timely insights into adherence patterns, hinders patient
accountability, and restricts proactive communication regarding potential issues.

1.3 Aim and Objectives of the Study

Aim: the primary aim of this study is To design and develop a web-based Medication
Management System that facilitates patient self-reporting of adherence and side effects, and
automatically generates and emails weekly summary reports to clinicians for improved remote
patient monitoring.

Objectives:
1.​ To review existing medication adherence applications and identify functional
requirements for a system focused on patient self-reporting and automated clinician
summaries.
2.​ To design a database schema suitable for storing patient medication schedules, adherence
logs (including reasons for non-adherence), and self-reported side effects.
3.​ To develop a responsive web application allowing patients to manage schedules, log
adherence, and report side effects.
 4.​ To implement a backend module that automatically generates concise weekly summary
reports based on patient-logged data.
5.​ To integrate a secure email service for dispatching these automated reports to designated
clinician email addresses.
6.​ To conduct a preliminary evaluation of the developed system's core functionality,
usability, and report generation capability.

1.4 Justification of the Research

For Patients: Potential for improved health outcomes through better adherence, enhanced
self-management, and feeling more connected to their medical personnel.
For Clinicians: Provides timely, objective data to inform clinical decisions, potentially enabling
earlier intervention for non-adherence or managing side effects, without adding significant
workflow like an admin portal.
For Healthcare System (Nigeria): Potential to reduce costs associated with poor adherence (e.g.,
hospital readmissions, emergency visits), improve efficiency in chronic disease management, and
contribute to the adoption of digital health solutions.
Academic Contribution: Addresses a specific gap in simple, automated patient-clinician
communication tools for medication management, particularly relevant in resource-constrained
settings or where complex EMR integration is challenging contributing a model for lightweight,
automated patient-clinician communication loops.

1.5 Scope of the Study

The system facilitates patients' self-reporting of medical adherence like if it has been taken or
skipped and the side effects which can also be sent as an emergency to the clinic via a web
interface, Key functionalities include inventory tracking and the generation/emailing of weekly
adherence/side-effect summary which the system sends to the preset clinical email.
The system will not provide medical diagnoses or replace clinical consultations. It does not
integrate directly with Electronic Health Record (EHR) systems."
the system will be developed with the latest technologies node, express, react, MongoDB, and
nodemailer for email services

1.6 Limitations of the Study

This project relies on self-reporting by patients which can be inaccurate or biased and does not
verify adherence through objective measures, it also depends on the patient's willingness to use
the web application consistently and the project does not address issues such as medical personal
overlooking emails

1.7 Research Questions

1.​ How can a web application be effectively designed to empower patients in self-reporting
medication adherence and side effects?
2.​ What architecture and technologies are suitable for reliably automating the generation
and secure email transmission of weekly patient adherence summaries to clinicians?
3.​ How usable and functionally effective is the prototype system in facilitating targeted
patient reporting and automated clinician communication?

1.8 Definition of Terms

1.​ Medication Adherence: The extent to which a patient takes medications as prescribed by
their healthcare provider.
2.​ Remote Patient Monitoring (RPM): The use of digital technologies to monitor patient
health data outside of traditional clinical settings.
3.​ Side Effect: An unintended secondary effect of a medication.
4.​ Web Application: A software application accessed via a web browser over a network.
5.​ Node.js: A JavaScript runtime environment used for server-side development.
6.​ MongoDB: A NoSQL document-oriented database program.
7.​ Nodemailer: A module for Node.js applications to allow email sending.
CHAPTER 2

LITERATURE REVIEW

2.0 Introduction

This chapter provides a comprehensive review on some existing literature on medication

adherence, digital health interventions, patient self-reporting, and automated clinician
communication. The primary objective of this review is to critically evaluate current research
trends, identify key challenges, and highlight gaps in implementation particularly in resource
constrained setting that the proposed web-based Medication Management System seeks to
address. The review uses a double lensed approach, examining both global advancements in
digital health solutions and Nigeria specific barriers, such as limited healthcare infrastructure,
low digital literacy, and socioeconomic factors affecting patient compliance. By putting all the
insights from recent peer reviewed studies together to form a single work, clinical trials, and
policy reports, this chapter not only establishes the theoretical foundation for the system’s design
but also emphasizes its potential to bridge critical gaps in patient-clinician engagement.
Specifically, the system aims to enhance medication adherence through real-time patient
monitoring, automated reminders, and data driven clinician feedback ultimately improving health
outcomes in both deserved and underserved populations.

2.1 Chapter Contents

This chapter will cover the following key areas:

1.​ A detailed examination of medication adherence, including its definition, scope,

significance, and consequences.
2.​ An exploration of digital health interventions designed to improve medication adherence,
focusing on their types, effectiveness, and limitations.
3.​ An analysis of patient self-reporting methods and their role in medication management.
4.​ A review of automated clinician communication strategies and their impact on patient
adherence.
 5.​ A synthesis of the literature to identify research gaps and propose areas for further
investigation.

2.2 Review of Related Studies

2.2.1: Understanding Medication Non-Adherence and its Impact

Medication adherence is defined by the World Health Organization as "the degree to which the
person’s behavior corresponds with the agreed recommendations from a health care
provider."(Dobbels et al., 2005), it is a very crucial element for effective disease management
and treatment outcomes. According to World Health Organization (WHO), approximately 50%
of patients do not take their medications as prescribed (Aljofan et al., 2023). This widespread
issue is often attributed to patient-related factors (Aljofan et al., 2023). The challenge of
medication non-adherence is highly noticeable given the increasing superiority in the number of
chronic conditions. For instance, in the United States, approximately 117 million individuals live
with such conditions, and projections suggest that by 2025, 18 million people in the United
Kingdom will have a long-term illness (Stewart et al., 2022; Abraham et al., 2024).

Medication non-adherence poses a serious burden on healthcare systems and economies. It can
worsen symptoms,possibly lead to secondary health complications, and also accelerate disease
progression, mostly in chronic illnesses (Stewart et al., 2022). For example, a study involving
330 HIV patients showed that consistent adherence to treatment was associated with no
progression from HIV to AIDS, compared to 8% among occasional adherents and 41% among of
people who were rare adherents (Gathright et al., 2017). This highlights the direct connection
between inconsistent medication use and adverse health outcomes. Consequently, worsened
health frequently necessitates increased healthcare utilization, including more frequent hospital
visits and also hospitalizations, which in its effects escalates the expenses spent on healthcare
costs. This cycle is particularly disadvantageous in the event of managing long-term chronic
conditions.

The economic impact of medication non-adherence is also considerable high , which among
many encompasses costs which are associated with wasted medications, increased healthcare
visits, hospital admissions, and lost productivity. in a recent issue of the Annals of
Pharmacotherapy, the article estimated that the annual cost of medication nonadherence, was
$528.4 billion in 2016 U.S. dollars. (EnlivenHealth, 2025), €1.25 billion in Europe (New
England Healthcare Institute, 2009), AU $7 billion in Australia (Pharmaceutical Group of the
European Union, 2008), and £339 million in the United Kingdom (IMS Institute for Healthcare
Informatics, 2012). Even in a case of modest improvements in adherence, such as in a case study
among hypertension patients in the UK, could result in annual savings exceeding £100 million
(AIHW, 2016). Furthermore, older adults with poor medication adherence reportedly incur an
additional US $2,000 annually in healthcare expenses due to more frequent hospital visits and
consultations (AIHW, 2016). The pervasive and costly nature of medication non-adherence
draws more on the critical need for accessible, scalable, and contextually relevant interventions
to achieve significant improvements in global health outcomes and economic stability.

Nigeria faces a significant challenge with medication non-adherence, with estimates indicating
that 50% to 75% of individuals in Nigeria do not take their medications as prescribed, although
comprehensive national data are limited. A study of 303 individuals with type 2 diabetes in
Nigeria found that over 80% did not adhere to their medication plans (Jackson et al., 2015). A
primary reason for non-adherence in this Nigerian study was forgetfulness, suggesting that
memory and other related factors impede proper medication intake (Jackson et al., 2015). This
finding, while highlighting a patient-related factor, also implies a potential lack of adequate
support systems, such as reminders or simplified regimens, which a strained healthcare system
may struggle to provide. Systemic issues in Nigeria, includes a shortage of healthcare
professionals and barriers to accessing care, increasing the negative consequences of
non-adherence, leading to increased hospitalizations and greater strain on the healthcare system.
The high rates of medication non-adherence, particularly in resource-limited settings like
Nigeria, strongly indicate underlying fragilities and inefficiencies within the healthcare system.
Addressing non-adherence has the potential to alleviate pressure on these overburdened systems.

2.2.2 Digital Health Interventions and Patient Self-Reporting for Adherence

This section explores digital health solutions and patient self-reporting as crucial strategies for
enhancing medication adherence. It analyzes the various types, their effectiveness, and alse the
challenges that are associated with their implementation, particularly regarding when being
integrated into clinical workflows. Digital health solutions have evolved beyond traditional
behavioral interventions, such as pillboxes and counseling calls, in supporting medication
adherence (Schneider et al., 2008). The scope of digital health has expanded from early internet
applications to encompass mobile apps, wearables, telemedicine, analytics, and artificial
intelligence (AI) (Cripps & Scarbrough, 2022). These tools offer the potential to improve
healthcare quality and delivery by directly addressing common barriers to adherence, including
forgetfulness, complex regimens, and low motivation. Mobile health (mHealth), mobile health as
defined by the World Health Organization (WHO) as medical and public health practices
supported by mobile devices (World Health Organization, 2011), it experienced rapid growth
alongside the increasing adoption of smartphones. By 2016, there were over 2 billion smartphone
users globally (eMarketer, 2015), with approximately 64% of adults in the US owning a
smartphone around that time (Pew Research Center, 2015). Studies have indicated mHealth's has
a high potential to improve adherence, especially for chronic diseases (Hamine et al., 2015). A
review focusing on cardiovascular medication adherence found that 73.9% of trials that were
using mHealth interventions (e.g., SMS reminders, apps) reported significant improvements,
even benefiting underserved populations (Arshed et al., 2023).

Various types of digital interventions aim to improve medication adherence. Simple reminder
systems, such as SMS and app notifications, directly target forgetfulness, which up to 60% of
patients identify as a primary reason for non-adherence (Gadkari & McHorney, 2012). A
controlled trial demonstrated that patients that were using reminders took significantly more
doses (a 11.9% increase) compared to those who did not (Fenerty et al., 2012). However, no
single reminder method (text, call, alarm) has been definitively proven superior for daily
medication adherence (Fenerty et al., 2012). Educational platforms, often web-based or utilizing
mobile messaging (e.g., WhatsApp), aim to enhance patients' understanding of their condition
and medication which is a concept known as Medication Information Literacy (MIL) (Li et al.,
2025; Atolagbe et al., 2023). Empowering patients with knowledge has been shown to
significantly improve adherence, as observed in diabetes patients who received an online
educational intervention (Atolagbe et al., 2023). Benefits included enhanced MIL, increased
decision self-efficacy, and potentially fewer adverse events (Li et al., 2025). Interactive
applications, employing gamification and feedback loops, utilize game elements (e.g., points,
goals, progress tracking) in non-game contexts to increase motivation and engagement (Tran et
al., 2024; De Croon et al., 2021). Real-time feedback and progress tracking can assist patients in
adjusting their behavior. The "Diabetes Companion" app by mySugr, which uses a "diabetes
monster" to encourage monitoring, exemplifies this approach and has received approval as a
medical device (Edwards et al., 2016). Gamification appears particularly effective for younger
patients or those motivated by visual feedback and goals. Comprehensive platforms integrate
multiple features (reminders, education, tracking, feedback) into a single interface to provide
holistic support (Tran et al., 2024). The mySugr app, which combines logging with gamification
and feedback, incorporates some aspects of a comprehensive platform (Edwards et al., 2016).
While such platforms hold promise by addressing adherence barriers multi-dimensionally,
user-centered design and evidence-based strategies remain critical for their success.

The evidence regarding the overall effectiveness of digital interventions has been mixed. Some
reviews have reported improved adherence outcomes with apps using featurs such as
gamification or incentives; however, significant heterogeneity in study populations,
methodologies, and outcome measures complicates definitive conclusions (Tran et al., 2024).
Conversely, one randomized trial found that low-cost reminder devices did not improve
adherence for patients with common chronic conditions taking few medications (Choudhry et al.,
2017). Nevertheless, patient perspectives suggest that gamified apps can motivate positive health
behaviors (Tran et al., 2024), and one retrospective study showed sustained adherence over
several months using a multi-component digital therapeutic app (Tran et al., 2024). The success
of these interventions appears to depend on their ability to engage users and meet their individual
needs (Tran et al., 2024). Low engagement limits the impact of these tools; therefore,
interventions need features that ensure consistent use (Choudhry et al., 2017). A lack of patient
involvement in the design process has been linked to misalignment and lower engagement (Tran
et al., 2024). While specific features matter, identifying universally desirable ones has proven
challenging due to the wide variety of features employed (Tran et al., 2024). Point-based features
are common, but their general appeal remains unclear (Tran et al., 2024). Personalized feedback
in web interventions has been well-received, whereas technical issues detract from usability (Xie
et al., 2020). Interventions often require tailoring to the characteristics of the patient population
being targeted. Studies frequently involve specific populations, which limits the generalizability
of their findings (Tran et al., 2024). Targeting interventions to high-risk individuals may increase
their effectiveness (Choudhry et al., 2017).
Patient self-reporting in digital health involves patients directly providing health information
(e.g., medication doses taken/missed, symptoms, side effects) through electronic tools such as
apps or web interfaces (Bourgeois et al., 2007; Xie et al., 2020). This approach captures detailed,
patient-centric data (Bourgeois et al., 2007), is relatively quick and inexpensive compared to
methods like electronic monitoring (Zeller et al., 2008), and allows for surveillance across large,
diverse populations, as well as rapid information processing, potentially enabling near real-time
monitoring (Bourgeois et al., 2007). In some studies, self-reported data collected electronically
has proven accurate when validated against other sources, occasionally even surpassing
clinician-gathered information (Bourgeois et al., 2007). Well-managed patient data supports the
understanding of individual health patterns and can potentially advance digitally assisted
precision medicine (Tran et al., 2024).

While practical, the accuracy of self-reported adherence is debatable. Studies comparing

self-reports (questionnaires, visual analogue scales) to objective measures like
Micro-Electro-Mechanical Systems (MEMS) have often found discrepancies. A significant
majority of patients (e.g., 78.8% in one cardiovascular study) tend to over-report their adherence
compared to MEMS data (Zeller et al., 2008). Denial of non-adherence is also common, and
patient beliefs about medication influence reporting (Zeller et al., 2008). Consequently,
self-reporting alone may be insufficient for accurately detecting poor adherence (Zeller et al.,
2008). However, other research indicates that self-reported drug use shows reasonable reliability
when compared to pharmacy records or pill counts. Questionnaires and scales are quick,
inexpensive, and easily administered in routine clinical practice where more resource-intensive
methods (like MEMS) are often infeasible (Zeller et al., 2008). Self-recording via apps might
also help patients manage complex regimens by addressing forgetfulness through reminders and
scheduling (Tran et al., 2024).

Capturing patient-reported outcomes (PROs), including symptoms and side effects, is vital.
Patient-provided information can be richer than conventional data, allowing for the monitoring
of more precise disease categories or symptom-based syndromes (Bourgeois et al., 2007). Digital
tools (apps, kiosks, web interfaces) facilitate this data collection (Bourgeois et al., 2007). Studies
have confirmed that valid symptom and medical history data can be collected electronically from
patients/parents, sometimes proving more accurate than clinician notes (Bourgeois et al., 2007).
Benefits include the early detection of disease cases (Bourgeois et al., 2007) and improved
patient-clinician communication (Tran et al., 2024). Patients using mHealth apps have reported
increased care satisfaction and better provider interactions, while providers have felt that these
tools aid clinical decision-making (Tran et al., 2024). Despite potential biases (recall, social
desirability), the patient's subjective experience is paramount for symptoms and side effects,
making self-report uniquely valuable (Zeller et al., 2008).

Despite their potential benefits, digital interventions encounter several challenges.

1.​ Usability and Accessibility:

Usability and digital literacy are significant concerns; apps must be designed with simple
language and intuitive interfaces (Tran et al., 2024). Technology avoidance and
difficulties with navigation can hinder adoption and may exclude individuals with lower
levels of technological proficiency (Tran et al., 2024; Xie et al., 2020). Furthermore,
recruitment methods that rely on digital skills, such as scanning QR codes, can introduce
bias into study samples (Xie et al., 2020). While not explicitly addressed within the
sources focused on the Nigerian context, research suggests that a correlation exists
between higher education and adherence, implying that general literacy could influence
the adoption of digital tools (Odesanya & Oragwu, 2015).

2.​ Engagement:

Maintaining long-term user engagement is another obstacle, often due to user fatigue.
Interaction and personalization are important factors for the success of medical adherence
systems (Xie et al., 2020), whereas repetitiveness or irrelevant features can lead to
disengagement (Tran et al., 2022). The lack of a consistent approach to defining and
measuring engagement across different studies further complicates the evaluation of these
interventions (Xie et al., 2020).

3.​ Privacy, Security, and Trust:

Privacy and security concerns also present substantial barriers, as patients may be
skeptical about third-party monitoring and the use of their data, particularly when
 incentives are involved. Establishing trust, robust governance, and respect for patient
autonomy is therefore crucial (Tran et al., 2024). The absence of recognized "gold
standards" for evaluating the usability and security of health apps adds to these
challenges (Tran et al., 2024), underscoring the need for clear guidelines built on a
foundation of trust (Tran et al., 2024).

4.​ Integration and Generalizability:

The reviewed sources predominantly examine digital tools as standalone interventions,

often lacking detail on their integration with existing clinical systems, such as electronic
health records or direct communication channels with clinicians (Xie et al., 2020; Tran et
al., 2024). This represents a significant gap, as seamless integration is frequently essential
for the scalability and long-term clinical utility of these interventions. Additionally, study
findings are often limited by specific recruitment strategies and the characteristics of the
populations studied (e.g., pregnant women in a single hospital, individuals with specific
chronic conditions), which can hinder the generalizability of the results (Li et al., 2025;
Atolagbe et al., 2023; Tran et al., 2024). Methodological heterogeneity across studies also
makes it difficult to compare findings (Tran et al., 2022). It has been suggested that
exploring preferred features within a general population cohort before tailoring
interventions could be a beneficial approach (Tran et al., 2022).

The consistency and accuracy of self-reported data depend on several factors: system usability
(Choudhry et al., 2017), perceived patient value (Zeller et al., 2008; Tran et al., 2024), trust and
privacy (Tran et al., 2024), feedback mechanisms (Xie et al., 2020), and patient characteristics
(recall bias, social desirability bias, denial, provider communication, patient beliefs/attitudes)
(Zeller et al., 2008; Atolagbe et al., 2023). A significant challenge lies in integrating patient
self-reported data into clinical workflows for timely review. While valuable for surveillance
(Bourgeois et al., 2007), systems often lack simple, automated ways to present this information
effectively to clinicians (Barbara et al.). This gap limits the practical application of self-reported
data in routine care, thus limiting its potential to inform clinical decisions promptly. Digital
health interventions and patient self-reporting are not distinct concepts but are often
interdependent; the effectiveness of digital tools is frequently enhanced by their capacity to
facilitate and act upon patient-generated data, creating a powerful feedback loop for adherence
support. For instance, gamification within an application becomes more effective when it can
track and provide feedback on self-reported adherence.

2.2.3: Automated Clinician Communication and Systemic Integration in Digital Health

This section discusses the importance of automated clinician communication and systemic
integration in digital health, reviewing existing systems, their limitations, and how a push-based
model can bridge current gaps. Effective clinician communication is essential for continuous care
and improved clinical outcomes (Maas et al., 2021). Accurate patient information reporting
serves both as a documentation tool and as a mechanism for professional reflection and feedback
(Maas et al., 2021). Documentation remains a time-intensive task, significantly contributing to
the workload of healthcare providers (Maas et al., 2021). A more efficient and systematic
approach to reporting is necessary to maintain data integrity while reducing administrative
burdens (Maas et al., 2021). Feedback from downstream clinicians, multidisciplinary care teams,
or patients back to the initial treating clinician is important for professional development and
clinical calibration (Cifra et al., 2021). Timely and consistent feedback enhances diagnostic
accuracy and fosters reflective practice (Cifra et al., 2021). Health information technology (IT)
offers an opportunity to strengthen this feedback and automate repetitive documentation, thereby
improving efficiency and the quality of care (Cifra et al., 2021).

Existing automated reporting systems demonstrate various approaches but also have inherent
limitations. Automated consultation reporting systems, such as Care2Report (C2R), explore
multimodal inputs (speech, action recognition, sensor data) to generate real-time consultation
reports. These systems construct a Patient Medical Graph (PMG) that integrates spoken dialogue,
observed actions, and clinical measurements, subsequently producing structured reports for
clinician review before integration into Electronic Medical Records (EMRs) (Maas et al., 2021).
However, these systems primarily focus on the consultation phase rather than the complete
continuum of patient care (Maas et al., 2021). Health IT-enabled outcome feedback efforts utilize
existing Electronic Health Record (EHR) systems to facilitate structured patient outcome
feedback. These platforms automate steps such as compiling patient lists, generating templated
feedback forms, and securely delivering feedback through internal messaging systems (Cifra et
al., 2021). This systematic approach minimizes reliance on individual clinician initiative and
offers a standardized mechanism for evaluating clinical outcomes (Cifra et al., 2021). Digital
platforms for patient self-reporting (web-based chronic disease programs, mHealth apps)
facilitate feedback mechanisms, often including self-monitoring and automated feedback aimed
at the patient (Bourgeois et al., 2007; Xie et al., 2020). While useful for patient engagement,
these systems rarely support feedback loops directed toward the initial treating clinicians (Tran et
al., 2022).

Despite technological advancements, several limitations hinder the effective implementation of

automated reporting and clinician feedback systems. Many systems lack seamless integration
with existing clinical workflows, primarily due to incompatibility across different EHR platforms
and information blocking practices (Cifra et al., 2021). The complexity of navigating multiple
systems or platforms discourages clinician adoption. Automated reporting tools often produce
excessive notifications with insufficient prioritization, leading to clinician fatigue and reduced
system utility (Nguyen et al., 2015). Without contextual filtering, such systems can become
disruptive rather than supportive. Ironically, tools designed to alleviate administrative workload
sometimes introduce new tasks such as data verification, system navigation, or responding to
alerts (Cabello-Collado et al., 2024; Cifra et al., 2021). These unintended consequences deter
consistent use, especially in high-pressure environments where clinicians have limited time and
support. Successful implementation requires attention to a range of sociotechnical factors,
including human-computer interaction, the relevance of clinical content, organizational culture,
and existing infrastructure (Cifra et al., 2021). Failure to account for these dimensions can lead to
system rejection, regardless of technical capabilities.

A clear gap exists in the design of many current systems: most require clinicians to actively seek
information, navigate separate interfaces, or interpret complex data outputs. This "pull-based"
feedback model is inherently limited, particularly in busy or resource-constrained settings (Cifra
et al., 2021). This approach, while providing data, can add to clinician workload and be
inefficient, especially given the problem of information overload. A "push-based" model, where
concise, standardized feedback is automatically delivered via familiar communication channels
like email, holds promise in overcoming these challenges (Cifra et al., 2021). This represents a
fundamental shift in design philosophy. Such a system minimizes cognitive and administrative
burden by delivering timely, essential outcome information directly to clinicians, supporting
standardization in feedback content and format, reducing reliance on clinician motivation or
availability to access feedback, and integrating effortlessly into existing digital infrastructure
(Cifra et al., 2021). This streamlined approach can address longstanding barriers to clinician
feedback and contribute to continuous professional development, better calibration in clinical
judgment, and ultimately, improved patient care. The transition from a "pull-based" to a
"push-based" automated communication system is a key design requirement for improving
clinician feedback and reducing workload, as it directly addresses the challenges of information
overload and adoption barriers prevalent in healthcare IT systems.

The Nigerian healthcare system includes traditional practices alongside a modern healthcare
system segmented into primary, secondary, and tertiary levels of care (Akiogbe et al., 2024).
Over 60% of Nigerians rely on private hospitals (Grandville Medical & Laser, 2025). The
healthcare sector consistently faces challenges (Akiogbe et al., 2024), including significant
underfunding and ongoing funding issues (Omoleke & Taleat, 2017; Akiogbe et al., 2024).
Infrastructure gaps are also prominent, with reports of obsolete infrastructure, inadequate
medical facilities, and overcrowding (Omoleke & Taleat, 2017; Akiogbe et al., 2024; Grandville
Medical & Laser, 2025; HealthTech Hub Africa, n.d.). Healthcare workforce shortages and
distribution issues are severe; Nigeria does not meet the WHO ratio of 1 doctor to 600 patients,
currently standing at approximately 1:5,000 (HealthTech Hub Africa, n.d.; Akiogbe et al., 2024;
Omoleke & Taleat, 2017). Brain drain and poor motivation further exacerbate these problems
(Omoleke & Taleat, 2017). Patients face significant access barriers, including limited access to
quality care, particularly in rural areas, and high costs due to the reliance on private hospitals
(Novatia Consulting, 2024; Grandville Medical & Laser, 2025; HealthTech Hub Africa, n.d.).
Many patients in rural areas travel for hours to see specialists (Grandville Medical & Laser,
2025). The prevalence of chronic diseases like hypertension and diabetes, affecting
approximately 30% of Nigerian adults, significantly strains the healthcare system (Novatia
Consulting, 2024).

The digital environment in Nigeria presents both opportunities and challenges. Mobile devices
are widely used in modernizing healthcare delivery due to their accessibility and connectivity.
The number of smartphone users in Nigeria was estimated to be between 25 and 40 million, with
projections exceeding 140 million by 2025, showing rapid growth among the younger generation
(Akiogbe et al., 2024). However, disparities persist in smartphone access and internet
connectivity, potentially limiting the universality of mHealth (Akiogbe et al., 2024). Limited
internet and electricity access in rural areas complicate virtual consultations (Grandville Medical
& Laser, 2025). Low digital literacy is another challenge, especially for the elderly, who may
struggle with mobile health platforms (Grandville Medical & Laser, 2025). Efforts such as
telemedicine training and multi-language support aim to address this (Grandville Medical &
Laser, 2025). Healthtech startups also face a lack of established regulatory frameworks
(HealthTech Hub Africa, n.d.).

The Nigerian healthcare landscape, characterized by significant systemic challenges alongside a

rapidly evolving digital environment, strongly illustrates the need and feasibility of simple,
accessible digital health interventions to bridge gaps in care delivery and improve patient
outcomes. The severe workforce shortages highlight the value of technology-supported remote
monitoring to extend the reach of limited healthcare professionals (Omoleke & Taleat, 2017;
Grandville Medical & Laser, 2025; Novatia Consulting, 2024). Given the limited adoption of
EMRs, a solution that does not require deep, complex integration with varied or non-existent
EMR systems, such as simple automated email reporting, appears more practical for broad
implementation (Akiogbe et al., 2024). Low digital literacy suggests the need for a system with a
simple, intuitive web interface (Grandville Medical & Laser, 2025). Easy-to-use platforms and
support can mitigate digital literacy barriers (Grandville Medical & Laser, 2025). The high rates
of chronic diseases directly necessitate improved long-term management and adherence support
(Novatia Consulting, 2024). Mobile health applications show potential to improve medication
adherence and enhance patient involvement (Akiogbe et al., 2024; Novatia Consulting, 2024).

Given these realities, a web-based application accessible via smartphones or computers, coupled
with a simple automated email reporting mechanism, appears feasible and contextually
appropriate for improving medication management support in Nigeria (Akiogbe et al., 2024;
Grandville Medical & Laser, 2025). This approach leverages existing mobile technology,
bypasses complex IT infrastructure challenges, and utilizes email as a widespread and
manageable communication method. In contexts with significant infrastructural and digital
literacy barriers, prioritizing simplicity and using widely accessible communication methods
(like email) in digital health solutions can significantly improve their feasibility, adoption, and
scalability, ultimately leading to more impactful improvements in patient care.

Table 2.1: Summary of Related Studies

S/N Author(s) & Title of Research Outcome of Research

Year Research Limitation(s)

1 Dobbels et al., Associations Medication Adherence

2005 Between adherence monitoring might
Internalizing generally influence
Symptoms and declined in behavior; further
Trajectories of pediatric research needed
Medication renal/liver on how
Adherence transplant anxiety-related
Among Pediatric patients, but behaviors affect
Renal and Liver higher anxiety adherence.
Transplant was linked to
more stable
adherence.
2 Aljofan et al., The rate of Identified Focused only on
2023 medication common adults; excluded
nonadherence nonadherence many
and influencing practices non-English or
factors: A (abandonment, duplicate studies;
systematic nonconforming, did not study
Review non-persistence) interventions;
and key some factors are
influencing country-specific.
factors:
socioeconomic,
healthcare team,
disease, therapy,
and
patient-related
issues (e.g.,
forgetfulness).

3 Gathright et The impact of Depression Few

al., 2017 medication increased cardiac-related
nonadherence on mortality risk in deaths limited
the relationship heart failure analysis; missing
between patients, but medication
mortality risk medication monitoring data
and depression nonadherence due to equipment
in heart failure was the direct issues or patient
predictor, refusal.
suggesting
nonadherence
 mediates the link
between
depression and
mortality.

4 EnlivenHealth, EnlivenHealth News recap

2025 Weekly Recap \ covering
pharmacy
advocacy
(ECAPS Act), AI
in pharmacy, new
drug approvals
(e.g., LDL-C
reduction,
hypertension),
and smart
medication safety
tech.
5 New England Thinking outside Poor medication Few high-quality
Healthcare the pillbox: A adherence causes studies; small
Institute, 2009 system-wide significant samples and
approach to healthcare waste. short follow-ups;
improving Effective varied adherence
patient interventions measurements;
medication include narrow focus on
adherence for simplified single diseases;
chronic disease regimens, patient multi-component
education, case interventions
management, and made isolating
pharmacist effects difficult;
counseling. Key conflicting
pillars for results.
improvement are
tailored
regimens, cost
reduction, and
addressing
patient behaviors.
6 Pharmaceutical Targeting 20-30% of As a professional
Group of the adherence: patients don't report, it may
European Improving adhere to have a bias
Union, 2008 patient outcomes medication, towards
in Europe leading to high promoting
through costs and reduced pharmacists'
community quality of care. roles and might
pharmacists’ Community lack the detailed
intervention pharmacists are methodological
crucial for rigor of
improving peer-reviewed
adherence research.
through
counseling,
antimicrobial
stewardship, and
preventative
actions.

7 IMS Institute Advancing the Identified 9 As a public

for Healthcare responsible use levers of service report, it
Informatics, of medicines: suboptimal may not include
2012 Applying levers medicine use detailed
for change (e.g., empirical testing
nonadherence, for all
errors, recommendations
polypharmacy) or may have a
costing $500 broad scope
billion globally without deep
 in 2011. Provided analysis of
case studies and specific
50 interventions.
recommendations
for policymakers
to improve
medicine use.

8 AIHW, 2016 Health Australia spent As a financial

expenditure $180.7 billion on report, it focuses
Australia health in on expenditure
2016–17 2016–17 (10% of data and may not
economic analyze the direct
activity), with impact of
governments spending on
funding 69%. specific health
Spending growth outcomes or the
was 4.7%, higher underlying
than previous reasons for cost
years, with variations.
significant funds
allocated to
hospitals and
new hepatitis C
treatments.
9 Jackson et al., Medication Medication Did not find a
2015 adherence in adherence was statistically
type 2 diabetes poor in Nigerian significant
patients in type 2 diabetes relationship
Nigeria patients (50.2% between general
low adherence). patient
Factors linked to characteristics
nonadherence and adherence,
included low limiting insights
literacy, into demographic
forgetfulness, influences.
high cost, limited
access, complex
regimens, poor
communication,
lack of trust, and
depression.

10 Schneider et Impact of Daily-dose The study may

al., 2008 medication blister packaging have a limited
packaging on improved sample size and
adherence and prescription refill specific patient
treatment regularity, population
outcomes in increased (elderly,
older ambulatory medication hypertension),
patients possession, and which could
lowered diastolic affect the
blood pressure in
elderly patients.
 It also enhanced generalizability
patients' memory, of findings.
confidence,
independence,
and perceived
quality of life,
with potential for
cost savings.

11 Cripps & Digital health Proposed a As a conceptual

Scarbrough, literacy – a key framework for framework and
2022 factor in digital health project insights,
realizing the literacy and it may lack
value of digital shared strategies empirical data on
transformation in from an EU long-term
healthcare project to effectiveness or
empower generalizability
individuals and beyond the
promote digital specific EU
inclusion in project context.
healthcare.
12 World Health World Report on 15% of the As a global
Organization, Disability 2011 global population report, it may
2011 lives with a lack granular
disability, a detail for specific
rising trend due regions or
to aging and conditions, and
chronic diseases. its findings rely
The report on varying data
reviews disability quality from
situations, different
barriers, and countries.
offers policy
recommendations
to improve lives.

13 eMarketer, Online Healthcare and Findings are

2015 Marketing pharma digital ad specific to 2015
Budget & User spend was $1.48 and may not
Behavior For billion in 2015 reflect current
The Healthcare (projected to trends. Relied on
Industry increase). Mobile self-reported
health app survey data,
adoption doubled which can have
(29% of US recall or social
internet users). desirability bias.
Many consumers
and healthcare
professionals use
smartphones for
 health
information.

14 Pew Research U.S. Smartphone 62% of US Based on

Center, 2015 Use in 2015 smartphone self-reported
owners used their survey data from
phone to look up 2015, which may
health not reflect
information in current trends
the past year, and could be
showing subject to recall
widespread use or social
of mobile devices desirability bias.
for health
inquiries.

15 Hamine et al., Impact of Systematic Evidence for

2015 mHealth chronic review found effectiveness was
disease mHealth tools, mixed; some
management on especially SMS, studies showed
treatment were commonly only modest
adherence and used and benefits.
patient generally Technical issues,
outcomes: a acceptable for provider
systematic chronic disease concerns about
review. management. workload, and
56% of RCTs cost were
showed
significant
 adherence identified
improvements. barriers.

16 Gadkari & Unintentional Unintentional Relied on

McHorney, Non-Adherence non-adherence self-reported
2012 to Chronic (forgetting, data, which may
Prescription running out, be subject to
Medications: carelessness) is inaccuracies. The
How not random but study's
Unintentional Is predicted by cross-sectional
It Really? medication design limits the
beliefs, chronic ability to
disease, and establish
demographics. It causality.
can predict future
intentional
non-adherence.

17 Fenerty et al., The Validity and The Turkish Data collected

2012 Reliability Study version of the from a single
of the Self-reported center, limiting
Self-reported Measure of generalizability
Measure of Medication to other
Medication Adherence Scale populations or
Adherence Scale (SMMA) is a healthcare
in Patients valid and reliable settings.
Taking Oral tool for type 2
diabetes patients
 Antidiabetic using oral
Treatment antidiabetics.

18 Li et al., 2025 Effectiveness of A web-based Sampling bias

a Web-Based education course from a single
Medication via WeChat urban hospital
Education significantly limits
Course on improved generalizability.
Pregnant pregnant Conducted
Women's women's during
Medication medication COVID-19,
Information information which might
Literacy and literacy and have influenced
Decision decision behavior. Did not
Self-Efficacy: self-efficacy. explore
Randomized long-term effects
Controlled Trial or direct impact
on medication
adherence.
19 Atolagbe et al., Effectiveness of Online Control and
2023 educational educational intervention
intervention in intervention groups were
improving significantly unbalanced.
medication improved Potential
adherence medication inaccuracies in
among patients adherence and self-reported
with diabetes in preference for data. Limited
Klang Valley, online materials generalizability
Malaysia in diabetes due to snowball
patients. Daily sampling and
WhatsApp regional
reminders were restriction.
beneficial, and
pharmacist-led
interventions
were effective
across
demographics.

20 Tran et al., Understanding Identified patient Qualitative study,

2024 Patient perspectives on which may limit
Perspectives on gamification and generalizability.
the Use of financial Focused on
Gamification incentives in patient
and Incentives in mHealth apps, perspectives
mHealth highlighting rather than direct
Applications to concerns about
Improve trivialization and
 Medication potential for behavioral
Adherence: medication outcomes.
Qualitative abuse.
Study Preprint Emphasizes need
for standards in
app design.

21 Tran et al., Patient Lung transplant Specific to lung

2024 engagement patients with transplant
attrition in longer recipients,
mobile health post-transplant limiting
(mHealth) time or generalizability.
remote patient non-English Interviews with a
monitoring speakers had small sample
(RPM) programs lower mHealth may not
decreases engagement. represent all
program Challenges non-engaging
benefits. included device patients.
issues,
communication
breakdowns, and
desire for more
personal
interaction.
22 Choudhry et Effect of Low-cost Adherence
al., 2017 reminder devices reminder devices measurement
on medication (pill bottle strip, (MPR) might be
adherence: The digital timer cap, inaccurate for
REMIND standard pillbox) patients stopping
Randomized did not medication
Clinical Trial significantly mid-fill or taking
improve as needed. Did
medication not differentiate
adherence in between
nonadherent as-needed use
patients with and
chronic discontinuation.
conditions.

23 Bourgeois et The Value of Patient Potential

al., 2007 Patient self-report was misclassification
Self-report for more sensitive in the gold
Disease than existing standard. Limited
Surveillance surveillance data number of
for identifying disease
disease categories
categories (e.g., assigned. Used a
fever, respiratory convenience
illness). Patients sample, limiting
found the generalizability.
self-report tool Tool was
easy to use and paper-based,
needing
 were willing to electronic testing
use it again. for rapid
surveillance.

24 Zeller et al., Patients' A majority of Self-reporting is

2008 self-reported patients (78.8%) an insufficiently
adherence to over-reported accurate method
cardiovascular their adherence for assessing
medication using to cardiovascular medication
electronic medication when compliance,
monitors as using self-report especially for
comparators measures detecting poor
compared to adherence.
electronic
monitors.
Self-reported
adherence
correlated poorly
with electronic
monitor data.
25 Odesanya & Medication 22% of Findings based
Oragwu, 2015 adherence outpatients were on primary data
among non-adherent, from selected
outpatients at the primarily due to healthcare
Jos University forgetfulness professionals,
teaching (32%). which may limit
hospital. Adherence was generalizability
linked to factors to the entire
like higher health sector or
education, male other
gender, and stakeholders.
satisfactory
knowledge of
medicines.

26 Tran et al., Effectiveness of Protocol for an Significant

2022 an mHealth App mHealth app anthropometric
That Uses (CommitFit) improvements
Financial using are not expected
Incentives and gamification and due to healthy
Gamification to financial baseline weight
Promote Health incentives to in most
Behavior promote health adolescents and
Change in behavior change small sample
Adolescents and in adolescents size. Two server
Caregivers: and caregivers, errors occurred,
Protocol for a aiming to reduce though mitigated.
Clinic-Based obesity.
 Randomized
Controlled Trial

27 Maas et al., Automated Proposed a Presents a

2021 medical real-time conceptual idea
reporting: From automated and prototype;
multimodal medical reporting lacks empirical
inputs to medical system data on full
reports through integrating implementation,
knowledge speech/action effectiveness, or
graphs recognition with long-term impact
knowledge in clinical
graphs (Patient settings.
Medical Graph)
to summarize
consultations and
reduce clinician
workload.

28 Cifra et al., Bridging the Health IT (EHR) Fragmented

2021 feedback gap: a can improve healthcare
sociotechnical clinical systems,
approach to decision-making information
informing by providing blocking, and
clinicians of timely, structured low
patients' feedback on interoperability
subsequent patient outcomes, hinder
overcoming implementation.
structural Clinician
 clinical course barriers, and time/effort and
and outcomes indirectly psychological
addressing barriers (fear of
psychological judgment)
barriers. remain
challenges.

29 Nguyen et al., The Use of Reviewed Most studies

2015 Technology for technology for were
Urgent Clinician urgent clinician quasi-experiment
to Clinician communication: al, lacked direct
Communications pagers increased patient outcome
: A systematic info but were metrics, and did
review of the disruptive; not compare
literature smartphones technology to
reduced time but in-person
increased communication.
interruptions; Focused on
novel tech specific clinician
(blogging, email) groups.
improved
two-way
communication
and real-time
access.
30 Cabello-Collad Automated Developed a Encountered
o et al., 2024 Generation of system using unspecified
Clinical Reports sensing "challenges
Using Sensing technologies and during
Technologies deep learning to development,"
with Deep automate clinical suggesting the
Learning report generation system is not
Techniques from fully mature or
patient-doctor widely
interactions, implemented.
aiming to reduce
administrative
burden and
improve
healthcare
outcomes.

31 Akiogbe et al., Cross-Analysis Cultural factors Focused on

2024 of mHealth influence university
Social mHealth students, limiting
Acceptance acceptance generalizability.
Among Youth: A among youth: Cross-sectional
Comparative Japanese youth design prevents
Study Between are cautious tracking attitude
Japan and China (performance-foc changes over
used), while time.
Chinese youth
show strong
 engagement
(trust-driven).

32 Grandville Telemedicine in Telemedicine is Challenges

Medical & Nigeria: The crucial for include limited
Laser, 2025 Future of Nigeria to internet/electricit
Healthcare address doctor y in rural areas,
Accessibility shortages, limited low digital
infrastructure, literacy,
and high costs. It developing
improves access regulatory
(rural areas, policies, and
24/7), reduces potential
costs, speeds resistance to
delivery change from
(AI-assisted), and patients and
enhances chronic doctors.
disease
management.
33 Omoleke & Contemporary Nigerian health Based on
Taleat, 2017 issues and sector faces perspectives of
challenges of severe selected
health sector in challenges: brain healthcare
Nigeria drain, poor pay, professionals,
obsolete which may limit
infrastructure, generalizability
inadequate to the entire
facilities, and health sector or
underfunding other
(4% of budget), stakeholders.
leading to a
"defective"
system and poor
doctor-to-patient
ratio.

34 HealthTech HealthTech HealthTech in Overall VC

Hub Africa, Africa emerges Africa is growing funding is still
n.d. in 2025 driven due to urgent below historical
by significant needs, digital norms. Funding
investments and transformation, is highly
innovation and local concentrated in a
innovation. It few countries,
attracts and fragmented
investment regulatory
(projected $11B frameworks
by 2025) and
focuses on
 pharmacy, AI, remain a
telemedicine, and challenge.
supply chain
solutions.

35 Novatia Hospital and Specializes in The company's

Consulting, Clinic feasibility studies online account
2024 Management for hospital/clinic appears
Systems management suspended,
Feasibility Study systems in making current
Services in Nigeria, covering details about
Nigeria economic, their services,
technical, legal, outcomes, or
and operational limitations
factors to unavailable.
enhance
efficiency and
patient care.

2.3 Research Gap

2.3.1 Research Gap and Proposed Project

Medication non-adherence presents a significant obstacle to achieving optimal therapeutic

outcomes, particularly in chronic disease management, leading to increased disease progression,
hospitalizations, and healthcare costs. In Nigeria, studies indicate high rates of non-adherence,
with forgetfulness being a primary cause, highlighting the need for context-specific
interventions. While digital health, especially mHealth, offers potential solutions using tools like
gamification and reminders, evidence remains heterogeneous in methodology and outcome, with
limited consensus on effective features and concerns about trivializing treatment or misusing
incentives. A key limitation is the lack of patient involvement in design, resulting in tools that
poorly address user needs. Similarly, self-guided web tools face challenges in adherence
measurement, accessibility, and engagement, limiting their utility in low-resource settings where
interpersonal trust is essential. Self-reported adherence is also biased, creating a disconnect
between patient experience and clinician awareness and hindering timely intervention. Although
health IT can streamline communication, complex systems require infrastructure and workflow
alignment, posing challenges in resource-constrained settings like Nigeria where "pull-based"
systems are inefficient.

Therefore, a core gap exists in the absence of simple, low-barrier, automated, push-based
systems for relaying patient-reported adherence and side-effect data to clinicians. Current digital
tools often lack real-time clinician feedback, and reporting solutions are too complex for
Nigerian settings. To address this, this project proposes a web-based Medication Management
System for Nigeria. This system will enable patients to easily self-report medication intake and
side effects, generating automated weekly summary reports emailed to clinicians. This
push-based model avoids complex integration and minimizes clinician workload. This approach
aims to:

1.​ Enhance clinician awareness of adherence and side effects,

2.​ Support timely intervention,
3.​ Foster clinician-patient communication, and
4.​ Improve adherence and outcomes.

The system's simplicity and accessibility make it suitable for resource-constrained environments,
offering a scalable solution for Nigeria and similar settings.
CHAPTER 3

SYSTEM ANALYSIS AND METHODOLOGY

This chapter establishes the analytical and methodological framework for the "Medication
Management System with Automated Doctor Reporting." It examines the problem domain,
explains the rationale for the proposed solution, and describes the systematic approach used for
system design and development. The methodologies, tools, and ethical considerations discussed
here lay the groundwork for the subsequent implementation phase.

3.0 Introduction

Purpose of the System

The "Medication Management System with Automated Doctor Reporting" is a web-based

platform enabling patients to self-report medication adherence and side effects, while
automatically sending weekly summaries to clinicians. This system addresses critical medication
non-adherence, especially in resource-constrained settings like Nigeria.

Chapter Objectives

1.​ Analyze the problem domain and current practices.

2.​ Outline limitations of existing approaches.
3.​ Justify the new digital system.
4.​ Detail development methodology and application.
5.​ Specify functional and non-functional requirements.
6.​ Present system design (architecture, database, UI/UX, modules).
7.​ Discuss selected technologies, tools, and ethical considerations.

3.1 Analysis of the Problem Domain and Current Practices

Medication non-adherence significantly affects treatment for chronic conditions like

hypertension, diabetes, and HIV/AIDS. Globally, about half of patients do not adhere to
prescribed medications, leading to worsened health outcomes and increased healthcare costs. In
Nigeria, non-adherence rates range from 50% to 75%, often due to forgetfulness, complex
regimens, or side effect concerns.

Timely side effect reporting is challenging; patients often lack structured communication
channels, delaying interventions. Nigeria’s strained healthcare system, with limited rural access
(over 50% of chronic disease patients reside there), exacerbates these issues.

Patients in Nigeria commonly use informal methods such as memory, handwritten notes, or
family reminders to manage medication. These are unreliable, especially for complex regimens,
often resulting in missed doses. Side effects are typically noted informally and reported only
during infrequent clinic visits, hindered by travel distance or high private care costs (over 60% of
Nigerians rely on private care).

Clinicians assess adherence and side effects via patient recall, prone to inaccuracies.
Communication is inefficient; patients rarely provide real-time updates. Clinicians receive data
only during limited scheduled appointments, constrained by Nigeria’s severe doctor shortage
(1:5,000 vs. WHO's 1:600). This lack of timely data hinders early detection of complications,
leaving clinicians reliant on unsure reports.

Current practices inadequately address adherence and side-effect reporting. Manual methods are
error-prone and unsustainable; lack of real-time communication impedes timely clinician
intervention. In Nigeria, low digital literacy, limited rural internet, and high healthcare costs
complicate monitoring. These deficiencies lead to suboptimal outcomes, preventable
hospitalizations, and increased costs. A digital system for patient self-reporting and automated
clinician reports is crucial to bridge these gaps and improve health outcomes in Nigeria’s
resource-constrained healthcare.

3.2 Limitations of Current Practices

Patients face significant obstacles with manual medication management. Forgetfulness,

particularly for older individuals or those with complex regimens, often leads to missed doses. In
Nigeria, low digital literacy among chronic disease patients (30% of adults) further compounds
issues with memory or handwritten notes, making consistent record-keeping unreliable.

Side effect reporting is challenging; patients struggle to document details like severity or timing,
delaying communication until infrequent clinic visits. Limited rural healthcare access (over 50%
of chronic disease patients) and high private care costs (over 60% of Nigerians rely on it) cause
significant reporting delays. Cultural stigmas, like fear of non-compliance, also deter open
reporting, a distinct barrier from financial limitations.

Clinicians struggle with unreliable patient data, relying on recall prone to inaccuracies or bias.
Nigeria’s severe doctor shortage (1:5,000 vs. WHO's 1:600) limits patient interactions, making
proactive monitoring difficult. Without digital tools, clinicians cannot track adherence or detect
side effects between visits, forcing reactive care. Overcrowded facilities and time constraints
further hinder thorough assessments.

These limitations significantly impact patients and the healthcare system. Inconsistent adherence
leads to suboptimal outcomes, complications, and mortality. Delayed side-effect reporting can
escalate issues. Systemically, these challenges strain Nigeria’s healthcare infrastructure,
increasing costs from preventable hospitalizations, especially for chronic diseases affecting 30%
of adults. Lack of structured monitoring perpetuates inefficiencies, burdening a
resource-constrained system.

3.3 Justification for the New System

The "Medication Management System with Automated Doctor Reporting" directly addresses
identified limitations with a web-based platform for Nigeria. It counters forgetfulness via
intuitive 'Taken'/'Skipped' dose logging and simplifies complex regimens through an organized
dashboard. Side-effect reporting improves with a real-time logging form, reducing delays.
Leveraging Nigeria’s projected 140 million plus smartphone users by 2025, the system employs
a simple interface for accessibility, even with low digital literacy or intermittent connectivity.

The system empowers patients by simplifying medication management and increasing

engagement. Its dashboard offers a clear schedule overview, aiding memory. Structured logging
replaces unreliable paper methods, ensuring accurate, timely data. Accessible via web on
smartphones or computers, it supports Nigeria’s diverse users, including those with limited
digital skills. These features promote accountability, improve adherence, and strengthen patient
connection to their care, potentially leading to better health outcomes.

For clinicians, the system provides concise, automated weekly reports via email, summarizing
adherence and side effects without complex EHR integration. This push-based model offers
timely, actionable data for informed, proactive decisions. In Nigeria’s overstretched healthcare
system , automation reduces administrative burden and improves care efficiency, addressing data
gaps and reliance on inaccurate patient recall.

Overall, the system transforms medication management by bridging the patient-clinician

communication gap. It replaces manual practices with a scalable, accessible digital solution that
promotes adherence, timely side-effect reporting, and proactive clinical interventions.
Addressing Nigeria-specific challenges like low digital literacy and limited healthcare access ,
the system could reduce complications, lower costs, and improve outcomes for chronic disease
patients, contributing to a more effective healthcare system.

3.4 Chosen Development Methodology

3.4.1 Selected Methodology

The "Medication Management System with Automated Doctor Reporting" utilized a hybrid
Iterative and Incremental Model, integrating UI Prototyping. This SDLC approach aimed to
deliver a functional MVP within university project constraints, allowing flexibility for feature
refinement and adaptation to Nigerian healthcare needs.

3.4.2 Justification for Chosen Methodology

This hybrid model was chosen for its alignment with project goals and constraints. The iterative
approach enabled early MVP development and testing within a 12-week timeline, which is
crucial for a solo developer. Incremental development allowed prioritization and staged
validation of features. UI prototyping facilitated rapid, intuitive interface design, essential for
diverse Nigerian users, including those with lower digital literacy. This model offered the
necessary flexibility for a student-led initiative, ensuring a user-focused MVP through
continuous supervisor feedback.

3.4.3 Phases/Stages of the Chosen Methodology

The 12-week development process comprised four key phases for the MVP, with subsequent
refinements:

1. Initial Planning & UI Prototyping: Defined project scope and MVP functionalities (user
authentication, medication logging, side-effect reporting, automated clinician reports).
Developed UI prototypes from wireframes to high-fidelity mockups using Next.js/shadcn/ui,
focusing on intuitive navigation and accessibility, refined by supervisor feedback.

2. MVP Implementation: Incrementally built core functionalities: user authentication, medication

management, adherence/side-effect logging, report generation, and automated emailing.
Prioritized backend logic, then developed a responsive frontend. Components were tested upon
implementation, ensuring stability with the data.

3. Testing & Refinement: Conducted manual functional testing of core user flows (registration,
logging, reporting). Focused on usability for patients with limited digital skills and report
delivery reliability. Supervisor feedback guided refinements to UI clarity, error handling, and
report optimization.

4. Documentation & Finalization: Prepared comprehensive documentation (architecture, code

comments, user guides). Final testing confirmed MVP functionality with mock data, adhering to
ethical guidelines. The system was finalized for demonstration, delivering a polished MVP
within the timeline.

3.5 Requirements Elicitation and Specification (Data Collection)

3.5.1 Method of Requirements Gathering

System requirements were gathered through a multi-faceted approach: project proposal analysis,
problem domain analysis (Sections 3.1–3.3) highlighting user needs like intuitive interfaces and
automated reporting , review of similar applications (e.g., Medisafe, MyTherapy) , logical
assumptions based on socioeconomic factors (e.g., mobile penetration vs. rural internet access) ,
and informal supervisor discussions to ensure feasibility within project constraints.

3.5.2 Functional Requirements

The MVP's functional requirements (FR1–FR7) prioritize core capabilities addressing critical
user needs. FR4 (Medication Adherence Logging), FR6 (Automated Weekly Report Generation),
and FR7 (Automated Emailing of Reports) were essential for tackling non-adherence and
communication gaps. Reminders were excluded from the MVP to focus on these core logging
and reporting functions.

1.​ FR1: User (Patient) Registration and Secure Authentication: The system must allow
patients to register with a unique email and password and log in securely to access their
dashboard. Authentication ensures only authorized users can manage medication data.
2.​ FR2: Patient Profile Management: The system must enable patients to create and update a
profile, including personal details (e.g., name, email) and configuration of a clinician’s
email address for automated report delivery.
3.​ FR3: Medication Scheduling: The system must allow patients to add, view, edit, and
delete medication details, including name, dosage, frequency (e.g., daily, twice daily),
and start/end dates, to support personalized schedules.
4.​ FR4: Medication Adherence Logging: The system must provide functionality for patients
to log each dose as “Taken” or “Skipped” with a timestamp, enabling accurate tracking of
adherence patterns.
5.​ FR5: Side Effect Recording: The system must allow patients to log side effects with
details, including description (e.g., nausea, dizziness), severity (e.g., mild, moderate,
severe), and date/time, to facilitate timely reporting.
6.​ FR6: Automated Weekly Report Generation: The system must compile adherence rates
(e.g., percentage of doses taken) and logged side effects for the past week into a concise
report, summarizing patient data for clinician review.
 7.​ FR7: Automated Emailing of Reports: The system must automatically send the generated
weekly report to the clinician’s pre-configured email address, using a scheduled process
to ensure timely delivery.

3.5.3 Non-Functional Requirements

Non-functional requirements (NFR1–NFR6) define system qualities. For the MVP, NFR1
(Usability), NFR2 (Reliability), and NFR3 (Security) were prioritized to ensure an accessible,
dependable, and ethical system, considering Nigeria’s user and healthcare context.

1.​ NFR1: Usability: The system must be intuitive and easy to use, with a clean interface and
simple navigation to accommodate patients with lower digital literacy. Usability will be
assessed through supervisor feedback on prototypes and task completion success during
testing.
2.​ NFR2: Reliability: Core functionalities, especially report generation and email dispatch,
must be dependable, achieving 99% success in report delivery during testing to support
clinician decision-making.
3.​ NFR3: Security: The system must implement measures to protect user data, including
password hashing for login credentials and secure storage of email addresses, adhering to
ethical data handling and Nigeria’s Data Protection Regulation (NDPR).
4.​ NFR4: Performance: The web application must respond to user actions (e.g., logging a
dose, submitting a side effect) within 2 seconds under normal conditions. Report
generation and emailing must complete within 5 seconds per report.
5.​ NFR5: Maintainability: The codebase must be organized with clear file structures,
modular components, and inline comments to facilitate understanding and potential
future modifications, suitable for a student project’s scope.
6.​ NFR6: Scalability (Conceptual): While the MVP is designed for limited use, the system’s
architecture (Node.js and MongoDB) supports conceptual scalability. Node.js’s
asynchronous processing can handle increased user requests, and MongoDB’s flexible
schema can accommodate growing patient data volumes. In a healthcare context, this
could mitigate challenges like managing large adherence logs or ensuring system
 availability during peak usage, enabling future expansion if deployed in a real-world
setting.

3.5.4 Data Requirements

The system handles various data types to support its functions. All data undergoes rigorous
handling to meet NDPR, privacy, and ethical standards, ensuring no real patient information is
exposed. This mitigates data breach risks and aligns with ethical development.

1.​ Patient Credentials: Email, hashed password, and user ID for secure authentication.
2.​ Patient Profile: Name, email, and clinician’s email address for report delivery.
3.​ Medication Details: Name, dosage, frequency, start/end dates, and associated patient ID.
4.​ Adherence Logs: Dose status (“Taken” or “Skipped”), timestamp, and linked medication
ID.
5.​ Side Effect Logs: Description, severity, date/time, and linked patient ID.
6.​ Clinician Contact Information: Email address for receiving automated reports.
7.​ Generated Reports: Weekly summaries of adherence rates and side effects, stored
temporarily for emailing.

3.6 System Design

3.6.1 Architectural Design

The "Medication Management System with Automated Doctor Reporting" employs a multi-tier
architecture (Presentation, Application, Data Tiers) for separation of concerns and
maintainability. A web application architecture ensures broad accessibility across devices,
beneficial in Nigeria’s diverse technological landscape.
The roles of the major components are as follows:

1.​ Frontend (Next.js): This is the presentation layer, providing the user interface that
patients interact with to manage their medications, log adherence and side effects, and
configure their profiles. Built with Next.js, it aims to provide a modern, responsive user
experience.
2.​ Backend API (Node.js/Express.js): This layer handles the application's business logic. It
receives requests from the frontend, processes data (e.g., user authentication, saving
medication details, logging adherence), interacts with the database, and orchestrates the
generation and sending of reports.
3.​ Database (MongoDB): This is the data persistence layer, responsible for storing all
application data, including user credentials, medication schedules, adherence logs, and
side effect records.
4.​ Email Service (Nodemailer): This component is used by the backend to send automated
weekly summary reports to the clinicians' pre-configured email addresses.

3.6.2 Database Design (Logical Design)

The system uses MongoDB, a NoSQL document database, for data storage. Chosen for its
flexible schema, good read/write performance, scalability, and strong Node.js integration via
Mongoose, it suits MVP development and future growth. The system's data is organized into the
following main collections:

1.​ Users (Patients): Stores information about the patients using the system.
2.​ Medications: Stores details of the medications prescribed to each patient.
3.​ AdherenceLogs: Records when patients take or skip their medication doses.
4.​ SideEffectLogs: Stores information about any side effects reported by patients.

The schema details for each collection are as follows:

Table 3.1: Users Collection Schema

Field Data Type Constraints Description

_id ObjectId Primary Key Unique identifier for the user

firstName String Required Patient's first name

lastName String Required Patient's last name

email String Required, Unique Patient's email address (used for login)

password String Required Hashed password for authentication

clinicianEmail String Optional Clinician's email address for reports

registrationDate Date Required Date when the patient registered

Field Data Type Constraints Description

_id ObjectId Primary Unique identifier for the medication

Key

patient ObjectId (ref: Required Reference to the patient this medication

Users) belongs to

name String Required Name of the medication

dosage String Required Dosage of the medication

schedule Array of Strings Required Array of times the medication should be taken
daily

startDate Date Required Date when the medication regimen started

 endDate Date Optional Date when the medication regimen ends (if
applicable)

Table 3.2: Medications Collection Schema

Table 3.3: AdherenceLogs Collection Schema

Field Data Type Constraints Description

_id ObjectId Primary Unique identifier for the adherence log

Key

patient ObjectId (ref: Users) Required Reference to the patient

medicatio ObjectId (ref: Required Reference to the medication

n Medications) taken/skipped

taken Boolean Required true if taken, false if skipped

logDate Date Required Date and time the adherence was

logged

Table 3.4: SideEffectLogs Collection Schema

 Field Data Type Constraints Description

_id ObjectId Primary Unique identifier for the side effect log
Key

patient ObjectId (ref: Required Reference to the patient

Users)

descriptio String Required Description of the side effect

n

severity String (enum) Required Severity of the side effect ('Mild', 'Moderate',
'Severe')

logDate Date Required Date and time the side effect occurred
3.6.3 User Interface (UI) and User Experience (UX) Design Considerations

The UI design prioritizes simplicity, ease of navigation, and clarity for accessibility, especially
for patients with varying digital literacy. Key MVP screens include:

1.​ Login Page: Allows registered patients to securely access their accounts.
2.​ Registration Page: Enables new patients to create their profiles.
3.​ Dashboard: Provides an overview of the patient's medications scheduled for the current
day with quick actions to mark them as taken or skipped. This serves as a 'Today's
Agenda' rather than active notification reminders, which were excluded from the MVP to
prioritize core logging and reporting functionalities. It also serves as the central point to
navigate to other sections.
4.​ Add/Edit Pill Reminder Form: Allows patients to input details for their medications,
including name, dosage, and schedule.
5.​ Log Side Effect Form: Enables patients to report any side effects they experience,
including a description and severity level.
6.​ Clinician Settings: Allows patients to enter or update the email address of their clinician
for receiving automated reports.
While visual mockups aid detailed UI/UX, the focus here is functional design. The
Next.js/shadcn/ui frontend incorporates modern UI/UX practices, ensuring responsiveness across
devices.

3.6.4 Module Design

The backend of the system is structured into several logical modules, each responsible for
specific functionalities:

1.​ Authentication Module: Handles user registration (/api/auth/register), login

(/api/auth/login), and other authentication tasks (authController).
2.​ User Profile Module: Manages user-specific data, such as updating the clinician's email
(/api/auth/clinician-email within authController).
3.​ Medication Management Module: Provides CRUD operations for patient medications
(/api/medications routes, medicationController).
4.​ Adherence Logging Module: Handles creation and retrieval of medication adherence logs
(/api/adherence routes, adherenceController).
5.​ Side Effect Logging Module: Manages recording and retrieval of side effect reports
(/api/side-effects routes, sideEffectController).
6.​ Reporting Module: Contains logic within reportService to query the database for
adherence and side effect data and generate weekly summary reports.
7.​ Email Service Module: Integrated within reportService, this module utilizes Nodemailer
to send generated weekly reports via email.
8.​ Scheduling Module: Implemented using node-cron, this module automatically triggers
the weekly report generation and emailing process, residing within reportService.
This modular design promotes separation of concerns, enhancing code understanding,
maintenance, and future extensibility.

3.7 System Flowcharts

This section provides visual representations of the key processes within the "Medication
Management System with Automated Doctor Reporting" using flowcharts. These diagrams
illustrate the sequence of steps involved in critical functionalities, enhancing the understanding
of the system's operational logic.
(Figure 3.6: User Registration and Login Flowchart)
(Figure 3.7: Patient Logging Medication Adherence Flowchart)
(Figure 3.8: Patient Recording a Side Effect Flowchart) [You will insert the flowchart diagram
here illustrating the process of a patient recording a side effect.]

(Figure 3.9: Automated Weekly Report Generation and Emailing Process Flowchart)

3.8 Choice of Technologies, Tools, and Instruments

3.8.1 Software Technologies

1.​ Backend:
a.​ Node.js: Selected for its non-blocking, event-driven architecture, suitable for
scalable network applications and its rich ecosystem.
b.​ Express.js: Chosen as a minimalist Node.js framework for building robust APIs
and handling server-side logic.
c.​ Mongoose: Utilized as the MongoDB ODM for Node.js, simplifying database
operations through schema definition and data manipulation.
2.​ Database:
a.​ MongoDB: A NoSQL document database, chosen for its flexible schema, good
read/write performance, scalability, and strong Node.js integration via Mongoose,
beneficial for MVP development.
3.​ Email Service:
 a.​ Nodemailer: A Node.js module for sending emails, chosen for its ease of use and
documentation, simplifying automated report emailing. Mailtrap was used for
email testing.
4.​ Authentication:
a.​ bcryptjs: Used for securely hashing user passwords, a critical security measure.
b.​ JSON Web Tokens (JWT): Selected for stateless session management, enabling
secure user identity verification and persistent sessions.
5.​ Frontend:
a.​ Next.js 14: A React framework with App Router, chosen for building the UI,
offering SSR, SSG, and a streamlined development experience.
b.​ TypeScript: Employed for static typing, enhancing code quality and
maintainability.
c.​ Tailwind CSS: Selected for utility-first styling, enabling rapid UI development.
d.​ shadcn/ui: A library of accessible UI components, accelerating interface
development.
e.​ Lucide React: Used for scalable vector icons.

3.8.2 Development Tools & Environment

1.​ Code Editor: Visual Studio Code was the primary IDE for development.
2.​ Version Control: Git and GitHub were used for version control and remote repository.
3.​ Package Manager: npm managed project dependencies.
4.​ API Testing Tool: Postman tested backend API endpoints.
5.​ Database Management Tool: MongoDB Compass provided a GUI for database
management.
6.​ Operating System: Windows 10 was the development operating system.

3.8.3 "Instruments" (Testing/Evaluation Approach - for MVP)

MVP testing primarily involved:

1.​ Manual Functional Testing: Verified core features (registration, login, medication
scheduling, adherence/side effect logging, report generation/email) and user flows.
 2.​ API Endpoint Testing (Postman): Ensured backend functionality and error handling.
3.​ End-to-End Testing: Confirmed seamless operation of key user scenarios from frontend
to backend.

3.9 Summary of Methodology

This chapter detailed the systematic development of the "Medication Management System with
Automated Doctor Reporting." It analyzed medication non-adherence and communication
challenges in Nigeria, justifying an Iterative and Incremental methodology with UI prototyping
to deliver an MVP within project constraints. The chapter outlined requirements, a multi-tier
system design, and technology choices, all while emphasizing ethical data handling. This
foundation supports the system's implementation, to be discussed in Chapter 4.
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