Twagirumukiza et al. Malaria Journal 2010, 9:206 http://www.malariajournal.com/content/9/1/206 Open Access RESEARCH © 2010 Twagirumukiza et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and repro- duction in any medium, provided the original work is properly cited. Research Evaluation of medication adherence methods in the treatment of malaria in Rwandan infants Marc Twagirumukiza 1,2 , Pierre Claver Kayumba 3,4 , Jan G Kips 1 , Bernard Vrijens 5 , Robert Vander Stichele 1 , Chris Vervaet 3 , Jean Paul Remon 3 and M Luc Van Bortel* 1 Abstract Objectives: To compare three methods for evaluating treatment adherence in a 7-day controlled treatment period for malaria in children in Rwanda. Methods: Fifty-six children (< 5 years) with malaria were recruited at the University Hospital of Butare, Rwanda. Patients were treated with quinine sulfate, taste-masked, pellets during seven days: three days in hospital (in-patient) followed by a four-day out-patient period. Three methods to evaluate medication adherence among patients were compared: manual pill count of returned tablets, patient self-report and electronic pill-box monitoring. These pill-boxes were equipped with a microchip registering date and time of every opening. Medication adherence was defined as the proportion of prescribed doses taken. The inter-dose intervals were analysed as well. Results: Medication adherence data were available for 54 of the 56 patients. Manual pill count and patient self-report yielded a medication adherence of 100% for the in- and out-patient treatment periods. Based on electronic pill-box monitoring, medication adherence during the seven-day treatment period was 90.5 ± 8.3%. Based on electronic pill- box monitoring inpatient medication adherence (99.3 ± 2.7%) was markedly higher (p < 0.03) than out-patient adherence (82.7 ± 14.7%), showing a clear difference between health workers' and consumers' medication adherence. Conclusion: Health workers' medication adherence was good. However, a significant lower medication adherence was observed for consumers' adherence in the outpatient setting. This was only detected by electronic pill-box monitoring. Therefore, this latter method is more accurate than the two other methods used in this study. Background Malaria is one of the world's most deadly diseases[1] with approximately 881,000 deaths every year, and nine out of ten deaths occurring in sub-Saharan Africa[1]. Addition- ally, 85% of all malaria-related deaths are recorded in chil- dren under five years of age. The effective control and treatment of malaria presents enormous challenges, especially in sub-Saharan Africa where access to medicines and health care is limited, and multiple cases of treatment failure have been reported[2]. Poor adherence to anti-malarial treatment, from both health workers and consumers, may importantly contrib- ute to treatment failure. Poor treatment adherence leads to sub-therapeutic drug concentrations in the body, which will not eradicate all parasites and allow growth of resistant parasites. Drug concentrations in the body can become subtherapeutic either by missed doses or by not timely taken doses. Hence, when assessing antimalarial treatment adherence it is also important to assess the timing of dose intake. However, the evaluation of medication adherence in daily practice or in research remains challenging[3,4], in particular in the developing settings where malaria is pandemic[5,6]. Some studies have used quantitative methods such as patient and clinician reports, but ques- tions can be raised about the reliability of these meth- ods[7,8]. Patient self-reports have the disadvantage that they might be influenced by the desire of the patient to comply, or his/her denial of the illness[4], whereas infor- mation obtained through clinician reports could be biased by the interest the clinician may have in the patient's treatment[9,10]. Therefore, a more objective and exact alternative is provided by electronic pill-box moni- * Correspondence: Luc.VanBortel@UGent.be 1 Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium Full list of author information is available at the end of the article