Cited by 679Clinical practice guidelines implementationSurvey Methodology and NonresponseHealth Sciences Research and Education

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Evidence of self-report bias in assessing adherence to guidelines

Adams, A., Soumerai, S., Lomas, J, Ross-Degnan, D·1999·International Journal for Quality in Health Care

DOI 10.1093/intqhc/11.3.187

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Abstract

Objective To assess trends in the use of self-report measures in research on adherence to practice guidelines since 1980, and to determine the impact of response bias on the validity of self-reports as measures of quality of care. Methods We conducted a MEDLINE search using defined search terms for the period 1980 to 1996. Included studies evaluated the adherence of clinicians to practice guidelines, official policies, or other evidence-based recommendations. Among studies containing both self-report (e.g. interviews) and objective measures of adherence (e.g. medical records), we compared self-reported and objective adherence rates (measured as per cent adherence). Evidence of response bias was defined as self-reported adherence significantly exceeding the objective measure at the 5% level. Results We identified 326 studies of guideline adherence. The use of self-report measures of adherence increased from 18% of studies in 1980 to 41% of studies in 1985. Of the 10 studies that used both self-report and objective measures, eight supported the existence of response bias in all self-reported measures. In 87% of 37 comparisons, self-reported adherence rates exceeded the objective rates, resulting in a median over-estimation of adherence of 27% (absolute difference). Conclusions Although self-reports may provide information regarding clinicians' knowledge of guideline recommendations, they are subject to bias and should not be used as the sole measure of guideline adherence.

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Hirschi, R., Rommel, C. A., Letsinger, J., Nirula, R., & Hawryluk, G. (2018) · World Neurosurgery · doi:10.1016/j.wneu.2018.04.215 · Cited by 9
The perceived needs-access gap for health services among persons with disabilities in a rural area within South Africa
Vergunst, R., Swartz, L., Hem, K.-G., Eide, A., Mannan, H., Maclachlan, M., Mji, G., & Schneider, M. (2018) · Disability and Rehabilitation · doi:10.1080/09638288.2018.1478001 · Cited by 9
Emergency Physician Training on Mild Traumatic Brain Injury: A Systematic Review
Patrick, S., Gaudet, L., Krebs, L. D., Chambers, T., & Rowe, B. H. (2017) · AEM Education and Training · doi:10.1002/aet2.10053 · Cited by 10
“These self-reported outcomes may be biased and inaccurately reflect a physician’s practice.(57,58) As a result, the positive changes in EP practice attributed to each tool may overestimate the effect due to social desirability bias.”
Background
Clinicians’ knowledge and practices regarding family planning and intrauterine devices in China, Kazakhstan, Laos and Mexico
Hoffman, S., Guindon, G., Lavis, J., Randhawa, H., Becerra-Posada, F., Boupha, B., Shi, G., Turdaliyeva, B., & for the Canada Prime Plus team (2016) · Reproductive Health · doi:10.1186/s12978-016-0185-1 · Cited by 9
A Cross-sectional Study Assessing Predictors of Essential Medicines Prescribing Behavior Based on Information-motivation-behavioral Skills Model among County Hospitals in Anhui, China
Zhao, Y., Wu, J.-Y., Wang, H., Li, N., Bian, C., Xu, S.-M., Li, P., Lu, H., & Xu, L. (2015) · Chinese Medical Journal · doi:10.4103/0366-6999.168046 · Cited by 9
“First, previous studies have demonstrated that self‐report questionnaire data collection may lead to systematic bias because participants may misrepresent their attitudes, behaviors or other information.[37] Second, the participants were sampled from county hospitals in three cities of Anhui, which may limit the overa…”
Background
Medication adherence and racial differences in diabetes in the USA: an update
Adams, A., Banerjee, S., & Ku, C. J. (2015) · Diabetes Management · doi:10.2217/dmt.14.55 · Cited by 9
Self-citation
Barriers in implementing evidence‐informed health decisions in rural rehabilitation settings: a mixed methods pilot study
Prakash, V., Hariohm, K., & Balaganapathy, M. (2014) · Journal of Evidence-Based Medicine · doi:10.1111/jebm.12114 · Cited by 9
“Use of self-reports can create higher probabilities of respondents choosing socially desirable responses (17, 18).”
Background
GPs' reasons for referral of patients with chest pain: a qualitative study
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“Although what doctors say they do is not the same as what they actually do, we believe the quality of the interviews was high [19].”
Background
Survey of systematic review authors in dentistry: challenges in methodology and reporting.
Major, M. P., Warren, S., & Flores-Mir, C. (2009) · Journal of Dental Education · doi:10.1002/j.0022-0337.2009.73.4.tb04718.x · Cited by 9
Using a Novel Small-Group Approach to Enhance Feedback Skills for Community-Based Teachers
Walsh, A., Armson, H., Wakefield, J., Leadbetter, W., & Roder, S. (2009) · Teaching and learning in medicine · doi:10.1080/10401330802574025 · Cited by 9
“17 , 18 However, as a feasible strategy for enhancing and measuring actual practice change following a continuing education intervention, commitment-to-change has been explored in a number of studies.”
Background
[Impact of Sfar experts' conference entitled "Modalities of sedation and/or analgesia in hospital setting"].
Gouin, P., Damm, C., Villette-Baron, K., Veber, B., & Dureuil, B. (2008) · Annales Francaise d'Anesthesie et de Reanimation · doi:10.1016/j.annfar.2008.03.004 · Cited by 9
The Impact of Conjugate Pneumococcal Vaccination on Routine Childhood Vaccination and Primary Care Use in 2 Counties
Szilagyi, P., Griffin, M., Shone, L., Barth, R. D., Zhu, Y., Schaffer, S., Ambrose, S., Roy, J., Poehling, K., Edwards, K., et al. (2006) · Pediatrics · doi:10.1542/peds.2006-0314 · Cited by 9
Accuracy of responses from postal surveys about continuing medical education and information behavior: experiences from a survey among German diabetologists
Trelle, S. (2002) · BMC Health Services Research · doi:10.1186/1472-6963-2-15 · Cited by 9
Exploring the Role of Workaholism and Social Support in Social Anxiety and Loneliness. Findings and Implications From a Cross-Sectional Study in a Romanian Sample
Ciobanu, V., Huțul, T., Karner‐Huțuleac, A., & Huțul, A. (2025) · Psychological Reports · doi:10.1177/00332941251347224 · Cited by 12
Detecting Activities of Daily Living in Egocentric Video to Contextualize Hand Use at Home in Outpatient Neurorehabilitation Settings
Kadambi, A., & Zariffa, J. (2025) · IEEE Transactions on Neural Systems and Rehabilitation Engineering · doi:10.1109/tnsre.2025.3569083 · Cited by 5
“These traditional approaches are limited by recall bias and provide only snapshots of function in clinical settings, failing to capture the diversity of real-world environments and compensatory strategies patients develop at home [3].”
The Relationship Between Family Communication and Adolescent Problematic Internet Use: The Chain Mediation Effects of Loneliness and Depression
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Treatment satisfaction with disease-modifying therapy is the only predictor of Adherence among multiple sclerosis patients from Upper Egypt
Khedr, E., Mahmoud, D. M., Hussein, H. B., Malky, I. E., Mostafa, S. S., & Gamea, A. (2024) · Scientific Reports · doi:10.1038/s41598-024-57116-9 · Cited by 8
“This wide range of the reported adherence rates could be explained by variability in the definitions of adherence across different studies and the response bias in self-reported measures 23 .”
Background
Meeting American Geriatrics Society Competencies: Are Residents Meeting Expectations for Quality Care of Older Adults?
Bynum, D. L., Wilson, L. A., Ong, T. D., Callahan, K. E., Dalton, T. O., & Ohuabunwa, U. (2015) · Journal of The American Geriatrics Society · doi:10.1111/jgs.13598 · Cited by 8
“Nevertheless these two factors would lead to an overestimation of the true frequencies of these behaviors being performed because previous work has shown that self-reported adherence to practice guidelines rates often exceed the objective rates when measured, lending further weight to the conclusion that residents are…”
Result
Anatomical Location of Pathology Is Predictive of Prolonged Fluoroscopy Time During ERCP: A Multicenter American Study
Alkhatib, A., Jalil, A. A. A., Faigel, D., Pannala, R., Crowell, M., & Harrison, M. (2015) · Digestive Diseases and Sciences · doi:10.1007/s10620-014-3508-5 · Cited by 8
Is Physician Awareness of Impending Death in Hospital Related to Better Communication and Medical Care?
Houttekier, D., Witkamp, F., van Zuylen, L., van der Rijt, C. V. D., & van der Heide, A. (2014) · Journal of Palliative Medicine · doi:10.1089/jpm.2014.0203 · Cited by 8
Infection prevention practices in Swedish emergency departments: results from a cross-sectional survey
Yanagizawa-Drott, L., Kurland, L., & Schuur, J. (2014) · European journal of emergency medicine · doi:10.1097/mej.0000000000000159 · Cited by 8
Exploring the Relationship between Location and Behaviour in Out of Hours Hospital Care
Brown, M. A., Pinchin, J., Blum, J. M., Sharples, S. C., Shaw, D., Housley, G., Howard, S., Jackson, S., Flintham, M., Benning, K., et al. (2014) · Interacción · doi:10.1007/978-3-319-07854-0_69 · Cited by 8
“Self-report measures have the advantages of being non-invasive, may produce rich qualitative data, and are relatively easy to employ, however they are also difficult to scale, highly subjective, and vulnerable to a range of potential reporting biases [1].”
Background
Factors That Impact Decision Making Among Rheumatologists in the Initiation of Treatment for Hypertension in Rheumatoid Arthritis
Nguyen-Oghalai, T. U., Hunnicutt, S. E., Smith, S., Maganti, R., & Mcnearney, T. (2007) · Journal of clinical rheumatology · doi:10.1097/rhu.0b013e318156bcc2 · Cited by 8
Adherence to PCSK9 Inhibitors in Clinical Practice
Blais, J. E., Zhong, W., Li, C. Y. V., Kongkaew, C., & Chan, A. H. Y. (2026) · JACC: Advances · doi:10.1016/j.jacadv.2026.102733 · Cited by 7
Measuring guideline adherence in physiotherapy: A scoping review of methodological approaches
Bahns, C., Scheffler, B., Bremer, A., & Kopkow, C. (2024) · Journal of Evaluation in Clinical Practice · doi:10.1111/jep.14218 · Cited by 8
“68 To improve comparability between participants, many of the included survey or questionnaire studies used clinical vignettes ( n = 17, 32.1%).”
Influential
Working 9 to always: relationships among workplace telepressure, ICT boundary creation, and workaholism
Wilder, E. J., Aziz, S., & Wuensch, K. L. (2023) · Health Psychology Report · doi:10.5114/hpr/165873 · Cited by 6
“While self-reports can make data collection more convenient for researchers, past studies have shown that they may result in response bias (Adams et al., 1999).”
Result
Doctors' adherence to guidelines recommendations and glycaemic control in diabetic patients in Quetta, Pakistan: Findings from an observational study
Saher, T., Al‐Worafi, Y. M., Iqbal, M. N., Wahid, A. H., Iqbal, Q., Khan, A., Atif, M., & Ahmad, N. (2022) · Frontiers in Medicine · doi:10.3389/fmed.2022.978345 · Cited by 370
“These studies have certain worth mentioning limitations like lack of an explicit criterion to define doctor’s adherence to pharmacotherapeutic recommendations of guidelines (24–28), use of self-reported practices as a proxy of objective adherence to guidelines (19, 37) which are always subject to bias as doctors may o…”
Background

Authors: Adams, A., Soumerai, S., Lomas, J., & Ross-Degnan, D.
Affiliations: Harvard University (US)
Canadian Foundation for Healthcare Improvement (CA)
ORCID: Adams, A.
Soumerai, S.
Venue: International Journal for Quality in Health Care
Publisher: Oxford University Press (OUP)
Published: 1999-06-01
Volume: 11
Issue: 3
Pages: 187-192
ISSN: 1353-4505 (ISSN-L)
1464-3677
DOI: 10.1093/intqhc/11.3.187
OpenAlex: W2074448530
Cited by: 679
References: 0
Citations by year: 2026: 28 · 2025: 19 · 2024: 28 · 2023: 23 · 2022: 17 · 2021: 27 · 2020: 28 · 2019: 36 · 2018: 36 · 2017: 36 · 2016: 37 · 2015: 36 · 2014: 44 · 2013: 39 · 2012: 36
FWCI: 11.86
Type: journal article
Language: en
Open access: closed
Locations: International Journal for Quality in Health Care (publishedVersion)
PubMed (publishedVersion)
Funders: Agency for Healthcare Research and Quality (5R18HS07357)
Topics: Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
Social Sciences › Sociology and Political Science › Survey Methodology and Nonresponse
Health Sciences › Health Professions › General Health Professions › Health Sciences Research and Education
Keywords: self-report bias, response bias, guideline adherence, clinical guidelines, quality of care, evidence-based medicine
MeSH terms: Humans, Interviews as Topic, Psychometrics, Surveys and Questionnaires, Reproducibility of Results, Bias, Practice Guidelines as Topic, Guideline Adherence

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Evidence of self-report bias in assessing adherence to guidelines

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