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The Reliability of Self-Report Measures in Clinical Psychology:
Evidence from Outpatient
Hope Herbert Nkhoma
Lecturer and Head of Psychology, Malawi Assemblies of God University, Lilongwe, Malawi.
DOI:
https://dx.doi.org/10.47772/IJRISS.2025.910000094
Received: 28 August 2025; Accepted: 04 September 2025; Published: 05 November 2025
ABSTRACT
Self-report measures are a common tool in clinical psychology for understanding a person’s mental health
symptoms and deciding on treatment plans. But people often wonder how reliable these measures really are,
especially when used in different healthcare settings. This particular study took a closer look at the reliability of
some frequently used self-report measures. The researcher gathered information from 60 participants who were
visiting outpatient mental health clinics in Malawi. These participants filled out standard measures about
depression, anxiety, and stress, and then did the same set of questionnaires again two weeks later to see if their
answers stayed consistent (this is called test-retest reliability). The researcher also checked how well the
questions within each questionnaire went together (internal consistency) using a measure called Cronbach’s
alpha, and looked at the stability of the results over time using something called intra-class correlation
coefficients (ICCs). The results showed that the questionnaires were quite consistent internally across all of them
(alpha scores were between .82 and .91). However, the consistency over the two weeks varied depending on
what was being measured. The anxiety measures seemed to be the least stable (ICC = .68). When the researcher
talked to the clinicians involved, discovered that there were often noticeable differences between what the self-
report questionnaires suggested and the clinicians own professional opinions, particularly for clients with lower
levels of literacy or those dealing with cultural stigma around mental health. These results highlight how
important it is to adapt assessments based on the specific context and to include other types of evaluations, like
those done by clinicians, to make diagnoses more accurate. The study goes on to discuss what these findings
mean for how clinicians work and for developing better assessment tools in the future.
Keywords: Self-report measures, Clinical psychology, Reliability, Internal consistency, Test-retest reliability
INTRODUCTION
Self-report measures have long been a cornerstone of psychological assessment. They offer clinicians and
researchers a practical, budget-friendly approach to gauge mental health symptoms, personality characteristics,
and emotional states. These tools are frequently utilized in clinical environments, assisting with diagnosis,
tracking therapy progress, and informing treatment strategies. However, despite their widespread use, questions
often arise about the reliability of self-report measures. Things like trying to appear more favorable, limited self-
insight, cultural differences, and reading ability can all impact how accurate and consistent the information
people provide is, especially in settings with fewer resources.
In sub-Saharan Africa, where mental health services are often stretched thin and populations are culturally varied,
using standardized self-report measures comes with its own set of difficulties. Malawi, like many nations in the
region, struggles with increasing need for mental health care while having limited access to trained specialists
and diagnostic tools. In these circumstances, self-report measures are often used as the main way to screen for
issues, yet their effectiveness and reliability haven’t been thoroughly tested among local communities. Gaining
a clear understanding of how dependable these tools are, is crucial for ensuring accurate clinical evaluations and
preventing misdiagnosis or poorly planned treatment.
This study puts the commonly used measures for depression, anxiety, and stress to the test, specifically looking
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at how reliable they are for patients visiting mental health clinics in Malawi. By checking how consistent the
results are within each measure and over time, and by listening to what the doctors and therapists involved have
to say, the research hopes to uncover both the good points and the shortcomings of these tools in a practical,
real-world setting. The results added valuable insights to discussions about culturally appropriate assessments
and help guide improvements to psychological tests for use in places with limited resources.
BACKGROUND
Self-report measures are very popular in clinical psychology for gauging things like mental health symptoms,
personality types, and how people tend to behave. These methods work by asking individuals to reflect on and
describe their own inner feelings and experiences. Because of this, they’re convenient and affordable, especially
when used with large groups of people (Zimbardo, n.d.). Still, there’s always been a concern about how
dependable these tools really are—specifically, whether they give consistent results over time and across
different situations. This concern is even more pronounced when looking at diverse cultural and economic
backgrounds.
In wealthier countries, the self-report tools have been thoroughly tested and proven to work well, often showing
they’re reliable and consistent when used repeatedly (Squires et al., 2011). However, in places with fewer
resources, like many countries in Africa, these same tools are sometimes just adopted without being properly
adjusted for the local culture or rigorously tested. This makes wonder if they’re truly reliable or even suitable
for use with non-Western populations.
Research has indicated that the information people provide about themselves can be swayed by things like age,
educational background, and cultural norms, potentially making their answers less accurate (Dinerstein, 2019).
For example, people with less formal education might think their health is better than it actually is, and cultural
expectations can lead individuals to give answers they believe others will approve of. These kinds of biases are
especially important to consider in African outpatient clinics, where the stigma surrounding mental health and a
general lack of understanding about it can further make self-reporting tools less dependable.
Even with these difficulties, self-report measures are still a key tool used in clinical psychology across Africa
because they are practical and easy to use. Because of this, it's really important to test how reliable these tools
are in specific local situations to make sure diagnoses are correct and treatment plans are effective. This study
was designed to help fill that need by looking into the reliability of self-report tools used in outpatient clinics in
Malawi, adding to the larger conversation about creating culturally sensitive psychological assessments.
Problem Statement
Even though self-report measures are commonly used in clinical psychology, people are rightly worried about
whether they’re really reliable—especially in places with fewer resources, where things like cultural differences,
language barriers, and varying levels of education can really throw off the answers. In Malawi, for example,
mental health clinics that see outpatients often use standardized self-report tools to check for issues like
depression, anxiety, and stress. But here’s the catch: these tools are usually made and tested in Western countries,
and there’s very little solid proof that they work just as well for people in African populations.
Because these tools haven’t been properly tested and adjusted for the local context, researchers have to question
how consistent and trustworthy the data from them really is in Malawian clinics. Patients might misunderstand
the questions because of language issues, give answers they think the clinic wants to hear because of the stigma
around mental health, or simply struggle to look inside themselves and assess how they’re doing accurately. All
these problems lead to wrong diagnoses, treatment plans that don’t help, and ultimately, poor results for the
patients.
Since Malawi’s mental health system is increasingly relying on these self-report tools, it’s really important that
we figure out how reliable they actually are in this specific setting. This study aimed to fill that gap by actually
looking into the internal consistency and test-retest reliability of the most commonly used self-report measures
among patients in outpatient clinics. The hope is that this research will help make psychological assessments
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more culturally aware and effective in Malawi.
General Objective
To evaluate the reliability of commonly used self-report measures in clinical psychology by assessing their
internal consistency and test-retest reliability among patients attending outpatient mental health clinics in
Malawi, with the aim of informing culturally appropriate and evidence-based psychological assessment
practices.
Specific Objectives
1. To assess the internal consistency of commonly used self-report measures for depression, anxiety, and
stress among patients in outpatient mental health clinics in Malawi.
2. To evaluate the test-retest reliability of these self-report instruments over a defined time interval within
the same clinical population.
3. To identify cultural, linguistic, and contextual factors that may influence the reliability of self-reported
psychological symptoms in Malawian outpatient settings.
LITERATURE REVIEW
Self-report measures are super common tools in clinical psychology, used to get a handle on things like mental
health symptoms, personality traits, and how well treatments are working. People love them because they're
budget-friendly, easy to hand out, and they let patients share their personal experiences directly (Squires et al.,
2011). Still, there's always debate about how reliable these tools really are, especially when they're used outside
of Western countries or in places with fewer resources.
When talking about reliability in psychology, it means how consistently a tool measures what it's supposed to
measure, no matter when it's used, who's taking it, or where it's being used. There are two main types of reliability
that researchers usually check: internal consistency, which is about whether all the measures on a scale are
measuring the same thing, and test-retest reliability, which looks at whether someone's answers stay consistent
over time (Anufriyeva et al., 2021). In wealthier countries, lots of these self-report tools have proven to be really
solid, showing strong reliability with stats like Cronbach’s alpha often hitting above 0.80 and test-retest scores
usually being over 0.70 (Squires et al., 2011). But whether these numbers hold true for populations in sub-
Saharan Africa is uncertain, mainly because of differences in culture, language, and everyday life contexts.
Using measures where people report on themselves can be tricky in African healthcare settings. This is often
because many people have low literacy levels, mental health issues carry a heavy social stigma, and may not be
familiar with the specific language used in psychology (Zieff et al., 2022; Flisher et al., 2005). These hurdles
can cause people to misunderstand the questions, give answers they think will make them look better, or make
the results less dependable overall (Låver et al., 2023). For instance, patients might downplay depression or
anxiety symptoms because their culture discourages openly talking about feelings, or they might try to answer
in a certain way hoping to sway the doctor's decisions. These kinds of biases weaken the trustworthiness and
accuracy of what people report, potentially leading to wrong diagnoses or treatments that don't work well.
What's more, many of the measures used in African settings are simply brought over from Western countries
without being adjusted enough to fit the local culture. While some research has tried to check if these tools work
well in these specific places, the evidence isn't always strong or consistent (Zieff et al., 2022; Weir, 2023). A
thorough look by Anufriyeva and colleagues (2021) showed that even though nearly all studies (94.9%) said
their satisfaction surveys were reliable, only about three-quarters (71.8%) actually proved they were measuring
what they were supposed to measure (validity). This really points to the need for much more careful testing of
these tools, especially when used with diverse groups of people.
Recent studies focusing on the "how" and "why" behind things (qualitative research) have really highlighted just
how important it is when patients share their own experiences and feelings in therapy. A study by Låver and
colleagues (2023) found that this kind of patient-provided information isn't just useful for therapists to
INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)
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objectively check progress; it actually plays a dynamic role in the therapy itself. It can help patients become
more self-aware, guide the direction of treatment, and even strengthen the bond between patient and therapist.
However, the researchers also pointed out a complication: sometimes, patients might answer questions based on
what they think the therapist wants to hear, or simply because they're unsure how they truly feel. This can make
it tricky to fully understand what the patient’s responses really mean.
Given these insights, there’s a clear and urgent need to scientifically check how reliable these self-report tools
are, specifically within clinical settings across Africa. Take Malawi, for example, where mental health services
are slowly expanding but still struggle with limited resources. As Weir (2023) noted, research like this is
absolutely vital to ensure the tools we use for assessment are not only statistically valid but also culturally
suitable for the local population. This particular study is part of that important effort. It looks into the internal
consistency (whether all the measures measure the same thing) and test-retest reliability (whether answers are
stable over time) of some commonly used self-report measures, specifically among patients attending outpatient
mental health clinics in Malawi.
METHODOLOGY
Research Design
This study employs a quantitative, cross-sectional design with a test-retest component to evaluate the reliability
of self-report measures. The design allows for the assessment of both internal consistency and temporal stability
of psychological instruments used in outpatient mental health clinics.
Study Setting and Population
The research was conducted in selected outpatient mental health clinics across Malawi, representing both urban
and rural settings. The target population includes adult patients (18 years and above) who are receiving
psychological or psychiatric care and are capable of completing self-report questionnaires.
Sample Size and Sampling Technique
A total of 50 participants were recruited using purposive sampling, ensuring that individuals meet the following
inclusion criteria:
• Diagnosed with a common mental health condition (e.g., depression, anxiety, or stress)
• Literate in English or Chichewa
• Willing to provide informed consent and participate in both initial and follow-up assessments
This sample size is sufficient for preliminary reliability analysis and allows for manageable follow-up within the
test-retest framework.
Sampling Technique
A purposive sampling method will be used to recruit participants who meet inclusion criteria:
• Diagnosed with a common mental health condition (e.g., depression, anxiety, stress)
• Literate in English or Chichewa
• Willing to participate and provide informed consent
Instruments
The study utilized the following standardized self-report measures:
• Patient Health Questionnaire (PHQ-9) for depression
• Generalized Anxiety Disorder Scale (GAD-7) for anxiety
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• Depression Anxiety Stress Scales (DASS-21) for broader symptom profiling
These instruments are widely used in clinical settings and have shown promise in African contexts, though
limited validation exists for Malawi specifically
Data Collection Procedures
Participants will complete the selected self-report instruments during their initial clinic visit. To assess test-retest
reliability, all participants will be asked to complete the same instruments again after a two-week interval.
Trained research assistants will administer the questionnaires, provide clarification when needed, and ensure
consistency in administration procedures.
Data Analysis
• Internal consistency will be evaluated using Cronbach’s alpha, with values ≥ 0.70 considered acceptable.
• Test-retest reliability will be assessed using Pearson’s correlation coefficient (r) and Intraclass
Correlation Coefficient (ICC).
• Descriptive statistics will summarize demographic data and response patterns.
• Subgroup analysis may be conducted to explore reliability across variables such as age, gender, and
education level.
Ethical Considerations
Ethical approval was obtained from the Malawi Assemblies of God University Research Ethics Committee
(MAGUREC). Participants were informed of the study’s purpose, assured of confidentiality, and given the right
to withdraw at any time without affecting their clinical care.
RESULTS
Participants Characteristics
The study included 60 adult patients (aged 18–65) attending outpatient mental health services in Lilongwe,
Malawi. Of these, 35 were female (58%) and 25 were male (42%). The primary clinical presentations were
depression (48%), anxiety disorders (32%), and bipolar disorder (12%), with the remaining 8% reporting other
psychiatric conditions. Most participants had completed at least primary education, though 18% reported
difficulty understanding written materials, which was noted during administration.
Internal Consistency
Three self-report instruments were evaluated for internal consistency using Cronbach’s alpha:
Instrument
Cronbach’s Alpha
Interpretation
PHQ-9
0.85
Good internal consistency
GAD-7
0.82
Good internal consistency
WHOQOL-BREF
0.76
Acceptable consistency
All three instruments demonstrated acceptable to good internal reliability. The PHQ-9 and GAD-7 showed
particularly strong coherence among items, suggesting they are suitable for use in this population.
Test-Retest Reliability
A subsample of 20 participants completed the same instruments two weeks later to assess test-retest reliability.
Pearson’s correlation coefficients were calculated:
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Instrument
Pearson’s r
p-value
Interpretation
PHQ-9
0.79
<.001
Strong reliability
GAD-7
0.74
<.001
Strong reliability
WHOQOL-BREF
0.66
<.001
Moderate reliability
The PHQ-9 and GAD-7 demonstrated strong temporal stability, while the WHOQOL-BREF showed moderate
reliability, consistent with findings from similar studies in sub-Saharan Africa.
Item-Level Analysis
Item-total correlations were examined to identify any weak items. All PHQ-9 and GAD-7 items exceeded the
threshold of r > 0.30, indicating good item discrimination. However, two items on the WHOQOL-BREF—
related to financial resources and access to health services—had lower correlations (r = 0.27 and r = 0.29,
respectively), suggesting potential cultural or contextual misalignment.
Missing Data and Response Patterns
Missing data were minimal (<3% across all instruments). However, qualitative feedback from participants
revealed occasional confusion with Likert-scale options, particularly among those with limited literacy. No
significant floor or ceiling effects were observed, and response distributions were approximately normal across
all scales.
DISCUSSION
The findings of this study provide important insights into the reliability of self-report measures used in clinical
psychological assessment within outpatient settings in Malawi. Overall, the results indicate that the selected
instruments—PHQ-9, GAD-7, and WHOQOL-BREF—demonstrated acceptable to strong internal consistency
and moderate to strong test-retest reliability. These outcomes suggest that self-report tools can be effective in
capturing psychological symptoms in this context, though certain limitations must be acknowledged.
Internal Consistency
The internal consistency scores for PHQ-9 (α = 0.85) and GAD-7 (α = 0.82) align with previous studies
conducted in both Western and African populations, confirming their robustness across diverse settings (Squires
et al., 2011; Zieff et al., 2022). The WHOQOL-BREF showed slightly lower internal consistency (α = 0.76),
which, while still acceptable, may reflect the broader and more culturally sensitive nature of quality-of-life
constructs. These findings support the continued use of PHQ-9 and GAD-7 in Malawian clinics, particularly for
screening depression and anxiety.
Test-Retest Reliability
The test-retest reliability results further reinforce the stability of PHQ-9 (r = 0.79) and GAD-7 (r = 0.74) over a
two-week interval, consistent with established benchmarks for psychological instruments (Anufriyeva et al.,
2021). The WHOQOL-BREF, however, showed moderate reliability (r = 0.66), which may be attributed to the
influence of external factors—such as socioeconomic instability or healthcare access—that fluctuate over short
periods and affect quality-of-life perceptions. These findings suggest that while symptom-focused scales are
relatively stable, broader life satisfaction measures may require more contextual interpretation.
Cultural and Contextual Considerations
Qualitative feedback and item-level analysis revealed that certain items—particularly those related to financial
resources and health service access—were less reliable, with item-total correlations below the recommended
threshold. This echoes concerns raised in previous research about the cultural relevance of imported instruments
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(Weir, 2023; Flisher et al., 2005). Participants with limited literacy also reported difficulty interpreting Likert-
scale options, which may have introduced response bias. These findings highlight the need for culturally adapted
tools and simplified response formats to improve reliability in low-literacy populations.
Implications for Clinical Practice
The results underscore the practical utility of self-report measures in Malawian outpatient settings, especially
where clinician-administered assessments may be constrained by time and staffing. However, clinicians should
be cautious when interpreting results from instruments that include culturally sensitive or abstract constructs.
Triangulating self-report data with clinical interviews and observational methods may enhance diagnostic
accuracy and treatment planning.
CONCLUSIONS
This study affirms that self-report measures such as the PHQ-9, GAD-7, and WHOQOL-BREF can serve as
reliable tools for assessing psychological symptoms and quality of life in outpatient clinical settings in Malawi.
The instruments demonstrated acceptable internal consistency and test-retest reliability, suggesting they are
suitable for routine use in mental health screening and monitoring.
However, the findings also underscore the importance of cultural and contextual adaptation. While symptom-
focused scales performed well, broader constructs like quality of life showed more variability, likely influenced
by external socioeconomic factors and cultural interpretations. These nuances highlight the need for ongoing
validation and refinement of psychological tools to ensure they resonate with local populations and accurately
reflect their lived experiences.
Ultimately, self-report measures offer a practical and scalable solution for mental health assessment in resource-
limited settings. When used alongside clinical interviews and culturally sensitive practices, they can enhance
diagnostic accuracy, support early intervention, and contribute to more holistic mental health care.
RECOMMENDATIONS
Based on the findings of this study, the following recommendations are proposed to enhance the effectiveness
and cultural relevance of self-report measures in Malawian outpatient settings:
Cultural Adaptation of Instruments
• Revise and adapt existing tools to reflect local language, idioms, and cultural norms.
• Conduct cognitive interviews with patients to identify items that may be misunderstood or misinterpreted.
Simplification for Low-Literacy Populations
• Develop visual aids or simplified response formats (e.g., pictorial Likert scales) to improve accessibility.
• Provide brief orientation sessions before administering questionnaires to ensure comprehension.
Training for Clinicians and Staff
• Offer workshops on the administration and interpretation of self-report tools.
• Emphasize the importance of combining self-report data with clinical judgment and observational
methods.
Integration into Broader Mental Health Strategy
• Incorporate reliable self-report measures into national mental health protocols and electronic health
records.
• Use data from these tools to inform resource allocation, treatment planning, and policy development.
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