BackgroundClinical guidelines are systematically developed statements that assist practitioners and patients to make healthcare decisions for specific clinical circumstances. Non-adherence of doctors to guidelines is thought to contribute significantly to poor delivery of clinical care, resulting in poor clinical outcomes.AimTo investigate adherence of doctors in rural district hospitals to clinical guidelines using the South African Hypertension Guideline 2006 as an example.SettingFour district hospitals in Bojanala district of North-West Province, South Africa.MethodsA cross-sectional study determined adherence practices of doctors from records of patients with established hypertension seen at the four district hospitals.ResultsOf the 490 total records documented by 29 doctors, screening for co-morbidity or associated factors was carried out as follows: diabetes mellitus 99.2%, obesity 6.1%, smoking 53.5%, dyslipidaemia 36.9%, abdominal circumference 3.3%; organ damage: eye 0, kidney 82%, heart 43.5%, chronic kidney disease 38.2%, stroke/transient ischaemic attack 15.9%, heart failure 23.5%, advanced retinopathy 0.2%, coronary heart disease 23.7%, peripheral arterial disease 13.9%. Critical tests/measurements were documented in the following proportions: blood pressure 99.8%, weight 85.3%, height 65.7%, body mass index 3.1%, urinalysis 74.5%, lipogram 76.1%, urea/creatinine 80.4%, electrocardiogram 42.9%, blood glucose 100%; risk determination and grading: diagnosis by hypertension severity 19%, low added risk 57.1%, moderate added risk 64.7%, high added risk 89.6%, very high added risk 89.2%. Adherence to therapies was as follows: first-line guideline drugs 69.4%, second line 84.7%, third line 87.8% and fourth-line 89.6%.ConclusionOverall adherence of doctors to treatment guidelines for hypertension was found to be low (51.9%). Low adherence rates were related to age (older doctors) and less clinical experience, and differed with regard to various aspects of the guidelines.