Cognitive behaviour therapy-informed guidelines for type 2 diabetes self-management: A Delphi method study

Introduction

The rise of type 2 diabetes mellitus (T2DM) has become a global epidemic with a noticeable prevalence in developing countries (Koochaksaraee et al., 2022). The epidemiology of the chronic condition is complex, as it is an amalgamation of biological factors, lifestyle choices and preferences, and socioeconomic factors (Geneti et al., 2022). The interaction of these factors contributes to the severity of the individual’s condition. It can cause acute and long-term diabetes-related complications, including cardiac complications, retinopathy, chronic kidney disease, and neuropathy (Vlachou et al., 2022). In addition to its comorbidities and complications, the condition entails a complex behavioural aspect, as it requires intentional actions by the individual to maintain health and well-being (Cornely et al., 2022). T2DM management is based on self-management, with the individual as the primary decision-maker responsible for more than 95% of specific activities required to achieve management goals (Koochaksaraee et al., 2022; Pienaar and Reid, 2020). Self-management levels vary, with adherence to medication and self-management ranging from 36% to 93% (Murwanashyaka et al., 2022). Individuals’ complex inner dynamics, characteristics, and lived experiences collectively shape perceptions and beliefs about T2DM, which can hinder or facilitate self-management practices (Nantha et al., 2019). Hence, self-management poses a formidable challenge, as some individuals may lack awareness of how these internal dynamics affect their self-management practices or struggle to confront and alter obstructive thoughts, emotions, and behaviours (Fiqri et al., 2022). Effective self-management occurs when individuals align their resources, principles, routines, and preferences with a nutritious diet, increased physical activity, blood glucose monitoring, medication adherence, prevention, and psychological well-being (Pamungkas et al., 2019). It is a dynamic process of adapting one’s cognitive, behavioural, and emotional responses to the condition to uphold a satisfactory quality of life (Pienaar and Reid, 2020). Numerous studies have indicated that emphasis should be placed on the psychological components influencing self-management (Azami et al., 2018). Cognitive behavioural therapy (CBT) is a psychological approach that addresses thoughts and behaviours that impede an individual’s quality of life and, in the case of T2DM, those that impede effective self-management (Koochaksaraee et al., 2022). CBT provides a framework for understanding innate self-management beliefs by first identifying the salient determinants of emotional responses and external behavioural practices, and then creating conscious connections between these interactions and self-management efficacy through the implementation of more helpful thoughts and behaviours (Nantha et al., 2019). The collaborative nature of CBT and the patient involvement required by self-management have proven complementary in facilitating effective self-management practices and glycaemic control (Clarke et al., 2019; Pan et al., 2020; Visagie et al., 2023). The goals of CBT for health-related conditions include empowering the patient, promoting treatment adherence, cultivating responsibility, and facilitating self-efficacy by implementing cognitive restructuring and cognitive disengagement, promoting self-and disease evaluation, and employing continuous action plans to maintain effective self-management practices (Cornely et al., 2022). It enables individuals to recognise that they have control over their self-management and empowers them to become active participants in improving it by employing decision-making, resource utilisation, and problem-solving skills (Motevalli et al., 2023). There is a need to conduct research related to CBT interventions and self-management that addresses core self-management-related thoughts, behaviours, and emotions and does not primarily focus on how CBT can improve the pathology that coincides with or is developed by the diagnosis and condition (e.g. depression; Koochaksaraee et al., 2022; Visagie et al., 2025). A further consideration is the context in which T2DM diagnosis is increasing. Mutyambizi et al. (2020) reported that 80% of individuals diagnosed with diabetes reside in low and middle-income countries, and there is a need for interventions that are cost-effective, accessible, and time-sensitive. Similarly, Pienaar and Reid (2020) found that, within these settings, there is a need for improved community awareness of diabetes, face-to-face information sharing, and training platforms for healthcare providers (HCPs) who consult with individuals diagnosed with T2DM. The advantage of CBT is that its structure and approach align with these requirements. It amalgamates the individual’s internal dynamics with practical skills, making it more user-friendly for HCPs with limited time and psychological training. Therefore, this study presented CBT-informed guidelines for promoting effective self-management practices to a panel of experts via the Delphi method. The aim was to evaluate the content, quality, and structure of the CBT-informed guidelines to optimise its usage in healthcare settings. In the future, these guidelines can be presented to HCPs to help create a more extensive network of professionals who can facilitate patients’ understanding of self-management-related cognitions, emotions, and behaviours, and to increase access to resources for individuals with type 2 diabetes who struggle with self-management.

Methods

Participant recruitment

Experts for the Delphi method were recruited by employing purposive sampling. The expert panel was recruited using specific inclusion criteria established prior to recruitment, in accordance with the Delphi method guidelines (Jünger et al., 2017; Niederberger and Spranger, 2020). Each criterion was designed to elicit the necessary expertise to assess the CBT-informed guidelines. The inclusion criteria were as follows:

Experts had to have advanced knowledge and sufficient experience in type 2 diabetes and/or CBT. This was to ensure that the experts could provide feedback that is clinically relevant and theoretically grounded, offering a comprehensive perspective (Foth et al., 2016; Skivington et al., 2021).

Registration with a professional regulatory board was required to ensure credibility in their input (Diamond et al., 2014; Jünger et al., 2017).

The experts had to have two or more years of professional experience in CBT and/or working with individuals with T2DM. This requirement ensured that the experts had moved past basic training to develop practical expertise relevant to implementation feasibility (Boulkedid et al., 2011; Keeney et al., 2011).

They had to have sufficient time to partake in the process. This was to ensure the integrity of the process and reduce attrition bias (Hohmann et al., 2023; Niederberger and Spranger, 2020).

The target panel size of 10–15 experts was determined based on methodological recommendations for heterogeneous Delphi panels. The focus was on gaining insights from different HCPs rather than achieving statistical representativeness (Diamond et al., 2014; Niederberger and Spranger, 2020). The panel composition included general practitioners, diabetes educators/nurses, dietitians, and psychologists to represent the core frontline providers in South Africa’s primary care pathway for T2DM. This ensured that the guidelines were grounded in the practical realities of resource-constrained settings, where specialist access is often limited, and provided complementary expertise across biomedical, educational, nutritional, and behavioural domains that are essential for holistic self-management (Foth et al., 2016). The recruitment process followed a structured path. Initial experts were identified from professional networks within South African healthcare, with a focus on diversity across professions and practice settings. Participant recruitment concluded when a diverse representation was achieved. The panel demonstrated diversity across professions, years of experience, age, and gender. Further considerations for conducting recruitment included that the panel size matched the recommended range (10–15) and that additional recruitment was not expected to yield new perspectives beyond those offered by the current panel. Participants who indicated their willingness to participate received an email containing the informed consent form, an information leaflet explaining the Delphi method, and additional information about the study’s purpose and the expected duration of the two research rounds. The independent person set up a time for an online consent session. Once consent was obtained, the CBT-informed guidelines were emailed to the expert. The panel included 12 experts: 3 psychologists (2 counselling and 1 clinical), 4 dieticians, 3 medical doctors, and 2 registered nurses (diabetes educators). Most panel members were knowledgeable about type 2 diabetes, but not all had experience or exposure to CBT. Table 1 summarises the demographics of the experts who participated in the first and second rounds.

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Table 1.

Demographics of the Delphi panel.

Expert code	Gender	Age	Ethnicity	Profession, years of practice and regulatory board
E1	Female	43	Caucasian	A counselling psychologist with 6 years of experience employing CBT and registered with the HPCSA. a
E2	Female	31	Caucasian	A dietician with 8 years of experience working with T2DM, registered with ADSA. b
E3	Female	50	Caucasian	A dietician with 26 years of experience working with T2DM, registered with the HPCSA. a
E4	Female	37	Caucasian	A medical doctor with 10 years of experience working with T2DM, registered with the HPCSA. a
E5	Female	51	Caucasian	A nurse with 26 years of experience working with T2DM, registered with the SANC. c
E6	Female	36	Caucasian	A clinical psychologist with 13 years of experience employing CBT, registered with the HPCSA. a
E7	Female	60	African	A dietician with 8 years of experience working with T2DM, registered with the HPCSA a .
E8	Male	56	Caucasian	A specialised physician with 23 years of experience working with T2DM, registered with the HPCSA. a
E9	Female	70	African	A nurse with 17 years of experience working with T2DM, registered with the SANC. c
E10	Male	65	Caucasian	A medical doctor with 40 years of experience working with T2DM, registered with the HPCSA. a
E11	Female	30	Caucasian	A dietician with 6 years of experience working with T2DM, registered with ADSA b and the HPCSA. a
E12	Male	32	Caucasian	A counselling psychologist with 4 years of experience employing CBT and registered with the HPCSA. a

a

The Health Professions Council of South Africa.

b

The Association for Dietetics in South Africa.

c

The South African Nursing Council.

Data collection

The two rounds of Delphi took place between June and September 2023. During the first round, the panel of experts were sent the CBT-informed guidelines manual (which included an explanation of the guidelines), an infographic summarising the CBT-informed guidelines process, and an open-ended questionnaire. The CBT-based guidelines were developed by using previous research conducted by the researcher. This included a rapid review to synthesise the current literature on CBT and self-management (Visagie et al., 2023) and an exploration of the thoughts, emotions, and behaviours of adults with type 2 diabetes through semi-structured interviews (Visagie et al., 2024). The experts could make comments and suggest changes to the manual, answer the open-ended questionnaire, and had a 2-week timeframe to provide their feedback. The first-round questionnaire encouraged the experts to express their overall impressions of the guidelines, identify the strengths and weaknesses, and rate the proposed guidelines out of 100. Lastly, the experts were invited to share any ideas or suggestions to enhance the guidelines’ effectiveness. This round aimed to refine the CBT-informed guidelines by delineating experts’ differing opinions through the identification of themes and consensus (Cataldi and Sena, 2021). The synthesis of responses received in round one, a refined open-ended questionnaire and the refined guidelines were emailed to the experts for the second-round review. Similarly, the experts had 2 weeks to provide their feedback. The second-round questionnaire included two key inquiries. It asked the experts to share their overall impressions of the revised guidelines and to provide feedback on any additional changes that should be incorporated. As defined in the Delphi procedure, this study aimed for an 80% consensus threshold. This consensus was reached after the first round; however, a second round was initiated to address expert feedback and suggestions (Figure 1).

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Figure 1.

Flow diagram of the Delphi process.

Results

Four main themes were identified during round one, namely, (1) the CBT-informed guidelines are clear and concise, (2) there is a need for information regarding role clarification, (3) it is important to consider the patient’s readiness to change before and during the implementation of the guidelines, and (4) the healthcare practitioners anticipate the guidelines to be time-consuming. The second round reiterated the guidelines’ clear and practical nature and suggested technical changes.

Second round feedback

Before the second round commenced, the following theme-based revisions were made to the guidelines, as shown in Table 2, Round 1 Themes and Corresponding Revisions. The refined guidelines and shortened questionnaire were sent to the experts during the second round.

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Table 2.

Theme-based revisions to CBT guidelines.

Theme-based revisions to CBT guidelines
Theme	Revision implemented
1. The CBT-informed guidelines are clear and concise	• Added ‘Key Takeaway’ summaries after each section, condensing the main principles into 1–2 bullet points. • Created a quick-reference infographic that summarises the main cognitive, behavioural and emotional techniques. (e.g., ‘If the patient struggles with overwhelming emotions, see emotional regulation techniques’). • Simplified language and structure
2. There is a need for information regarding role clarification	• Identified the HCPs that may benefit from employing the guidelines (doctors, nurses, dieticians, health educators) and their respective roles. • Listed the responsibilities of the HCPs, such as providing psychoeducation, facilitating cognitive restructuring, and assigning homework. • Listed the patient responsibilities, which could include self-monitoring, completing between-session activities, and reporting challenges and setbacks.
3. It is important to consider the patient’s readiness to change before and during the implementation of the guidelines	• Integrated Prochaska’s Transtheoretical Model as a readiness screening tool linking thoughts and behaviours to the readiness stages • Goal setting highlighted following the SMART guideline and the collaborative nature. • Proposed scaling question to monitor thoughts, behaviours, emotions or patient-identified areas
4. The healthcare practitioners anticipate the guidelines to be time-consuming.	• Developed worksheets that can be used by the HCPs or the patient, which included: • An infographic of the commonly encountered thoughts, emotions and behaviours (HCP). Assisting the HCPs in identifying these components • A psychoeducation worksheet titled, what is CBT? • A thought record worksheet

The panel’s feedback during the second round praised the content’s comprehensiveness and practicality, echoing the first round’s feedback and reaffirming its significance for HCPs. Most experts commended specific improvements, such as including key takeaway messages at the end of each section, integrating Prochaska’s stages of change to assess patient readiness, clarifying roles, and adding worksheets for HCPs and patients (Prochaska et al., 2015). These changes were seen as valuable enhancements to the guidelines. Some panel members suggested minor technical adjustments to spelling and grammar, and a few experts proposed adding additional CBT-related components. Basic CBT skills and techniques were included to ensure simplicity for HCPs unfamiliar with CBT. Overall, this feedback played a crucial role in refining the guidelines, making them adaptable and accessible for HCPs, diverse populations, and various clinical settings.

Discussion

The study aimed to evaluate the content, quality, and structure of the CBT-informed guidelines Upon their first round of evaluation, the Delphi panel provided feedback that was summarised into four themes, namely (1) the CBT-informed guidelines are clear and concise, (2) there is a need for information regarding role clarification, (3) it is important to consider the patient’s readiness to change before and during the implementation of the guidelines and (4) the healthcare practitioners anticipate the guidelines to be time-consuming. The second-round analysis found that the changes made enhanced the guidelines’ efficiency and feasibility. Minor technical changes were proposed, and there was a general improvement in the guidelines’ comfort and ease of implementation. The guidelines were divided into three phases: the introduction phase, the working phase, and the consolidation phase. The introduction phase aimed to familiarise patients with the CBT model by first assessing their readiness to change, providing psychoeducation, setting collaborative goals, and implementing a mood check. The working phase focussed on the emotional, behavioural, and cognitive elements that required change. The consolidation phase aimed to solidify the skills and techniques acquired by the patient by setting homework, identifying resources, and setting an action plan for future challenges. During each phase, the CBT guidelines aimed to educate patients, promote cognitive flexibility (including cognitive awareness, reappraisal, and acceptance), and assign homework tasks. Similarly, research findings reported that CBT interventions are effective when emphasising components such as psychoeducation, cognitive restructuring, and setting homework assignments (Andreae et al., 2020; Li et al., 2023). Accordingly, Abbas et al. (2023) and Motevalli et al. (2023) found that these strategies facilitate cognitive and emotional functions related to effective self-management. The CBT guidelines were based on core CBT principles but were not intended as a therapeutic intervention, and their format and delivery method were adapted accordingly. The phases served as guidelines for HCPs to determine which techniques and skills from each phase should be introduced and practised by the patient. This format aims to make the guidelines more feasible, cost-effective, and accessible than traditional CBT interventions. An infographic summarising the phases and their respective skills and techniques was provided to the experts. It aimed to orient experts and enable HCPs to easily navigate to their patients’ required skills, techniques, or regulatory strategies. The second round’s feedback reverberated the guidelines’ clarity and practicality. The experts stated that the changes succinctly articulated the guidelines’ goal while remaining comprehensive enough to ensure thorough implementation and the continuation of the intervention. Guo et al. (2022) adapted their programme and reported positive effects on diabetes distress, emotion regulation, and self-management. Similarly, Jenkinson et al. (2022), Li et al. (2023), and Visagie et al. (2023) for peer review reported that the presence of core CBT components contributed to the efficacy of an intervention. An additional aspect requiring attention was clarifying the roles and responsibilities of the HCP and the patient. This was addressed following the first round of feedback, and the guidelines were amended to specifically state the aims for HCPs, imploring HCPs to do a needs analysis of their patient and orienting them within each phase. The fundamental role of an HCP delivering the guidelines is to foster the patient’s self-efficacy by placing them at the centre of self-management. The guidelines aimed to facilitate this process by assessing patient readiness, fostering collaboration through goal setting and resource identification, and enabling patient responsibility through homework assignments and action plans. Research has found that patient-centred interventions promoted effective self-management outcomes (AlHaqwi et al., 2023; Asmat et al., 2022). Kunkes et al. (2022) reported that this approach allowed HCPs to understand their patients’ values and priorities better, providing a clearer rationale behind self-management decisions. Similarly, a systematic review by Asmat et al. (2022) highlighted the need to explore and understand the situational and sociocultural factors that affect self-management and to consider these factors when implementing patient-centred care. In accordance, the guidelines aimed to present a framework that could be tailored to the individual’s needs, financial resources, and personal beliefs, making them more relatable. Role clarification extended to which HCPs can implement these guidelines and how much time the implementation will require. Owing to the guidelines’ non-therapeutic nature, they aim for various HCPs to implement these skills and techniques. Currently, few psychologists, psychiatrists, and multidisciplinary teams are based at the clinics that serve individuals with type 2 diabetes, especially in developing countries (Guo et al., 2022). Thus, having multiple HCPs who can provide CBT skills and techniques can enhance accessibility. Visagie et al. (2023) conducted a review of CBT interventions for type 2 diabetes self-management and found that several HCPs were pre-trained in various CBT formats. Interventions were still effective, and having various HCPs trained to implement programmes promoted accessibility, community engagement, and resource availability (Visagie et al., 2023). Similarly, Guo et al. (2022) emphasised the importance of training HCPs to implement basic mental health interventions to address the limitations of human-intensive, expert-based interventions and to increase participants’ engagement. Currently, the guidelines require no formal training. The current scope of the research was to develop the guidelines as a non-therapeutic approach, and future research is planned to address and develop training programmes for the CBT guidelines. No time indications or limits were proposed for the different phases to promote engagement and ease adherence to the guidelines, and additional resources and changes were developed in response to the first-round feedback. These resources and changes were designed to orient HCPs to the most valuable takeaway message and to provide tangible examples that facilitate their proficiency and autonomy in implementing the guidelines. During the second round, specific feedback acknowledged these changes and noted that the key takeaway messages, worksheets, and clearly defined roles clarified the previously expressed confusion about roles.

Conclusion

These findings highlight the challenges and multifaceted nature of T2DM self-management. The flexible nature of the guidelines addresses the challenges posed and provides a framework for HCPs to adopt a more holistic approach to self-management. In resource-limited settings, time constraints and other logistical challenges may hinder the implementation of full-fledged CBT programmes. A more relaxed framework can aid HCPs in engaging more extensively with individuals with type 2 diabetes, thereby prioritising the most relevant and impactful CBT components and making integration into existing healthcare systems more feasible.