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BELITUNG!NURSING!
JOURNAL!
Volume 3 Issue 6
Belitung Nursing Journal (BNJ) is a bi-monthly, International, peer reviewed journal

published by Belitung Raya Foundation, in collaboration with the Academy of Nursing of
Belitung and Indonesian National Nurses Association, Belitung Indonesia.
BNJ contributes to the advancement of evidence-based nursing, midwifery and healthcare by

disseminating high quality research and scholarship of contemporary relevance and with
potential to advance knowledge for practice, education, management or policy. BNJ
welcomes submissions of evidence-based clinical application papers, original research,
systematic review, case studies, perspectives, commentaries, letter to editor and guest
editorial on a variety of clinical and professional topics.
The Official Publication of Belitung Nursing Journal – Belitung Raya Publisher-

Belitung Raya Foundation
ISSN: 2477-4073 (Online) | ISSN: 2528-181x (Print)

Belitung Nursing Journal is indexed by DOAJ, Google Scholar, ISJD, WorldCat,
Journal TOCs, and ROAD
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BELITUNG!NURSING!
JOURNAL!
Volume 3 Issue 6
© Belitung Nursing Journal - Belitung Raya Publisher – Belitung Raya Foundation, 2017
Belitung Raya Publisher

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Volum e 3 issue 6
Library of Congress Catagloging-in-Publication Data

Belitung Nursing Journal Volum e 3 Issue 6
P-ISSN !2528-181x
Copyright 2017, by Belitung Nursing Journal - Belitung Raya Publisher – Belitung

Raya Foundation. All rights reserved. This book is protected by copyright. No part
of it maybe reproduced, stored in retrieval system, or transmitted, in any form or by
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critical articles and reviews and testing and evaluation materials provided by
publisher.
! iii!
EDITORIAL TEAM
Editor-in-Chief
Assoc. Prof. Yupin Aungsuroch, PhD, RN, Faculty of Nursing, Chulalongkorn University, Bangkok,
Thailand
Advisory International Editorial Board

Asst. Prof. Rapin Poolsok, PhD, RN, Faculty of Nursing, Chulalongkorn University, Bangkok,
Thailand
Jed Ray Montayre, PhD, RN, Department of Nursing, Auckland University of Technology,
Auckland, New Zealand
Pakamas Keawnantawat, PhD, RN, Ramathibodi School of Nursing Faculty of Medicine
Ramathibodi Hospital Mahidol university, Thailand, Thailand
Virya Koy, RN, SNA, MNSc, MHPEd, PhD, President of Nursing Council of Cambodia and Vice
Rector of Chenla University.
Hasanuddin Nuru, S.Kep, Ners, M.Kes, PhD, Faculty of Health Science, University of Islam
Makassar, Indonesia.
Abdulkareem Suhel Iblasi, MSN, Nurse Manager - Wound Care. King Saud Medical City, Ministry
of Health, Saudi Arabia, Saudi Arabia
Associate Editors
Sqn.Ldr. La-Ongdao Wannarit, RN, MNS, The Royal Thai Air Force Nursing College, Thailand
Su-ari Lamtraktul, RN, MNS, Department of Pediatric Nursing, The Royal Thai Army Nursing
College Bangkok, Thailand, Thailand
Surachai Maninet, RN, MNS, Faculty of Nursing, Ubon Ratchathani Rajabhat University, Thailand
Thi Thanh Huong Nguyen, MNS, Namdinh University of Nursing, 257 Han Thuyen, Namdinh,
Vietnam, Viet Nam
Agianto, S.Kep.,Ns., MNS, School of Nursing, Lambung Mangkurat University. Jl. A. Yani KM 36
Banjarbaru, South Kalimantan, Indonesia., Indonesia
Rian Adi Pamungkas, BNS, MNS, School of Health Science of Mega Rezky Makassar, Indonesia
Fauzan Saputra, S.Kep, Ns, MNS, Bumi Persada Nursing College and Public Health Office of
Lhokseumawe, Aceh, Indonesia
Melyza Perdana, S.Kep, Ns.,MNS, School of Nursing, Faculty of medicine Universitas Gadjah
Mada, Indonesia., Indonesia
Ety Hastuti, S.Kep, Ners, M.Kep, Director of Inpatient Services of the General Hospital of
dr.H.Marsidi Judono, Belitung, Indonesia
Nazliansyah S.Kep.Ns.MNS, Academy of Nursing of Belitung, Indonesia
Kusuma Wijaya Ridi Putra, S.Kep, Ners, MNS, Kerta Cendekia Nursing Academy, Sidoarjo,
Indonesia
Journal Manager
Joko Gunawan, BNS, PhD (c), Faculty of Nursing, Chulalongkorn University, Bangkok Thailand
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Table of Contents
Articles
IDENTIFICATION OF URINARY INCONTINENCE IN PEOPLE AGED 65 AND PDF
OVER: A TURKEY SAMPLE 636-644
Birsel Canan DEMİRBAĞ, Gulpinar ASLAN, Ayşe Berivan BAKAN
ITEM ANALYSIS AND INTERNAL CONSISTENCY OF CHILDREN’S SLEEP PDF

HABIT QUESTIONNAIRE (CSHQ) IN INDONESIAN VERSION 645-655
Sri Hartini, Sunartini -, Elsisabeth Siti Herini, Satoshi Takada
CAREGIVERS’ NEEDS IN CARING FOR RELATIVES WITH SCHIZOPHRENIA PDF

IN MEDAN INDONESIA: A PHENOMENOLOGICAL STUDY 656-661
Jenny Marlindawani Purba
EFFECTIVENESS OF PROGRESSIVE MOBILIZATION LEVEL I AND II ON PDF

HEMODYNAMIC STATUS AND DECUBITUS ULCER RISK IN CRITICALLY ILL 662-669
PATIENTS
Ni Wayan Rahayu Ningtyas, RR Sri Endang Pujiastuti, Nina Indriyawati
THE ASSOCIATION OF ISLAMIC BASED CARING MODEL AND PDF

COMMITMENT TO ORGANIZATION IN STAFF NURSES 670-676
Yuda Ayu Timorita, Tri Hartiti, Bambang Edi Warsito, Suhartini Ismail
EFFECT OF MULTI MICRONUTRIENT SUPPLEMENTATION ON PDF

HEMOGLOBIN LEVELS IN PREGNANT WOMEN WITH ANEMIA 677-685
Rati Purnama Sari, Noor Pramono, Sri Wahyuni, Muchlis Achsan Udji
Sofro, Melyana Nurul Widyawati
DARK CHOCOLATE’S EFFECT ON MENSTRUAL PAIN IN LATE PDF

ADOLESCENTS 686-692
Sandy Isna Maharani, Noor Pramono, Sri Wahyuni
COMPARISON OF THE EFFECTIVENESS OF TWO LEVELS OF SUCTION PDF

PRESSURE ON OXYGEN SATURATION IN PATIENTS WITH 693-696
ENDOTRACHEAL TUBE
Muhaji Muhaji, Bedjo Santoso, Putrono Putrono
EFFECT OF ACUPRESSURE THERAPY POINT LI 4, SP 6, AND BL 60 ON PDF

DURATION OF THE FIRST STAGE OF LABOR IN PRIMIGRAVIDA AND 697-701
NEWBORN’S APGAR SCORE
Fara Imelda Theresia Patty, Suhartono Suhartono, Ngadiyono Ngadiyono,
Mardiono Mardiono
EFFECT OF YOGA ON DURATION OF THE SECOND STAGE OF LABOR AND PDF

PERINEAL RUPTURE IN PRIMIGRAVIDA MOTHERS 702-706
Ana Setyowati, Suhartono Suhartono, Ngadiyono Ngadiyono, Rr Sri
Endang Pujiastuti, Dyah Dyah
EFFECT OF CONSUMING TOMATO (LYCOPERSIUM COMMUNE) JUICE IN PDF

LOWERING BLOOD PRESSURE IN PREGNANT MOTHERS WITH 707-711
HYPERTENSION
Theresia Anita, Agus Suwandono, Ida Ariyanti, Noor Pramono, Suryati
Kumorowulan
HYPNODIALYSIS FOR ANXIETY RELIEF AND ADHERENCE TO PDF

MEDICATION, KIDNEY DIET AND FLUID INTAKE IN PATIENTS WITH 712-721
CHRONIC KIDNEY DISEASE
Siti Hajar Wati, Mardiyono Mardiyono, Warijan Warijan
EFFECT OF YOGA AND ACUPRESSURE ON PAIN AND FUNCTIONAL PDF

CAPABILITY OF LOWER BACK IN PREGNANT MOTHERS DURING THE 722-728
THIRD TRIMESTER OF PREGNANCY
Dewi Candra Resmi, Suharyo Hadisaputro, Runjati Runjati
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CLINICAL INDICATORS OF FEEDING SELF-CARE DEFICIT BASED ON PDF
BARTHEL INDEX MEASUREMENT IN PATIENTS SUFFERING FROM STROKE 729-734
Intansari Nurjannah, Vini Febriyani Zulfa, Dwi Harjanto, Erna Fitriana,
Ngatini Ngatini
EFFECTIVENESS OF MUSIC THERAPY ON ANXIETY AND Β-ENDORPHIN PDF

LEVELS IN PRIMIGRAVIDA DURING THE THIRD STAGE OF PREGNANCY 735-742
Surya Dayyana, Suryono Suryono, Melyana Nurul Widyawati, Syarief
Thaufik Hidayat
EFFECT OF PSYCHOEDUCATION ON ANXIETY IN PATIENTS WITH PDF

CORONARY HEART DISEASE 743-749
Yuli Sulistiyo, Bedjo Santoso, Shobirun Shobirun, Soeharyo Hadisaputro,
Leni Latifah, Rr Sri Endang Pujiastuti
EFFECTIVENESS OF LAVENDER AROMATHERAPY AND CLASSICAL MUSIC PDF

THERAPY IN LOWERING BLOOD PRESSURE IN PREGNANT WOMEN WITH 750-756
HYPERTENSION
Sri Maisi, Suryono Suryono, Melyana Nurul Widyawati, Ari Suwondo,
Suryati Kusworowulan
COMBINATION OF COLD PACK, WATER SPRAY, AND FAN COOLING ON PDF

BODY TEMPERATURE REDUCTION AND LEVEL OF SUCCESS TO REACH 757-764
NORMAL TEMPERATURE IN CRITICALLY ILL PATIENTS WITH
HYPERTHERMIA
Nur Eka Dzulfaijah, Mardiyono Mardiyono, Sarkum Sarkum, Djenta Saha
EFFECT OF PREGNANCY EXERCISE ON DURATION OF THE FIRST AND PDF

SECOND STAGE OF LABOR IN PRIMIGRAVIDA MOTHERS DURING THE 765-770
Iin Wahyuni, Noor Pramono, Titi Suherni, Melyana Nurul Widyawati
EFFECT OF ROSELLE (HIBISCUS SABDARIFFA) ON CHANGES IN PDF

HEMOGLOBIN LEVELS IN PREGNANT WOMEN WITH ANEMIA TAKING 771-777
IRON SUPPLEMENT
Rif’atun Nisa, Ariawan Soejoenoes, Sri Wahyuni
BINAHONG LEAVES (ANREDERA CORDIFOLIA TENORE STEEN) EXTRACT PDF

AS AN ALTERNATIVE TREATMENT FOR PERINEAL WOUND HEALING OF 778-783
POSTPARTUM MOTHERS
Dita Selvia Aditia, Syarief Thaufik Hidayat, Nur Khafidhoh, Suhartono
Suhartono, Ari Suwondo
EFFECT OF COMBINATION OF BREAST CARE AND OXYTOCIN MASSAGE PDF

ON BREAST MILK SECRETION IN POSTPARTUM MOTHERS 784-790
Kadek Yuli Hesti, Noor Pramono, Sri Wahyuni, Melyana Nurul Widyawati,
Bedjo Santoso
EFFECT OF EGGSHELL FLOUR ON BLOOD CALCIUM LEVELS IN PREGNANT PDF

MICE 791-795
Ida Ratna Safitri, Supriyana Supriyana, Bahiyatun Bahiyatun
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DEMİRBAĞ C B, et al. Belitung Nursing Journal. 2017 December;3(6):636-644
Accepted: 4 November 2017
http://belitungraya.org/BRP/index.php/bnj/
© 2017 Belitung Nursing Journal

This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License which permits
unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
ORIGINAL RESEARCH ISSN: 2477-4073
IDENTIFICATION OF URINARY INCONTINENCE IN PEOPLE AGED 65

AND OVER: A TURKEY SAMPLE
Birsel Canan DEMİRBAĞ1*, Gulpinar ASLAN2, Ayse Berivan BAKAN3

1
Karadeniz Teknik University, Health Science Faculty, Nursing Department, Trabzon, TURKEY
2
First and Immediate Aid Program, Agri Ibrahim Cecen University Health Services Vocational School, Agrı, Turkey
3
Department of Nursing, Agri Ibrahim Cecen University School of Health, Agrı, Turkey
*Correspondence:
Associate Prof. Canan DEMİRBAĞ
Karadeniz Teknik University, Health Science Faculty, Nursing Department,Trabzon
TURKEY, Tel: +90 (0462) 230 04 76 ; Fax: +90 (0462) 230 04 75
Email: cdemirbag@gmail.com
ABSTRACT
Objective: This study aims to identify urinary incontinence and its prevalence in people aged 65 and over.
Methods: This descriptive study was conducted between April and June, 2017. It was conducted with 1527 volunteer people
aged 65 and over who applied to A Family Health Centre. Data were collected through face-to-face interviews, using
Personal Identification Form and International Consultation on Incontinence Questionnaire- Short Form (ICIQ-SF).
Results: Of all the participants, 50.7% were male, and 78.8% were aged between 65 and 74. Besides, 31.2% of them had
urinary incontinence, and ICIQ-SF mean score was found 11.44 ± 5.01. The most prevalent incontinence type was found to
be urge urinary incontinence. ICIQ-SF total scores of elderly people with urinary incontinence were higher in those who
were aged 85 and over, who were illiterate, who did not have health insurance, and who had more than one chronic disease
and multiple medicine use.
Conclusion: Urinary incontinence is a health problem which maintains its importance in people aged 65 and over. People in
this age group do not express this problem because they feel shy; therefore, their quality of life deteriorates.
Keywords: Elderly, Prevalence, Urinary Incontinence
INTRODUCTION
Ageing is a change and transformation The World Health Organization predicts that
process which starts in mother’s womb and approximately 1.2 million people will be 60
continues until death. Ageing process is and over in the year 2025, and this number
affected mostly by healthy lifestyle. World will reach up to 2 million in 2050; and 80% of
population has been progressively ageing the elderly population will live in the
thanks to the technological developments in developing countries (WHO, 2002). Our
health field, the importance given to country is among the developing countries
protective health services, and the positive where ageing process is fast. Proportion of
developments in personal lifestyle elderly population in Turkey was reported to
perceptions. Ageing of the population is be 8%, which included 43.6% males and
expressed with the increase in the people aged 56.4% females. Population projections report
65 and over in the total population (Özcan & that elderly population will increase to
Kapucu, 2014). 10.12% in 2023, 20.8% in 2050, and 27.7% in
636 BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017

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DEMİRBAĞ, C. B., ASLAN, G., BAKAN, A. B. (2017)!
2075. These proportions indicate that the Various studies conducted at local level
elderly population in our country has been reported prevalence of incontinence between
increasing gradually (Beğer & Yavuzer, 2012; 20% and 40 %, which is based on health
Institute, 2014). survey results rather than patient complaints
(Dursun et al., 2014; Onur, Deveci, Rahman,
Age-related physiological changes in the body Sevindik, & Acik, 2009). Studies show that
system bring problems in relation to this despite its prevalence and serious
period. Ageing brings along many problems, complications especially in terms of elderly
primarily chronic diseases, which could affect people, urinary incontinence is a problem,
daily life activities in a negative way. Urinary which is neglected especially in the units
incontinence problem is among the most providing primary preventive health services.
common ones. People who assimilate urinary Health policies of our country adopt a
incontinence with ageing try to overcome this preventive health approach. Through
problem with personal precautions. Urinary surveying people who apply to health
incontinence causes various skin lesions institutions, it is very important to identify
ranging from maceration and irritation to and report the increasing prevalence of
pressure ulcer; it could also make the person urinary incontinence among elderly people in
become dependant by causing depression, our country so that awareness can be raised
disorders in walking functions, falling, and about the issue. This study aims to identify
social isolation (Cankurtaran, Soyuer, & urinary incontinence and its prevalence in
Akin; Kim, Yoshida, & Suzuki, 2011). people aged 65 and over who apply to FHCs.
Urinary incontinence is defined by the

International Continence Society (ICS) as METHODS
involuntary loss of urine that is objectively Research Design
demonstrable and causes social or hygienic This study, which is descriptive in nature,
problems (Abrams et al., 2002). Although aims to identify urinary incontinence in
urinary incontinence is not accepted as part of people aged 65 and over. It was conducted
ageing, its prevalence is higher among elderly between April 2017 and June 2017.
people. Studies on elderly people report
urinary incontinence prevalence between 8% Target Population and the Participants
to 34% worldwide, this proportion reaches up The study was conducted in 7 FHCs which
to 70% in elderly people in nursing centres provided primary health service in Ağrı city
(Abrams et al., 2002; Ilçe & Ayhan, 2011). centre. The participants were 1527 (out of
The number of people with urinary 1547) volunteer people who were aged 65 and
incontinence among elderly is not known over and who applied to these FHCs between
exactly in our country, which indicates that the aforementioned dates. Exclusion criteria
this problem cannot be expressed. In addition, of the sample: Elderly people who have
it is important to note that there is little neurological problems such as dementia and
research about elderly population in FHCs Alzheimer, bladder cancer, paralysed, have
(Family Health Centres), which provide communication problems were not involved
primary preventive health services. An in the study.
analysis of the studies on incontinence also
indicates lack of studies for men (Yaycı, Data Collection
2010). Data were collected through face-to-face
interviews conducted by the researcher, using
Identification of incontinence is a social, Descriptive Information Form and
psychological and hygienic problem which International Consultation on Incontinence
involves not only the people at all ages but Questionnaire Short Form (ICIQ-SF).
also those around them; and primary Descriptive Information Form: The form was
preventive health services, where elderly prepared by the researchers in line with the
people apply most frequently, should be the related literature. Descriptive Information
units to be applied for treatment. Form has 21 questions which aim to collect
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BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017! 637

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data about gender, age, marital status, Data Analysis

education level, fertility features, presence of Data were analysed in SPSS statistical
chronic diseases, medicine use, presence of programming, using descriptive statistics,
urinary incontinence, and issues about Shapiro Wilk, Mann-Whitney U, Kruskal-
consulting a doctor and receiving treatment. Wallis and Spearman Correlation Tests.
International Consultation on Inconti-nence
Questionnaire Short Form (ICIQ-SF): This Ethical Considerations
form was first developed by Avery et al. Prior to the study, necessary permissions were
(2004), and Cronbach’s alpha value was obtained from City Directorate of Public
found 0.95 (Avery et al., 2004). Turkish Health, and ethical committee approval was
validity and reliability was performed by obtained (27/04/2017-E.10477). The
Çetinel et al. (2004), and Cronbach’s alpha participants were informed about the study,
value was found 0.71 (Çetinel, Özkan, & Can, and verbal consent was obtained from those
2004). The present study found the who accepted to participate in the study.
Cronbach’s alpha value as 0.77. ICIQ-SF,
which is used for the identification of urinary
incontinence, included 4 questions which aim RESULTS
to collect data about the degree, frequency, Of all the participants, 50.7% were male,
and type of incontinence within the last 4 78.8% were aged between 65 and 74, 72.3%
weeks as well as the effects on quality of life. were married, and 56.3% were illiterate.
ICIQ-SF total score is obtained through 60.4% had medium financial level. 57.6% had
Visual Analogue Scale type questions which a chronic disease and 32.5 % of them had
examine the frequency and amount of more than one chronic disease, 57.6 % used
incontinence and its effect on quality of life. medicine that should be taken regularly and
Type of urinary incontinence was separately 32.5% used multiple medicines (see Table 1).
identified with a question which asks about
the cases when urinary incontinence happens.
Table 1 Descriptive Features of the Participants (N=1527)

Variables S %
Gender Female 753 49.3
Male 774 50.7
Age 65 to 74 1204 78.8
75 to 84 234 15.3
85 and over 89 5.8
Marital Status Married 1104 72.3
Single/Widow(er) 423 27.7
Education Level Illiterate 859 56.3
Literate/Primary school 468 30.6
Secondary School 91 6.0
High School 79 5.2
University 30 2.0
Presence of Health Insurance Yes 1040 68.1
No 487 31.9
Financial Situation Good 327 21.4
Medium 923 60.4
Bad 277 18.1
Presence of a Chronic Disease Yes 879 57.6
No 648 42.4
Chronic Disease Hypertension 234 26.6
Diabetes 113 12.9
Heart Disease 53 6.0
Cancer 20 2.3
COPD 112 12.7
Prostatic Hypertrophy 37 4.2
638 BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017! !

Variables S %
Osteoporosis 24 2.7
More than one chronic disease 286 32.5
Regular Medicine Use Yes 879 57.6
No 648 42.4
Medicine Group Tension 234 26.6
Diabetes 113 12.9
Heart 53 6.0
Cancer 20 2.3
COPD 112 12.7
Prostate 37 4.2
Osteoporosis 24 2.7
Multiple Medicine Use 286 32.5
Table 2 Distribution of Elderly Women’s ICIQ-SF Total Mean Scores According to Their Fertility Features
(N=753)
Urinary
Incontinence ICIQ-SF
Variables S (%) U/KW
Yes No X ±SD
S (%) S (%)
Type of Caesarean section 6 (0.7) 0 6 (100) -
Delivery Normal spontaneous vaginal 662 264 398 12.04±5.15
delivery (87.9) (39.9) (60.1) KW:2.606
Both 62 (8.2) 20 42 10.40±4.50
(32.3) (67.7)
Never had delivery 23 (3.05) 7 (30.4) 16 10.57±6.21
(69.6)
87 (11.6) 42 55 12.07±5.14
Yes
(43.3) (56.7) U:5179.5
Hysterectomy
666 249 407 11.86±5.15
No
(88.4) (38.0) (62.0)
ICIQ-SF Total Score
X ±SD X ±SD
Number of 8.14±3.27 r .194*
Pregnancies (min.1, max. 21)
Number of 7.68±2.97 r .210**
Deliveries (min.1, max. 21)
*p<0.01 | **p<0.001
Average number of pregnancies was found 30.4% of the women who never had delivery.
8.14±3.27, and average number of deliveries It was found that those who had caesarean
was 7.68±2.97. Of all the women who had section did not have urinary incontinence.
delivery, 90.7% were found to have normal Urinary incontinence was found to exist in
spontaneous vaginal delivery. 11.6% of the 47.1% of the women who underwent
women were found to have undergone hysterectomy and 37.8% of those who did not.
hysterectomy. An analysis of urinary No significant differences were found
incontinence according to delivery type between the groups in terms of ICIQ-SF total
showed that urinary incontinence existed in scores; however, a significant, positive
39.9% of the women who had normal relationship was detected between the number
spontaneous vaginal delivery, in 32.3% of the of pregnancies and deliveries and ICIQ-SF
women who had both types of delivery, and in total scores (see Table 2).

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It was 31.2% of the elderly participants were Findings show that ICIQ-SF mean score of
found to have urinary incontinence, 54.4 % of elderly people participating in the study was
them consulted a doctor, and 47% of those 11.44 ± 5.01, and the scores ranged from 0 to
who did not consult a doctor were found to do 22. The most common urinary incontinence
so because they felt embarrassed. 39.1% of type was urge type incontinence (37%) and
the participants with urinary incontinence mixed type incontinence (36.1%) (see Table
received treatment; the treatment type was 4).
medicine for 82.8%; and 55.9% of those who
received treatment was found to benefit from An analysis of some socio-demographic and
it. It was also found that 70% of the disease-related features of the elderly people
participants with urinary incontinence with urinary incontinence and the distribution
problem were not willing to receive any of ICIQ-SF total scores showed that scores
training about this issue (see Table 3). were significantly higher in women who were
aged 85 and over, who were illiterate, who
had more than one chronic disease, and who
used multiple medicines (see Table 5).
Table 3 Knowledge of Elderly People about Urinary Incontinence

Variables S %
Yes 476 31.2
Presence of Urinary Incontinence
No 1051 68.8
Experience of consulting a doctor Yes 259 54.4
No 217 45.6
Reason for not consulting a doctor Embarrassment 102 47.0
Perceiving it normal 85 39.2
Other 30 13.8
Yes 186 39.1
Having had a treatment before
No 290 60.9
Exercise 9 4.8
Type of Treatment Medicine 154 82.8
Surgery 23 12.4
Having benefitted from the treatment Yes 104 55.9
No 82 44.1
Willingness to receive training about Urinary Yes 143 30.0
Incontinence No 333 70.0
Table 4 Type of Urinary Incontinence and ICIQ-SF Total Mean Scores

Type of Urinary Incontinence N %
I never have incontinence 8 1.7
Urge Type incontinence 176 37.0
Stress Type incontinence 71 14.9
Mixed Type incontinence 172 36.1
Nocturnal Type incontinence 14 2.9
I have incontinence without any apparent reason 5 1.1
I always have incontinence 30 6.3
X ±SD
11.44 ± 5.01
ICIQ-SF
(min.0, max. 22)

Table 5 Descriptive Features of the Participants who have Urinary Incontinence and Distribution of ICIQ-SF
Total Mean Scores (N=476)
Variables S (%) U/KW
X ±SD
Female 291 (61.1) 11.89±5.14 U:23869.0*
Gender
Male 185 (38.9) 10.71±4.72
Age 65 to 74 342 (71.8) 11.22±4.93
75 to 84 88 (18.5) 11.30±5.25 KW:7.088*
85 and over 46 (9.7) 13.30±4.80
Married 320 (67.2) 11.24±5.04 U:23339.5
Marital Status
Single/Widow(er) 156 (32.8) 11.83±4.93
Illiterate 320 (67.2) 11.90±5.19
Literate/Primary school 117 (24.6) 10.94±4.36
Education Level KW:10.656*
Secondary School 24 (5.0) 9.54±4.05
High School 15 (3.1) 8.53±5.46
Health Insurance Yes 307 (64.5) 11.03±4.91 U:22589.0*
No 169 (35.5) 12.19±5.10
Good 85 (17.9) 10.78±5.24
Financial Situation Medium 268 (56.3) 11.44±4.99 KW:2.581
Bad 123 (25.8) 11.89±4.87
Presence of a chronic Yes 361 (75.8) 11.66±5.10
U:18722.5
disease No 115 (24.2) 10.76±4.65
Chronic Disease Hypertension 78 (16.4) 11.85±5.08
Diabetes 34 (7.1) 10.24±4.74
Heart Disease 16 (3.4) 9.13±3.28
Cancer 8 (1.7) 12.13±5.44
COPD 44 (9.2) 9.93±5.14
KW:16.403*
Prostatic Hypertrophy 23 (4.8) 11.65±5.30
osteoporosis 12 (2.5) 12.33±4.66
More than one chronic disease 146 (30.7) 12.61±5.15
Yes 361 (75.8) 11.66±5.10
Regular Medicine Use 10.76±4.65 U:18722.5
No 115 (24.2)
Tension 78 (16.4) 11.85±5.08
Diabetis 34 (7.1) 10.24±4.74
Heart 16 (3.4) 9.13±3.28
Cancer 8 (1.7) 12.13±5.44
Medicine Group 44 (9.2) 9.93±5.14 KW:16.403*
COPD
Prostate 23 (4.8) 11.65±5.30
Osteoporosis 12 (2.5) 12.33±4.66
Multiple Medicine Use 146 (30.7) 12.61±5.15
*p<0.05
DISCUSSION Santos, Pereira, Zambon, & Marques, 2012).

An analysis of the studies about elderly Similarly, studies about elderly people living
people shows that urinary incontinence is a in the USA reported urinary incontinence in
common problem which affects quality of life. 15% to 30% of elderly people living in their
In their study conducted with people aged 65 homes and 50% of elderly people living in
and over, Burti et al. found that 38.4% of the nursing homes (Adedokun & Wilson, 2004;
participants had urinary incontinence (Burti, Adelmann, 2004). A study conducted with
!

!
elderly people living in nursing homes in our Kaşıkçı et al. reported 44.1 % urge type,
country found that 30% of women had urinary 39.3% stress type, and 34.2% mixed type
incontinence (Arıkan, Özcan, Bardak, & urinary incontinence (Kaşıkçı et al., 2015).
Ktenci, 2002). Another study conducted with The present study found 37% urge type,
people aged over 65 found that 32.9% of men 36.1% mixed type, and 14.9% stress type
and 54.5% of women had urinary incontinence. Higher urge type incontinence
incontinence (H. Dogan, 2009). In a similar proportions in our study could be explained
vein, in their study conducted with elderly by the current chronic diseases that elderly
people living in nursing homes, Cankurtaran people participating in the study have, which
et al. found that 36.7% of women and 32.7% is regarded among risk factors.
of men had urinary incontinence, which
caused serious effects on their quality of life Studies indicate that prevalence of urinary
(Cankurtaran et al.). Ateşkan et al. reported incontinence increases with the increase in
that 57.1% of women and 21.5% of men had age (Gunes, Gunes, & Pehlivan, 2000;
urinary incontinence (Ateşkan, Mas, Doruk, Hawkins et al., 2011; Ilçe & Ayhan, 2011;
& Kutlu, 2000). In their study conducted with Öztürk, Toprak, & Basa, 2012). The present
women aged 65 and over, Kaşıkçı et al. study has also found that prevalence of
reported that 51.6% of the participants had incontinence increases as age increases.
urinary incontinence (Kaşıkçı, Kılıç, Avşar, & Prevalence of incontinence is affected by age-
Şirin, 2015). The present study found that related factors such as limitations in
31.2% of the elderly people had urinary movements and decrease in muscle control
incontinence at various degrees, and 61.1 % (Diokno et al., 2007; Öztürk et al., 2012).
were female. Similar to the findings of our Results are in line with the related literature.
study, prevalence of urinary incontinence was
high among females. This higher prevalence Studies report that urinary incontinence was
can be explained with urethral length more prevalent in groups with low education
differences, pelvic floor anatomy, and socio-economic levels. Education and
pregnancies, number of deliveries, and socio-economic level affects various
hormonal activities (Burti et al., 2012; İnci & processes such as an individual’s need for
Ergen, 2009). applying health services, expectations from
the health services provided, and assessment
Types of urinary incontinence was identified of the health service received (Burti et al.,
according to the responses; “I have 2012; Z. Dogan et al., 2015; Hawkins et al.,
incontinence while coughing, sneezing” and 2011). Similar results have been indicated in
“I have incontinence while moving or the present study, too.
exercising” responses indicate stress type
incontinence, “I have incontinence while I Various studies indicate that prevalence of
finish peeing and button up” response urinary incontinence increases with the
indicates urge type incontinence. When the increase in the number of pregnancies and
responses include both urge type incontinence deliveries (Gunes et al., 2000; Kaşıkçı et al.,
and stress type incontinence, it indicates 2015; Kocaöz & Eroğlu, 2002). This result
mixed type incontinence. Apart from these, “I can be associated with the fact that pelvic
have incontinence while sleeping” response floor muscles loosen in women who had
indicates nocturnal incontinence (Ilçe & delivery. Results of the present study are in
Ayhan, 2011). A study conducted by İlçe et line with the related literature.
al. reported 65.5% mixed type, 20% urge type
and 12.7% stress type incontinence (Ilçe & Chronic diseases such as heart diseases,
Ayhan, 2011). Similarly, Arıkan et al. tension, diabetes, osteoporosis and prostate
reported 72% stress type, 16% mixed type, are associated with urinary incontinence
and 8% urge type urinary incontinence (Hawkins et al., 2011; İnci & Ergen, 2009;
(Arıkan et al., 2002). Doğan et al. reported Minassian, Stewart, & Wood, 2008). A
23.7% urge type, 6.3% stress type, and 8.8% number of studies found no relationships
mixed type urinary incontinence (Diokno, between urinary incontinence and diseases
Estanol, Ibrahim, & Balasubramaniam, 2007). such as tension, diabetes, and heart diseases

(Ilçe & Ayhan, 2011; Öztürk et al., 2012). should be taken to give special training to
The present study also found that prevalence healthcare personnel about this issue in order
of urinary incontinence increases in people to improve their knowledge and skills.
who have more than one chronic disease.
In their study conducted with women, Öztürk REFERENCES

et al. found that 42.8% of women had urinary Abrams, P., Cardozo, L., Fall, M., Griffiths, D., Rosier,
incontinence, but 69.8% of them never P., Ulmsten, U., . . . Wein, A. (2002). The
consulted a doctor about this complaint. When standardisation of terminology of lower
urinary tract function: report from the
they were asked about the reason why they Standardisation Sub-committee of the
did not consult a doctor, 21% said International Continence Society. American
“embarrassment”, 64.5% said “disregard”, journal of obstetrics and gynecology, 187(1),
and 15% said “other reasons” (Öztürk et al., 116-126.
2012). Adedokun, A. O., & Wilson, M.-M. G. (2004). Urinary
incontinence: historical, global, and
epidemiologic perspectives. Clinics in
In their study conducted in nursing homes, geriatric medicine, 20(3), 399-407.
Cankurtaran et al. found that although 34.5% Adelmann, P. K. (2004). Prevalence and detection of
of the participants were detected to have urinary incontinence among older Medicaid
recipients. Journal of health care for the poor
urinary incontinence problem, only 34.2% of and underserved, 15(1), 99-112.
them were diagnosed with urinary Arıkan, E., Özcan, E., Bardak, A., & Ktenci, A. (2002).
incontinence (Cankurtaran et al.). In a similar Huzurevinde Yaşayan Bir Grup Kadında
vein, Kök et al. found that patients who had Üriner Enkontinans. Geriatri, 5(1), 7-10.
had urinary incontinence for 8 years did not Ateşkan, Ü., Mas, M. R., Doruk, H., & Kutlu, M.
(2000). Yaşlı Türk popülasyonunda üriner
consider urinary incontinence as a health inkontinans: Görülme sıklığı, muhtemel klinik
problem and thus did not apply to a health tipleri ve birey açısından öneminin
institution or receive any treatment due to this değerlendirilmesi. Geriatri, 3(2), 45-50.
problem (Kök, Şenel, & Akyüz, 2006). 31.2% Avery, K., Donovan, J., Peters, T. J., Shaw, C., Gotoh,
M., & Abrams, P. (2004). ICIQ: a brief and
of the elderly people participating in this robust measure for evaluating the symptoms
study had urinary incontinence, 45.6% of and impact of urinary incontinence.
them did not consult a doctor, 47% of those Neurourology and urodynamics, 23(4), 322-
who did not consult a doctor did so because of 330.
“embarrassment” and 39.2 % because they Beğer, T., & Yavuzer, H. (2012). Yaşlılık ve yaşlılık
epidemiyolojisi. Klinik gelişim, 25(3), 1-3.
found this situation normal. This result could Burti, J. S., Santos, A. M. B., Pereira, R. M. R.,
be associated with the factors that people do Zambon, J. P., & Marques, A. P. (2012).
not perceive urinary incontinence as a life- Prevalence and clinical characteristics of
threatening problem, they think that the urinary incontinence in elderly individuals of a
low income. Archives of gerontology and
problem is a natural consequence of aging, geriatrics, 54(2), e42-e46.
and it might cause worries about becoming Cankurtaran, F., Soyuer, F., & Akin, S.
socially isolated or being blamed. It could HUZUREVİNDE KALAN YAŞLILARDA
also be associated with the finding about İDRAR KAÇIRMA PROBLEMİ VE
majority of the participants’ reluctance to MOBİLİTE İLE İLİŞKİSİ. GÜmÜŞhane
Ünİversİtesİ saĞlik bİlİmlerİ dergİsİ, 594.
receive training about urinary incontinence. Çetinel, B., Özkan, B., & Can, G. (2004). ICIQ-SF
Türkçe versiyonu validasyon (geçerlilik)
Urinary incontinence, as it is a health problem çalışması. Türk Üroloji Dergisi, 30(3), 332-
whose symptoms could be decreased to 338.
Diokno, A. C., Estanol, M. V. C., Ibrahim, I. A., &
minimum with treatment, should be given Balasubramaniam, M. (2007). Prevalence of
importance particularly in FHCs, which urinary incontinence in community dwelling
provide primary preventive health services. men: a cross sectional nationwide
Diagnosis and treatment records of elderly epidemiological survey. International urology
people should be kept regularly, and and nephrology, 39(1), 129-136.
Dogan, H. (2009). A COMPARATIVE STUDY FOR
systematic monitoring should be performed EMPLOYEE JOB SATISFACTION IN
with a view to increasing quality of life of this AYDIN MUNICIPALITY AND NAZILLI
group of patients. Necessary precautions
!

!
MUNICIPALITY. Ege Academic Review, activities of daily living. Archives of

9(2). gerontology and geriatrics, 61(2), 217-223.
Dogan, Z., Yalcin, A., Atmis, V., Cengiz, O. K., Aras, Kim, H., Yoshida, H., & Suzuki, T. (2011). The effects
S., Varli, M., . . . Atli, T. (2015). The of multidimensional exercise on functional
prevalence of urinary incontinence and factors decline, urinary incontinence, and fear of
associated with urinary incontinence in falling in community-dwelling elderly women
community dwelling older Turkish people. with multiple symptoms of geriatric
European Geriatric Medicine, 6(5), 417-421. syndrome: a randomized controlled and 6-
Dursun, P., Dogan, N. U., Kolusari, A., Dogan, S., month follow-up trial. Archives of gerontology
Ugur, M. G., Komurcu, O., . . . Karaca, M. and geriatrics, 52(1), 99-105.
(2014). Differences in geographical Kocaöz, S., & Eroğlu, K. (2002). Kadınlarda stres üriner
distribution and risk factors for urinary inkontinans yaygınlığı ve bunu etkileyen
incontinence in Turkey: analysis of 6,473 faktörlerin belirlenmesi (The frequency and
women. Urologia internationalis, 92(2), 209- determination of stress urinary incontinence in
214. women). Hemşire Araştırma Derg, 4, 29-39.
Gunes, G., Gunes, A., & Pehlivan, E. (2000). Urinary Kök, G., Şenel, N., & Akyüz, A. (2006). GATA
incontinence prevalence among adult women Jinekoloji Polikliniğine başvuran 20 yaş üstü
in the area of Yesilyurt. Turgut Ozal Med Cent kadınların üriner inkontinans açısından
J (Turkish), 7, 54-57. farkındalık durumlarının değerlendirilmesi.
Hawkins, K., Pernarelli, J., Ozminkowski, R. J., Bai, M., Gülhane Tıp Dergisi, 48(3), 132-136.
Gaston, S. J., Hommer, C., . . . Yeh, C. S. Minassian, V. A., Stewart, W. F., & Wood, G. C.
(2011). The prevalence of urinary (2008). Urinary incontinence in women:
incontinence and its burden on the quality of variation in prevalence estimates and risk
life among older adults with medicare factors. Obstetrics & Gynecology, 111(2, Part
supplement insurance. Quality of life research, 1), 324-331.
20(5), 723-732. Onur, R., Deveci, S. E., Rahman, S., Sevindik, F., &
Ilçe, A., & Ayhan, F. (2011). YAŞLILARDA ÜRİNER Acik, Y. (2009). Prevalence and risk factors of
VE FEKAL İNKONTİNANSIN female urinary incontinence in eastern Turkey.
BELİRLENMESİ, YAŞAM KALİTESİNE International journal of urology, 16(6), 566-
ETKİSİ: BİLGİLENDİRME ve EĞİTİM. 569.
Anatolian Journal of Clinical Investigation, Özcan, M., & Kapucu, S. (2014). Üriner İnkontinansı
5(1). Olan Geriatrik Hastalara Hemşirelik
İnci, K., & Ergen, A. (2009). Yaşlılarda Üriner Yaklaşımı. Hacettepe Üniversitesi Hemşirelik
İnkontinans ve Farmakolojik Tedavisi. Fakültesi Dergisi, 1(2).
Turkish Journal of Geriatrics, 13(1), 59-66. Öztürk, G. Z., Toprak, D., & Basa, E. (2012). yaş üzeri
Institute, T. S. (2014). Elderly Statistics. Accessed. 1, kadınlarda üriner inkontinans sıklığı ve
from etkileyen faktörlerin değerlendirilmesi. Şişli
http://www.turkstat.gov.tr/PreHaberBultenleri. Etfal Hastanesi Tıp Bülteni, 46(4), 170-176.
do?id=21520 WHO. (2002). Active ageing: A policy framework. The
Kaşıkçı, M., Kılıç, D., Avşar, G., & Şirin, M. (2015). Aging Male, 5(1), 1-37.
Prevalence of urinary incontinence in older Yaycı, M. (2010). Dile getirilmeyen, sorgulanması
Turkish women, risk factors, and effect on gereken bir problem. üriner inkontinans.
Dirim Tıp Gazetesi, 85(1), 1-7.
Cite this article as: DEMİRBAĞ, C. B., ASLAN, G., BAKAN, A. B. (2017). Identification of
urinary incontinence in people aged 65 and over: a Turkey sample. Belitung Nursing Journal, 3(6),
636-644.

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Hartini S, et al. Belitung Nursing Journal. 2017 December;3(6):645-655


ITEM ANALYSIS AND INTERNAL CONSISTENCY OF CHILDREN’S

SLEEP HABIT QUESTIONNAIRE (CSHQ) IN INDONESIAN VERSION
Sri Hartini1*, Sunartini2, Siti E. Herini2, and Satoshi Takada3

1
School of Nursing, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
2
Department of Pediatrics, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
3
Graduate School of Health Sciences, Kobe University, Japan
*Correspondence:
Sri Hartini, BSN., M.Sc., PhD
School of Nursing, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
Jl. Farmako Sekip Yogyakarta 55281
E-mail: srihartini.psik@ugm.ac.id
Phone number: +62274-545674; Fax number: +62274-631204
Abstract
Background: The Children’s Sleep Habit Questionnaire (CSHQ) has been utilized for assessing sleep behavior problems in
children aged 4-10 years in many countries. However, a proper tool to detect of sleep behavior problems in Indonesian
children has not been proven.
Aims: The aim of our study was to test the item analysis and internal consistency of the Children’s Sleep Habit
Questionnaire (CSHQ) in Indonesian version.
Methods: We used a cross-sectional design and 305 mothers of pre- and primary school children in Yogyakarta Indonesia
participated in this study. The Indonesian version of the Children’s Sleep Habit Questionnaire was used for assessing the
sleep behavior problems in children. Internal consistency was evaluated by using the Cronbach α method. The internal
consistency was tested with Cronbach alpha coefficients. Pearson’s Product Moment was completed to estimate the
correlation between all items of CSHQ with Subscales and total scores of CSHQ.
Results: Internal consistency of all items of the Children’s Sleep Habit Questionnaire was 0.80. Internal consistency of
subscales ranged from 0.42 (parasomnias) to 0.66 (night wakening). 31 of 33 items had significant positive correlation with
total score of Children’s Sleep Habit Questionnaire. Inter-subscales with the highest correlation were sleep onset delay with
parasomnias, parasomnias with sleeps disordered breathing, and sleep disorder breathing with night waking.
Conclusions: The Indonesian version of the Children’s Sleep Habit Questionnaire is suitable for screening sleep behavior
problems in Indonesian children aged 4-10 years.
Keywords: Item analysis, Internal consistency Children’s Sleep Habit Questionnaire, Indonesia, Sleep Behavior Problems
INTRODUCTION
The prevalence of sleep problems was duration, sleep anxiety, night waking,
estimated approximately 35 to 40% in school- parasomnias, sleep disordered breathing, and
age-children (Fricke-Oerkermann et al., daytime sleepiness (Owens, Spirito, &
2007). One recent study mentioned that 37- McGuinn, 2000). Archbold and team reported
38% of Indonesian adolescents were suffering that the USA children had sleep behavioral
from sleep problems in both urban and rural problems such as habitual snoring (17%),
areas (Sofyani, Supriatmo, & Lubis, 2014). sleep-disordered breathing (11%), insomnia
Sleep behavior problems in children consists (41%), and excessive daytime sleepiness
of bedtime resistance, sleep onset delay, sleep (14%) (Archbold, Pituch, Panahi, & Chervin,
BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017 645

Hartini, S., Sunartini., Herini. S. E., Takada S. (2017)!
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2002). While in Japan, delay of sleep phase, samples. The internal consistency of CSHQ
reduction of sleep length, and increasing was reported as 0.68 for community samples
daytime sleepiness were found as sleep and 0.78 for clinical samples. The test-retest
problems in some seventh grade children reliability of the subscales ranged from 0.62
(Shinkoda, Matsumoto, Park, & Nagashima, to 0.79. The validity of the CSHQ was
2000). Older children were also reported to evaluated by comparing total scores and
have more delayed sleep onset time and subscale scores of community and clinical
increased daytime sleepiness (Goldman, samples. The total scores and subscale scores
Richdale, Clemons, & Malow, 2012; Sadeh, in the clinical samples were significantly
Raviv, & Gruber, 2000). higher compared to the community samples.
The sensitivity and specificity of the CSHQ
There are many methods to measure the sleep were reported at 0.80 and 0.72, respectively
behavior problems in children. The Children’s (Owens et al., 2000). Internal consistency of
Sleep Habit Questionnaire (CSHQ) is one subscales score of CSHQ were reported in
method that is commonly used for screening Chinese children (0.44 to 0.63), in Portuguese
of sleep behavior problems in school-aged (0.44 to 0.74), and in Dutch children (0.47 to
children approximately 4 to 10 year-old based 0.68) (Z. Liu et al., 2014; Waumans et al.,
on the International Classification of Sleep 2010). The test-retest reliability was also
Disorder Pediatric Diagnoses (American investigated in Chinese, Dutch, and German
Academy of Sleep, 2005). The CSHQ, children (Chinese children: 0.54 to 0.76,
developed by Judith Owens, consists of a 33- Dutch: 0.47 to 0.93, and German: 0.46-0.81)
item, parent-rated questionnaire for assessing (Z. Liu et al., 2014; Schlarb et al., 2010;
the behaviors associated with common Waumans et al., 2010).
pediatric sleep difficulties (Owens et al.,
2000). The CSHQ consists of eight subscales The numbers of Indonesian children who
which are associated with common sleep suffer from sleep problems have nearly
behavior problems in children: bedtime identical scores with the sample populations
resistance, sleep onset delay, sleep duration, of children in many countries. It is necessary
sleep anxiety, night waking, parasomnias, to provide a proper tool for assessing the sleep
sleep disordered breathing, and daytime problem in Indonesian children. The validity
sleepiness. The CSHQ was developed in 2000 and reliability of CSHQ have good internal
in the USA, and has been translated, adapted, consistency in the USA and other countries;
and culturally validated to several societies, however it has not been proven in Indonesian
such as Portugal, China, Germany, and children. We believe that the investigation of
Netherlands (Z. Liu, Wang, Tang, Wen, & Li, item analysis of CSHQ in Indonesian version
2014; Loureiro, Pinto, Pinto, Pinto, & Paiva, will provide beneficial results contributing to
2013; Schlarb, Schwerdtle, & Hautzinger, data concerning the global internal
2010; Waumans et al., 2010). Several studies consistency of CSHQ, particularly in
were conducted in the USA, Australia, India, Indonesia. The aim of this study was to
Japan, and Canada to evaluate sleep in larger investigate the item analysis and internal
populations by using CSHQ (Byars, consistency of CSHQ in Indonesian version.
Yeomans-Maldonado, & Noll, 2011;
Hoffmire, Magyar, Connolly, Fernandez, &
van Wijngaarden, 2014; Iwadare et al., 2013; METHODS
Joseph & Mathew; X. Liu, Liu, Owens, & Study design and participants
Kaplan, 2005; Markovich, Gendron, & We used a cross-sectional design in this study.
Corkum, 2015; Price, Wake, Ukoumunne, & The participants were the mothers of children
Hiscock, 2012). aged 4-10 years old attending in kindergarten
and primary school. Three hundred and five
During the process of developing this scale, mothers were enrolled in this study.
Owens et al. assessed the CSHQ validity and Participants include 148 (48.5) boys and 157
reliability in the community and clinical (51.5) girls aged 4-10 years-olds. The mean of
samples, and performed the test-retest age was 7.07±2.36 for children and 35.8±7.40
reliability measurement in the community for mothers (Table 1). 89.5% of mothers were

Muslim, 9.2% were non-Muslim, and 1.3% no undergraduate, and 0.7% did not disclose
answer. Most of mothers had obtained an information). The parents’ occupations were
education level past senior high school (2.3 % as private employees (80.3 %), government
primary school; 22.3% junior high school; employees (10.2 %), seller (6.6 %), and owner
55.4% senior high school; 19.3% (small shop, 2 %).
Table 1 Participants Background (n=305)

Participants Mean±SD n (%)
1. Children
• Age 7.04±2.36
• Sex
Male 148(48.5)
Female 157(51.5)
2. Mothers
Aged 35.8±7.40
Educational background
• Primary school 7(2.3)
• Junior high school 68(22.3)
• Senior high school 169(55.4)
• Undergraduate level 59(19.3)
• No answer 2(0.7)
Occupation
• Private employee 245(80.3)
• Government employee 31(10.2)
• Seller 20(6.6)
• Owner Shop 3(1.0)
3. Religion
• Muslim 273(89.5)
• Non-Muslim 28(9.2)
SD, standard deviation
Instrument questionnaire was translated from English into

The Children Sleep Habit Questionnaire Indonesian and then re-translated by another
(CSHQ) was utilized to assess sleep behavior linguist back into English.
problems in children aged 4-10 years. CSHQ
was developed by Owens based on the Ethical considerations and procedures
International Classification of Sleep Disorders The study was conducted in Yogyakarta from
pediatric diagnoses (Owens et al., 2000). It August 2014 to August 2015. The study was
consists of 33 items, which are divided into 8 approved by the Medical and Health Research
subscales (i.e. bedtime resistance, sleep onset Ethics Committee (MHREC), Faculty of
delay, sleep duration, sleep anxiety, night Medicine, Universitas Gadjah Mada and
waking, parasomnias, sleep disordered granted permission by Local government of
breathing, and daytime sleepiness). We were Yogyakarta Province. The study was
asking the parents to recall sleep behaviors of conducted in accordance with the Declaration
their children in past weeks. Items were of Helsinki 2008. The questionnaires and
assessed on a three-point scale: usually, if the written informed consent were distributed to
sleep behavior occurred 5-7 times a week; the participants. We provided information on
sometimes, for 2-4 times a week; and rarely, how to fill in the forms and the mothers of the
for 0-1 time a week (Owens et al., 2000). children completed the questionnaires. After
There were 6 reversed items, which are scored the forms were filled, the questionnaires were
in the opposite direction. We were granted checked for misplaced information.
permission from the original author both to
utilize and to translate the questionnaire. The

!
Statistical analysis RESULTS

Statistical analysis was performed using SPSS Internal consistency of CSHQ
version 19.0 (IBM SPSS, IBM, New York, Internal consistency of total of CSHQ was
USA). Descriptive analyses were used to 0.80. Internal consistency of subscales of
calculate participants’ characteristics. The CSHQ ranged from 0.42 (parasomnias) to
internal consistency was tested with Cronbach 0.66 (night wakening). The other subscales
alpha coefficients. Pearson’s Product Moment were relatively moderate (bedtime resistance
was completed to estimate the correlation 0.45, sleep duration 0.57, sleep anxiety 0.43,
between all items of CSHQ with Subscales sleep disordered breathing 0.56, and daytime
and total scores of CSHQ. sleepiness 0.49). Table 2 shows the internal
consistency of CSHQ.
Table 2 Internal consistency of the Children’s Sleep Habit Questionnaire (n=305)

CSHQ Alpha
Total of CSHQ 0.80
Bedtime resistance 0.45
Sleep onset delay NA
Sleep duration 0.57
Sleep anxiety 0.43
Night wakening 0.66
Parasomnias 0.42
Sleep disordered breathing 0.56
Daytime sleepiness 0.49
CSHQ, Children Sleep Habit Questionnaire; NA, Not analyzed
Validity of CSHQ snored loudly). There was no significant

Correlation between items with total score correlation between falls asleep in 20 minutes
of CSHQ (subscale of sleep onset delay) with total score
Most of CSHQ items (31 of 33 items) have of CSHQ. The range correlation of items in
significant positive correlation with total score the subscale of bedtime resistance, sleep onset
of CSHQ. Correlation between items with delay, sleep duration, sleep anxiety, night
total score of CSHQ ranged from 0.11 (falls wakening, parasomnias, sleep disordered
asleep in 20 minutes) to 0.82 (goes to bed at breathing, and daytime sleepiness with total
same time, afraid of sleeping alone, sleeps the score of CSHQ were 0.13-0.82, 0.1, 0.22-
right amount, sleeps same amount each day, 0.82, 0.26-0.82, 0.31-0.82, 0.16-0.82, 0.48-
afraid of sleeping in the dark, awakes once 0.82, and 0.13-0.33, respectively (Table 3).
during night, alarmed by scare dream, and
Table 3 Correlation between items with total score of Children’s Sleep Habit Questionnaire (n=305)
Items of CSHQ R Items of CSHQ R
Bedtime resistance Parasomnias
Goes to bed at same time (1) 0.82*** Wets the bed at night (12) 0.18**
Falls asleep in own bed (3) 0.15** Talks during sleep (13) 0.30***
Falls asleep in other’s bed (4) 0.13* Restless and moves a lot (14) 0.48***
Needs parent in room to sleep (5) 0.26*** Sleepwalks (15) 0.16**
Struggles at bedtime (6) 0.29*** Grinds teeth during sleep (17) 0.82***
Afraid of sleeping alone (8) 0.82*** Awakens screaming, sweating (22) 0.48***
Alarmed by scary dream (23) 0.82***
Sleep onset delay
Falls asleep in 20 minutes (2) 0.10
Sleep duration Sleep Disordered Breathing
Sleeps too little (9) 0.22*** Snores loudly (18) 0.82***
Sleeps the right amount (10) 0.82*** Stops breathing (19) 0.48***
Sleeps same amount each day (11) 0.82*** Snorts and gasps (20) 0.82***
Sleep anxiety Daytime Sleepiness
Needs parent in room to sleep (5) 0.26*** Wakes by himself (26) 0.22***

Items of CSHQ R Items of CSHQ R

Afraid of sleeping in the dark (7) 0.82*** Wakes up in negative mood (27) 0.24***
Afraid of sleeping alone (8) 0.36*** Others wake child (28) 0.33***
Trouble sleeping away (21) 0.44*** Hard time getting out of bed (29) 0.15*
Takes long time to be alert (30) 0.30***
Night wakening Seems tired (31) 0.33***
Moves to other’s bed in night (16) 0.31*** Watching TV (32) 0.13*
Awakes once during night (24) 0.82*** Riding in car (33) 0.28***
Awakes more than once (25) 0.82***
*, P<0.05; **, P<0.01; ***, P<0.001; CSHQ, Children Sleep Habit Questionnaire
Correlation between items with subscales subscales of CSHQ. The highest score item
of CSHQ correlated with the bedtime resistance scale
The items of CSHQ are divided into 8 was goes to bed at same time and afraid if
subscales (i.e. bedtime resistance, sleep onset sleeping alone, correlated with the sleep
delay, sleep duration, sleep anxiety, night duration was sleeps the right amount,
wakening, parasomnias, sleep disordered correlated with the sleep anxiety was afraid of
breathing, and daytime sleepiness). sleeping alone, correlated with the night
Correlation coefficients between items with wakening was awakes once during night,
bedtime resistance, sleep onset delay, sleep correlated with the parasomnias was restless
duration, sleep anxiety, night wakening, and moves a lot and awakens screaming and
parasomnias, sleep disordered breathing, and sweating, correlated with the sleep disordered
daytime sleepiness were 0.43-0.67, 1, 0.51- breathing was snores and gasps, and
0.87, 0.43-0.77, 0.47-0.91, 0.24-0.83, 0.71- correlated with the daytime sleepiness was
0.87, and 0.14-0.62, respectively). Table 4 sleepiness during watching TV.
shows correlation between items with
Table 4 Correlation between items with subscales of the Children’s Sleep Habit Questionnaire (n=305)
Items Subscales R
Goes to bed at same time (1) Bedtime resistance 0.67***
Falls asleep in own bed (3) Bedtime resistance 0.43***
Falls asleep in other’s bed (4) Bedtime resistance 0.53***
Needs parent in room to sleep (5) Bedtime resistance 0.45***
Struggles at bedtime (6) Bedtime resistance 0.45***
Afraid of sleeping alone (8) Bedtime resistance 0.67***
Falls asleep in 20 minutes (2) Sleep onset delay 1***
Sleeps too little (9) Sleep duration 0.51***
Sleeps the right amount (10) Sleep duration 0.87***
Sleeps same amount each day (11) Sleep duration 0.86***
Needs parent in room to sleep (5) Sleep anxiety 0.43***
Afraid of sleeping in the dark (7) Sleep anxiety 0.53***
Afraid of sleeping alone (8) Sleep anxiety 0.77***
Trouble sleeping away (21) Sleep anxiety 0.67***
Moves to other’s bed in night (16) Night wakening 0.47***
Awakes once during night (24) Night wakening 0.91***
Awakes more than once (25) Night wakening 0.90***
Wets the bed at night (12) Parasomnias 0.27***
Talks during sleep (13) Parasomnias 0.55***
Restless and moves a lot (14) Parasomnias 0.83***
Sleepwalks (15) Parasomnias 0.24***
Grinds teeth during sleep (17) Parasomnias 0.65***
Awakens screaming, sweating (22) Parasomnias 0.83***
Alarmed by scary dream (23) Parasomnias 0.65***
Snores loudly (18) Sleep disordered breathing 0.86***
Stops breathing (19) Sleep disordered breathing 0.71***
Snorts and gasps (20) Sleep disordered breathing 0.87***
Wakes by himself (26) Daytime sleepiness 0.48***

!
Items Subscales R
Wakes up in negative mood (27) Daytime sleepiness 0.36***
Others wake child (28) Daytime sleepiness 0.54***
Hard time getting out of bed (29) Daytime sleepiness 0.14*
Takes long time to be alert (30) Daytime sleepiness 0.49***
Seems tired (31) Daytime sleepiness 0.47***
Watching TV (32) Daytime sleepiness 0.62**:
Riding in car (33) Daytime sleepiness 0.61***
Correlation between subscales of CSHQ there was no significant correlation with total
with total scores of CSHQ score of CSHQ. Correlation between
All of subscales of CSHQ were positive subscales with total of CSHQ ranged from
correlated with total score of CSHQ (Table 5). 0.49 to 0.85 (except sleep onset delay).
There was one item (sleep onset delay) where
Table 5 Correlation between subscales with total score of the Children’s Sleep Habit Questionnaire (n=305)
Subscales of CSHQ R
Bedtime resistance 0.73***
Sleep onset delay 0.10
Sleep duration 0.82***
Sleep anxiety 0.72***
Night wakening 0.85***
Parasomnias 0.78***
Sleep disordered breathing 0.85***
Daytime sleepiness 0.49***
Inter-subscales correlation disordered breathing and sleep disorder

Correlations among subscales with the highest breathing with night wakening (Table 6).
correlation were parasomnias with sleep
Table 6 Correlation among CSHQ subscales

Bedtime Sleep Parasomnias SDB Night Daytime Sleep Sleep
resistance duration wakening sleepiness anxiety onset
delay
Bedtime 1 0.61 0.45 0.57 0.66 0.11 0.50 0.01
resistance
Sleep duration 0.61 1 0.63 0.79 0.80 0.13 0.57 0.05
Parasomnias 0.45 0.63 1 0.90 0.69 0.25 0.53 0.02
SDB 0.57 0.79 0.90 1 0.84 0.23 0.59 0.01
Night wakening 0.66 0.80 0.69 0.84 1 0.21 0.58 0.01
Daytime 0.11 0.13 0.25 0.23 0.21 1 0.17 -0.05
sleepiness
Sleep anxiety 0.50 0.57 0.53 0.59 0.58 0.17 1 0.07
Sleep onset delay 0.01 0.05 0.02 0.01 0.01 -0.05 0.07 1
CSHQ, Children Sleep Habit Questionnaire. SDB, Sleep Disordered Breathing
DISCUSSION numbers with others countries (Sofyani et al.,

The present study is the first report regarding 2014). Proper scale measurements for
item analysis and internal consistency of the assessing sleep behaviors problems has not
Indonesian version of Children’s Sleep Habit been proven in Indonesian children. The
Questionnaire (CSHQ). This finding is CSHQ is the International scale to assess
important, because the large number of sleep behaviors problems in children aged 4-
children who are suffering from sleep 10 years based on the International
problems in Indonesia parallels similarly Classification of Sleep Disorders pediatric

diagnoses. Several studies on its validity and most influential factors for sleep disturbances
use for assessing sleep behaviors problem in Indonesian children (urban and suburban
have been conducted in USA, Portuguese, in area) were environmental noise and
Dutch, China, Australia, and Canada (Z. Liu et consuming beverages that contain caffeine
al., 2014; Loureiro et al., 2013; Markovich et (Sofyani et al., 2014). Mindell, Sadeh,
al., 2015; Owens et al., 2000; Price et al., Kohyama & How reported that children's bed
2012; Waumans et al., 2010). share and room share were higher in Asian
region (Asian region: China, Hong Kong,
We found that the internal consistency of total India, Indonesia, Japan, Korea, Singapore,
score of CSHQ was 0.80, with subscales Malaysia, Philippines, Taiwan, Thailand and
ranged from 0.42 (parasomnias) to 0.66 (night Vietnam, bed share: 64.7%, room share:
waking). These findings are in acccordance 87.5%) compared than Caucasian region
with those studies from USA (Cronbach alpha (Caucasian region: US, Australia, Canada,
ranged from 0.36-0.70), Netherlands New Zeeland, and UK, bed share: 11.8%,
(Cronbach alpha ranged from 0.47-0.68), room share: 22%). Furthermore, outcome
China (Cronbach alpha ranged from 0.42- showed that children who sleep in a separate
0.73), and Portugal (Cronbach alpha ranged room obtain more sleep, wake less at night,
from 0.54-0.72) (Z. Liu et al., 2014; Loureiro have less difficulty at bedtime, fall asleep
et al., 2013; Owens et al., 2000; Waumans et faster, and are perceived as having fewer
al., 2010). Previous study also reported sleep problems (Mindell, Sadeh, Kohyama, &
similar findings on internal consistency of How, 2010).
total of CSHQ in China (0.80) and Israel
(0.81). The subscales with the highest internal We found that the highest correlations of
consistency in this study were sleep duration, inter-subscales were parasomnias with sleep
night waking, sleep disordered breathing, and disordered breathing, and sleep disorder
daytime sleepiness. This study replicates the breathing with night waking. This result was
highest measures of internal consistency in similar with the study from Canada that
USA (bedtime resistance, sleep duration, and reported the highest correlation inter-
daytime sleepiness), China (bedtime subscales were sleep disordered breathing
resistance, sleep duration, night wakening, with night waking (Markovich et al., 2015).
and daytime sleepiness), Netherland (bedtime However, compared with the study from USA
resistance, sleep duration, and daytime (Owens et al., 2000). There were differences
sleepiness) and Portugal (bedtime resistance, in the highest correlation inter-subscales
sleep duration, night wakening, and daytime (bedtime resistance with sleep anxiety, sleep
sleepiness) (Z. Liu et al., 2014; Loureiro et al., duration with daytime sleepiness, and daytime
2013; Owens et al., 2000; Tzchishinsky, Lufi, sleepiness with sleep onset delay). This
& Shochat, 2008; Waumans et al., 2010). finding may be due to the differences of
Regarding the internal consistency coefficient children’s age and cultural background
of total CSHQ, it is somewhat higher in between Indonesia and USA. In Indonesian
Indonesia compared to those study from USA society, people commonly live together with
(0.68), Chinese (0.73) and 0.77 in Portugal their extended families. In some families,
children (Z. Liu et al., 2014; Loureiro et al., aunt, uncles, and caregiver live in the same
2013; Owens et al., 2000). The differences in house. Moreover most of the influential
reliability of total CSHQ could possibly be factors for sleep disturbances in Indonesian
explained by age and cultural background children were environmental noise and
differences. There were three sleep problems consuming beverage that contain caffeine
in Indonesian children in urban areas: disorder (Sofyani et al., 2014). Correlation between
of initiation and maintaining sleep, disorder of items, subscales with total score of CSHQ
excessive somnolence, and sleep were found that all items (except: falls asleep
hyperhidrosis (Sofyani et al., 2014). While in 20 minutes) and 7 subscales had strong,
sleep problems such as bedtime resistance, positive correlation with total score of CSHQ.
sleep onset delay, and nighttime awaking These finding are in accordance with the
were revealed among elementary school study from China that was reported by Liu et
students in USA (Surani et al., 2015). The al. (2014), demonstrating that the eight

!
subscales of CSHQ are statistically clinically referred for evaluation of insomnia.

acceptable. Several limitations in this study Sleep Medicine, 12(9), 898-905.
Fricke-Oerkermann, L., Plück, J., Schredl, M., Heinz,
should be mentioned. The studied area was K., Mitschke, A., Wiater, A., & Lehmkuhl, G.
limited in the Java Island. The present study (2007). Prevalence and course of sleep
was conducted in the central part of Java problems in childhood. Sleep, 30(10), 1371-
Island, because the culture of this area is 1377.
Goldman, S. E., Richdale, A. L., Clemons, T., &
prevalent in Indonesia. More than 100 million Malow, B. A. (2012). Parental sleep concerns
people live on Java Island (Indonesia, 2012). in autism spectrum disorders: variations from
and they share the same history and Javanese childhood to adolescence. Journal of autism
culture. People in this area speak both and developmental disorders, 42(4), 531-538.
Indonesian and Javanese (in private life). We Hoffmire, C. A., Magyar, C. I., Connolly, H. V.,
Fernandez, I. D., & van Wijngaarden, E.
consider the people who live in this area to be (2014). High prevalence of sleep disorders and
representative of the general Indonesian associated comorbidities in a community
population. In addition socio-economic sample of children with Down syndrome.
situation of parents was not measured in this Journal of clinical sleep medicine: JCSM:
official publication of the American Academy
study. Moreover, the test retest to conduct of Sleep Medicine, 10(4), 411.
reliability was not conducted in this present Indonesia, S. (2012). Statistical yearbook of Indonesia
study. 2015.
Iwadare, Y., Kamei, Y., Oiji, A., Doi, Y., Usami, M.,
Kodaira, M., . . . Saito, K. (2013). Study of the
sleep patterns, sleep habits and sleep problems
CONCLUSION in Japanese elementary school children using
The Indonesian version of the Child Sleep the CHSQ-J. Kitasata Med J, 43, 31-37.
Habit Questionnaire (CSHQ) seems to have Joseph, T. J., & Mathew, M. C. Sleep Behaviour and
adequate internal consistency. Using Product Academic Grade In School-Going Adolescent
ChildrenIn A Rural Area.
Moment Correlation, seven of eight subscales Liu, X., Liu, L., Owens, J. A., & Kaplan, D. L. (2005).
were found with high and positive correlation Sleep patterns and sleep problems among
with total score of CSHQ. The Indonesian schoolchildren in the United States and China.
version of the CSHQ is therefore suitable for Pediatrics, 115(Supplement 1), 241-249.
screening sleep behavior problems in Liu, Z., Wang, G., Tang, H., Wen, F., & Li, N. (2014).
Reliability and validity of the Children's Sleep
Indonesian children aged 4-10 years. Habits Questionnaire in preschool‐aged
Chinese children. Sleep and Biological
ACKNOWLEDGEMENTS Rhythms, 12(3), 187-193.
We would like to thank to Dr. Judith. A. Owens, MD. Loureiro, H. C., Pinto, T. R., Pinto, J. C., Pinto, H. R., &
MPH for granting permission and translate the Child Paiva, T. (2013). Validation of the children
Sleep Habit Questionnaire into Indonesian. The authors sleep habits questionnaire and the sleep self
would also like to acknowledge mothers of the children report for Portuguese children. Sleep Science,
for their contribution to the present study 6(4), 151-158.
Markovich, A. N., Gendron, M. A., & Corkum, P. V.
CONFLICT OF INTEREST (2015). Validating the Children’s Sleep Habits
The authors of this paper have no conflicts of interest to Questionnaire against polysomnography and
report. All authors have materially participated in the actigraphy in school-aged children. Frontiers
present research and/or article preparation. in psychiatry, 5, 188.
Mindell, J. A., Sadeh, A., Kohyama, J., & How, T. H.
(2010). Parental behaviors and sleep outcomes
in infants and toddlers: a cross-cultural
REFERENCES
comparison. Sleep Medicine, 11(4), 393-399.
American Academy of Sleep, M. (2005). International
Owens, J. A., Spirito, A., & McGuinn, M. (2000). The
classification of sleep disorders. Diagnostic
Children's Sleep Habits Questionnaire
and coding manual, 148-152.
(CSHQ): psychometric properties of a survey
Archbold, K. H., Pituch, K. J., Panahi, P., & Chervin, R.
instrument for school-aged children. Sleep-
D. (2002). Symptoms of sleep disturbances
new york-, 23(8), 1043-1052.
among children at two general pediatric
Price, A. M. H., Wake, M., Ukoumunne, O. C., &
clinics. The Journal of pediatrics, 140(1), 97-
Hiscock, H. (2012). Outcomes at six years of
102.
age for children with infant sleep problems:
Byars, K. C., Yeomans-Maldonado, G., & Noll, J. G.
longitudinal community-based study. Sleep
(2011). Parental functioning and pediatric
Medicine, 13(8), 991-998.
sleep disturbance: an examination of factors
Sadeh, A., Raviv, A., & Gruber, R. (2000). Sleep
associated with parenting stress in children
patterns and sleep disruptions in school-age

children. Developmental psychology, 36(3), (2015). Sleep habits of elementary and middle
291. school children in South Texas. Sleep
Schlarb, A. A., Schwerdtle, B., & Hautzinger, M. disorders, 2015.
(2010). Validation and psychometric Tzchishinsky, O., Lufi, D., & Shochat, T. (2008).
properties of the German version of the Reliability of the Chil-dren’s Sleep Habits
Children’s Sleep Habits Questionnaire Questionnaire Hebrew Translation and Cross
(CSHQ-DE). Somnologie-Schlafforschung Cultural Comparison of the Psychometric
und Schlafmedizin, 14(4), 260-266. Properties. Sleep Diagnosis and Therapy, 3(3),
Shinkoda, H., Matsumoto, K., Park, Y. M., & 30-34.
Nagashima, H. (2000). Sleep–wake habits of Waumans, R. C., Terwee, C. B., Van den Berg, G.,
schoolchildren according to grade. Psychiatry Knol, D. L., Van Litsenburg, R. R. L., &
and clinical neurosciences, 54(3), 287-289. Gemke, R. J. B. J. (2010). Sleep and sleep
Sofyani, S., Supriatmo, S., & Lubis, I. Z. (2014). disturbance in children: Reliability and
Comparing sleep disorders in urban and validity of the Dutch version of the Child
suburban adolescents. Paediatr Indones, Sleep Habits Questionnaire. Sleep, 33(6), 841-
54(5), 299-304. 845.
Surani, S., Hesselbacher, S., Surani, S., Sadasiva, S.,
Surani, Z., Surani, S. S., . . . Subramanian, S.
----------------------------------------------------------------------------------------------------------------
CHILDREN’S SLEEP HABIT QUESTIONNAIRE (CSHQ)
KEBIASAAN TIDUR ANAK

(Anak Usia Prasekolah dan Usia Sekolah)
A. Identitas Anak
Nama :
Jenis kelamin : □ Laki-laki □ Perempuan
Tanggal lahir :
Tanggal pengisian kuesioner :
Riwayat kejang : □ Ya □ Tidak
Berat lahir (kg) :
B. Identitas Ibu
Nama :
Usia :
Usia pada saat melahirkan :
Tingkat pendidikan : □ SMP □ SMA □ PT
Pernyataan berikut adalah tentang kebiasaan tidur anak dan kemungkinan kesulitan tidur anak anda. Pikirkan
selama satu minggu terakhir tentang kebiasaan anak anda ketika menjawab pertanyaan ini. Jawaban "Selalu" jika
terjadi 5 kali atau lebih dalam seminggu; Jawaban "kadang-kadang" jika terjadi 2-4 kali dalam seminggu;
Jawaban "Jarang atau tidak pernah" jika terjadi 0-1 kali dalam seminggu. Silahkan mengindikasikan, apakah
anak anda mengalami gangguan tidur atau tidak dengan memberi tanda centang [√] pada kolom "Ya" atau "Tidak"
atau "Tidak dapat diterapkan"
I. Waktu tidur
Tulislah waktu tidur anak: ___________________________
Selalu Kadang Jarang Apakah ada
(5-7) -kadang (2-4) (0-1) masalah ?
Item Ya Tidak Tidak dapat
diterap kan
Anak pergi ke tempat tidur pada waktu yang sama setiap

malam ® (1)
Anak tertidur dalam 20 menit setelah berada tempat
tidur ® (2)
Anak tertidur di tempat tidur sendiri ® (3)
Anak tertidur di tempat tidur orang tua atau saudara (4)
Anak membutuhkan orang tua di ruangan untuk tertidur (5)
Anak berontak pada waktu tidur (menangis,
menolak berada di tempat tidur dll) (6)
Anak takut tidur dalam kegelapan (7)
Anak takut tidur sendiri (8)

!
II. Perilaku tidur

Tulis kebiasaan jumlah tidur anak anda setiap hari : ……. Jam dan …… menit (dengan menggabungkan tidur
malam dan siang)
Selalu Kadang Jaran g Apakah ada masalah ?

Item (5-7) -kadang (0-1) Ya Tida Tidak
(2-4) k terkaji
Anak tidur terlalu sedikit (9)
Anak tidur dalam jumlah yang cukup ® (10)
Anak tidur dalam jumlah yang sama setiap hari ® (11)
Anak mengompol pada malam hari (12)
Anak berbicara pada saat tidur (13)
Anak gelisah dan banyak bergerak selama tidur (14)
Anak berjalan saat tidur (15)
Anak berpindah ke tempat tidur orang lain selama
malam hari (orang tua, kakak, adik dll) (16)
Anak menggeretakkan gigi pada saat tidur (17)
Anak mendengkur keras (18)
Anak kelihatan berhenti bernapas selama tidur (19)
Anak mendengus dan atau terengah-engah pada
saat tidur (20)
Anak memiliki kesulitan tidur jauh dari rumah
(mengunjungi kerabat, liburan) (21)
Anak terbangun pada malam da n menjerit,
berkeringat dan minta di hibur (22)
Anak terbangun dan khawatir dengan mimpi yang
menakutkan (23)
III. Bangun pada malam hari
Selalu (0-1) Kadang Jarang Apakah ada

-kadang (2- (0-1) masalah ?
Item 4) Ya Tidak Tidak
terkaji
Anak terbangun sekali dalam semalam (24)
Anak terbangun lebih dari sekali dalam semalam (25)
IV. Bangun pagi
Tuliskan waktu terhadap kebiasaan bangun anak di pagi hari: _____________________

Selalu Kadang Jarang Apakah ada masalah ?
(5-7) -kadang (0-1)
Item
(2-4) Ya Tidak Tidak
terkaji
Anak bangun sendiri ® (26)
Anak bangun dalam suasana hati yang negative (27)
Orang lain atau saudara membangunkan anak (28)
Anak memiliki kesulitan beranjak dari tempat tidur
di pagi hari (29)
Anak membutuhkan waktu yang lama untuk waspada di pagi hari
(30)
V. Kantuk di siang hari
Selalu Kadang Jarang Apakah ada masalah ?

(5-7) -kadang (0-1)
Item
(2-4) Ya Tidak Tidak
terkaji
Anak tidur siang
Anak tiba-tiba tertidur di tengah kegiatan / perilaku aktif
Anak kelihatan lelah (31)

Selama minggu terakhir, anak anda terlihat sangat mengantuk atau tertidur selama di bawah ini (Berilah centang)
Tidak Sangat Tertidur (3)
mengantuk mengantu
(1) k (2)
Menonton TV (32)
Perjalanan dengan mobil (33)
Cite this article as: Hartini, S., Sunartini., Herini. S. E., Takada S. (2017). Item analysis and internal
consistency of children’s sleep habit questionnaire (CSHQ) in Indonesian version. Belitung Nursing
Journal, 3(6), 645-655.

Purba JM. Belitung Nursing Journal. 2017 December;3(6):656-661
Accepted: 14 December 2017

CAREGIVERS’ NEEDS IN CARING FOR RELATIVES WITH

SCHIZOPHRENIA IN MEDAN INDONESIA: A PHENOMENOLOGICAL
STUDY
Jenny Marlindawani Purba*
Department of Community and Psychiatric Nursing, Faculty of Nursing, University of Sumatera Utara, Medan, Indonesia
*Correspondence:
Jenny Marlindawani Purba, S.Kp, MNS, Ph.D
Department of Community and Psychiatric Nursing, Faculty of Nursing
University of Sumatera Utara, Medan, Indonesia
E-mail: Jhuan_702@hotmail.com
Abstract
Background: A caregiver is a primary nurse and has a major role in providing care for people with schizophrenia. Caring
for those with schizophrenia for a long period of time is a challenge for families, especially caregivers. Various needs ought
to be studied by nurses to assist caregivers in providing optimal care for family members who experience schizophrenia.
Objective: This qualitative study aims to explore the needs of caregivers in treating schizophrenia at home.
Methods: The method used in this study is the method of purposive sampling with the number of participants as many as 10
people with criteria: 1) have family members diagnosed with schizophrenia, 2) directly involved in home care patients, 3)
caring for schizophrenia for more than one year, 4) willing to be a participant by signing informed consent, 4) being able to
identify what is needed in treating schizophrenia. Colaizzi is used to analyze interview data.
Results: The results of the study found four themes of caregiver needs in caring for schizophrenia patients at home, namely:
1) seeking information about schizophrenia, 2) sought schizophrenic relatives’ recovery, 3) looking for appropriate
rehabilitation for relatives with schizophrenias, and 4) utilizing mental health facilities.
Conclusions: It is expected that nurses have the knowledge and skills in identifying and helping families, especially
caregivers, to meet unmet needs so they can optimize home care.
Keywords: Need, Caregiver, Schizophrenia
INTRODUCTION
Schizophrenia is a persistent and serious Therefore it takes an active role of the family,
neurobiological disorder of the brain, a especially caregiver to treat schizophrenia at
clinical syndrome that can result in damage to home. Caring for a family member with
life both individually, family and community disabilities such as schizophrenia is a major
(Stuart, 2014). Schizophrenia is also a chronic role for women in Asian countries such as
disease disorder that is quite high in Japan, Taiwan, Malaysia, Philippines and
prevalence. The prevalence of schizophrenia Indonesia (Talwar & Matheiken, 2010).
in the world from the median of schizophrenia
is 4.6 / 1,000 for the prevalence of points, 4.0 A caregiver or other family member is
/ 1,000 for lifetime prevalence and 7.2 / 1,000 important in the healing process for
for morality risk. schizophrenic patients. In the course of
treating patients, due to this disorder being
As a chronic illness of mental illness, the chronic or relapse, a caregiver must have
treatment of schizophrenia takes a long time. sufficient knowledge in treating patients with

!
Purba, J. M. (2017)!
schizophrenia and is able to recognize the to participate by signing informed consent,

needs that are met in caring for patients with and 4) able to identify the things needed in
schizophrenia (Rafiyah, 2011). treating schizophrenia.
The results of Agiananda (2006) study Data Collection

indicates that the unmet needs are the need for Researchers used in-depth interviews using
improved health (changes or improvements in interview guides to gather information. The
symptoms of schizophrenia), the need for interview was conducted for approximately 60
mental health services (group meetings and minutes for each meeting. The probing
vocational training, sharing groups for technique is used to ask questions and record
caregiver, cheap /generic, continuous care, interview results. After that, the researcher
friendly and friendly service from health transcribed the interview result. Furthermore,
workers at the site), and the need for active the researchers grouped the data and narrated
action from health workers (information about it into the form of themes, sub themes and
schizophrenia, the involvement of patients in main categories.
treatment planning, therapists plan therapy
according to the needs of the patient and Instrument
always evaluate the results of the treatment, The instrument used in this study is the
and help bridge the family’s issues related to researcher himself. The interview guide
patient care) (Agiananda, 2006). consists of 10 open-ended questions
developed by the researcher himself and has
Therefore, this study needs to be done to been validated by three psychiatrists.
explore what needs should be met by Triangulation is used to check the validity of
caregivers in treating schizophrenia at home. research data.
Nurses does not only focus on schizophrenia
alone, but also pays special attention to the Data Analysis
needs of the caregivers, so nurses can assist Researchers used the Colaizzi method (Polit
caregivers in meeting the needs associated & Beck, 2008). The process of data analysis
with treatment and care of schizophrenic includes: 1) reading repeated interview
patients. Thus, the family, especially transcripts and identifying the meaning of the
caregivers can optimally perform home care statement, 2) reviewing the interview results
on sick family members. by focusing on phrases and sentences related
to caregiver needs in treating schizophrenia,
3) finding meaning words of transcripts, 4)
METHODS rereading transcripts and grouping similar
Study Design themes and writing them into a description
The design of this study usesthe related to caregiver caring for schizophrenia,
phenomenology design which aims to explore 5) describing the complete phenomenon, 6)
the ability of caregivers in identifying the identifying the essence of the transcript, and
needs of caring for family members suffering 7) conducting member checks to participants
from schizophrenia. This phenomenology to validate some of the existing themes. The
study can provide a deep understanding of the principles of trustworthiness of Guba and
caregiver's needs in caring for family Lincoln (1989) were applied to ensure the
members who are experiencing schizophrenia. rigor of the study. A member checking was
done with primary caregivers of persons with
Research Subjects schizophrenia. Findings were also reanalyzed
A total of 10 participants participated in the with an experienced researcher, called as peer
study. The purposive sampling method is used checking (Gunawan, 2015).
in selecting research participants. The
inclusion criteria of the study participants
were: 1) having a family member diagnosed RESULTS
with schizophrenia, 2) being directly involved The results of this study found four themes: 1)
in home care, 3) taking care of schizophrenia seeking for information about schizophrenia,
patients for more than a year, 4) being willing 2) sought the healing of schizophrenic

Purba, J. M. (2017)!
!
patients, , 3) the need for group support, 4) "... already been hospitalized three times ...
looking for appropriate rehabilitation for healed ... his girlfriend relapsed again ... it
confused us ... my child is still taking
relatives with schizophrenia patients, and 5) medication ..." (Participant 2)
the need for easy mental health facilities that The patient's healing is the participants' main
are affordable. desire, so caregiver seeks to bring patients
Theme 1. Seeking for information about regularly treated every month.
schizophrenia "... hope to recover ... the medicine is taken
Information about the disease is needed by regularly ... there’s only two left ... came to
caregivers in caring for schizophrenic patients the poly to continue treatment ..."
(Participant 1)
at home. The information they get from health
Caregiver assured himself that by taking
workers and other sources helps them to take
medication on a regular basis the patient's
care of their sick family.
".... I asked the doctor about my son's illness can heal.
illness, he said his mentality was disturbed, "... when my sibling was severely sick-the
I asked another doctor, he said it was medication was not taken regularly ...always
chronic, probably Schizophrenia... " restless... difficult to sleep ... disturbing
(Participant 1). others ... currently calm ... sometimes help
clean the house, that's it, taking medicine
Participant's need for information on the cause regularly ..." (Participant 5)
of schizophrenia. Group support is needed by participants in
"... suddenly came home from work angry ...
yelled ... held the phone ... talked to people caring for family members who have
... but no ... strange behavior ... silence ... schizophrenia. Caregiver is very happy to
showered at night ... played music loudly." accompany family members to the outpatient
(Participant 7). medical treatment because they can meet
"... the Doctor explained there was a
disturbance in my sibling’s brain ... had to
other families.
"... it feels good to meet with others ... we
take medicine for my sibling to calm down,
vent ... if there is a problem in taking care of
that's it, I'm curious, sometimes I googled to
the child ... we exchange opinions ...
find out the cause of my sibling’s pain."
persuade to take medicine ...." (Participant
(Participant 3)
3)
Drug compliance is needed to prevent the
Participants expressed their opinion that they
recurrence of the disease, although the drugs
needed a meeting with members of the family
consumed by patients sometimes cause side
who suffered the same illness as their family
effects that makes patients uncomfortable.
members. They usually discuss with other
This condition makes caregiversworried,
families while waiting for nurse calls in the
because they do not know the side effects of
outpatient poly.
the treatment of Schizophrenia. This is "... we like to exchange ideas, share
expressed by the participants as follows: experiences with others ... waiting to be
"... my son's eyes glared upwards, he called ... so we share stories with others."
complained his neck was tense, I was (Participant 7)
confused, I stopped the medication, took "... the good thing is this, there's a place
him for medication again, the doctor where we gather, help each other, we both
changed the medicine without explanation have family members who suffer from
..." (Participant 6) schizophrenia” (Participant 9)
"... my mother complained her feelings were
all over the place, hair is pulled after taking
the medicine, the next day we went for Theme 3. Looking for appropriate
check up again and the doctor changed the rehabilitation for Schizophrenia patients
medicine, he said it didn’t fit ..." (Participant Caregiver is in dire need of rehabilitation for
4) family members with schizophrenia, because
"... a few moments ago, the medication was
replaced by the doctor, it wasn’t suitable,
with rehabilitation the patient has the skills so
my child was restless, and the medication that the patient can adjust to the environment.
was changed again, then it fit him ... "... there should be a place for my child to
(Participant 8) learn skills, so they can work, sew, cook,
whatever it is, as long as my child is kept
busy ..." (Participant 8)
Theme 2. Sought the healing of "... if there is any kind of workshop for my
schizophrenic patients sick sibling, I’d be happy, I’d be willing to
Participants expressed their curiosity about pay , let him have work, not kept at home,
the mental state of sick family members.
!
Purba, J. M. (2017)!
eat and sleep, let him have friends because schizophrenia resulted in delays in realizing
there are others together ..." (Participant 5) the mental state of a family member
experiencing schizophrenia (Cahyono &
Theme 4. Utilizing mental health facilities Asrap, 2017).
Problems in accessible mental health services
were felt by participants who accompanied Group support received by caregivers in this
family members who went to an outpatient study was obtained from families with
clinic. Mental health services that are located schizophrenia. A caregiver requires group
far from the family members’ home becomes support as a forum to share experiences in
a big problem for them. caring for family members with
"... my home is far... we change
transportation three times ... not to mention
Schizophrenia. The support of this group can
taking my child ... the fare is expensive, I help caregivers develop adaptive coping and
also have to work and sell..." (Participant be able to reduce their tension. In addition,
10) nurses can also provide support to caregivers
"... traffic on the way ... far away, my and patients. The nurse can provide health
husband is not healthy, the child still have to
go to the hospital, why is there no medicine education about the actions the family can
for my child, not to mention queuing, take to control the signs and symptoms of
because there are many others wanting Schizophrenia. Nurses can also give family
treatment, every month I come with my child therapy (Attendance, 2010). A systematic
..." ( Participant 8)
review showed that caregivers need to receive
caregiving support from others including
professional health care providers, other
DISCUSSION family members, friends as well as self-help
The results of this study indicate that groups to help them to live with and care for
participants need information about their family member diagnosed with
schizophrenia, causes and treatment. This schizophrenia effectively, thus those group
information is important for them to assist in resources need to be made available at the
caring for family members who are community level (Tungpunkom, Napa,
schizophrenic. This information will facilitate Chaniang, & Srikhachin, 2013). Magliano
the caregiver in recognizing signs and adds that adequate supportive support
symptoms of Schizophrenia, drug types, received by families can improve the family's
benefits and actions to be taken to overcome ability to deal with any challenges in care so
the side effects of taking medication. In this that they can overcome the difficulties
study, participants received information from encountered while treating schizophrenic
health workers such as doctors and nurses. In patients at home (Magliano, 2008).
addition, one participant looked for
information about schizophrenia from the Rehabilitation of patients with schizophrenia
internet. The results of this study are in line is another requirement of caregivers that have
with previous research suggested that not been achieved optimally. Participants
caregivers get information about mental revealed that rehabilitation can improve a
illness experienced by family members from patient's ability to adapt to his environment.
doctors, nurses and the Internet They have confidence that patients will get
(Sabanciogullari & Tel, 2015). In addition, better quality of life by following the
caregivers also need information related to the rehabilitation program. Research conducted
actions to be taken when facing the by Purba showed that schizophrenia patients
aggressiveness of the patient, overcoming who were given rehabilitation intervention
medication non-compliance, coping with drug had better social skills than schizophrenia
side effects, communicating with patients, patients who were not given rehabilitation
information on illness, symptoms, how and intervention (Purba, 2013). The provision of
where to seek help in the event of a crisis, this rehabilitation program can improve and
recognize the signs and symptoms of maintain its health and social skills and can
recurrence, and who can help them when they also prevent recurrence. Rehabilitation
need help. The family's lack of understanding, programs in the form of occupational
especially caregivers about the symptoms of therapies, vocational training and social skills

Purba, J. M. (2017)!
!
training can also improve social skills and ACKNOWLEDGEMENTS

work skills of the patient, so it is expected that The study was supported by a Scholarship awarded from
Directorate General of Research and Development
they already have enough social skills when Ministry of Research, Technology and Higher Education
returning to their family and society with the Institute of Research University of Sumatera
(Friedrich & Wancata, 2015). Utara Number: 003/SP2H/LT/DRPM/2017.
In this study, caregivers want an accessible

mental health service. In fact, most caregivers
REFERENCES
complained that mental health service is far Agiananda, F. (2006). Assessment of family burden,
from their house. Therefore, they did not have needs and resources in caring for
time to bring relatives to see the psychiatrist schizophrenics: a case study. FK Universitas
and other mental health professional Indonesia. Retrieved from
regularly. Consequently, incidents of relapse http://www.lib.ui.ac.id
Attendance, A. (2010). Phenomenological study of
rate are higher. A previous study showed that family experience about the burden and
mental health care professional should involve source of family support in caring for clients
all family members in the care plan for the with hallucinations. FIK Universitas
relatives with schizophrenia (Yang, Hsieh, Indonesia. Retrieved from
http://www.lib.ui.ac.id
Lee, & Chen, 2017). The accessible mental Cahyono, S. A. T., & Asrap, A. (2017). I am open
health service is very important for both paranoid: A case study of social welfare
caregivers and schizophrenia persons. They problems of people with schizophrenia. Media
tended to accept the helpfulness of Informasi Penelitian Kesejahteraan Sosial,
professional help from health professional 39(1), 1-14.
Chen, S., Wu, Q., Qi, C., Deng, H., Wang, X., He, H., . .
such as psychiatrist and mental health nurse. . Liu, T. (2017). Mental health literacy about
This is because caregivers would like to seek schizophrenia and depression: a survey among
professional help for their loved one (Chen et Chinese caregivers of patients with mental
al., 2017). disorder. BMC psychiatry, 17(1), 89.
Friedrich, F., & Wancata, J. (2015). Needs of Family
Caregivers of Schizophrenia Patients.
European Psychiatry, 30, 95.
CONCLUSION Gunawan, J. (2015). Ensuring trustworthiness in
The result of this study indicates that qualitative research. Belitung Nursing Journal,
caregivershave several needs that must be met 1(1), 10-11.
Magliano, L. (2008). Families of people with severe
in caring for family members who experience mental disorders: difficulties and resources.
schizophrenia. Caregiver seeks to meet those Copenhagen: World Health Organization.
needs by seeking information about diseases Polit, D. F., & Beck, C. T. (2008). Nursing Research:
from health workers and the internet. In Generating and Assessing Evidence for
Nursing Practice: Wolters Kluwer
addition, caregivers also identify the need for Health/Lippincott Williams & Wilkins.
healing guarantees by asking health workers. Purba, J. (2013). The influence of rehabilitation
Caregiver efforts to meet the needs of group interventions on social disability in people
support through discussions with other with schizophrenia treated at Mental Hospital
caregivers. Caregiver also needs a place to of North Sumatra Province. Graduate School,
Universitas Sumatera Utara. Retrieved from
train patients to work and not become a repository.usu.ac.id
family burden. An easily accessible health Rafiyah, I. (2011). burden on family caregivers caring
facility is an unmet caregiver requirement. for patients with schizophrenia and its related
Therefore, special attention is needed from factors. Nurse media journal of nursing, 1(1),
29-41.
health service institutions and local health Sabanciogullari, S., & Tel, H. (2015). Information
departments to enable mental health services needs, care difficulties, and coping strategies
in polies so that the availability of health in families of people with mental illness.
workers and medications can help caregivers Neurosciences, 20(2), 145.
in optimizing their ability to care for family Stuart, G. W. (2014). Principles and Practice of
Psychiatric Nursing-E-Book: Elsevier Health
members who experience schizophrenia at Sciences.
home. Talwar, P., & Matheiken, S. T. (2010). Caregivers in
schizophrenia: A cross cultural perspective.
Indian journal of psychological medicine,
32(1), 29.

!
Purba, J. M. (2017)!
Tungpunkom, P., Napa, W., Chaniang, S., & Srikhachin, Yang, C. I., Hsieh, M. Y., Lee, L. H., & Chen, S. L.
P. (2013). Caregiving experiences of families (2017). Experiences of caring for a sibling
living with persons with schizophrenia: a with schizophrenia in a Chinese context: A
systematic review. JBI Database of Systematic neglected issue. International journal of
Reviews and Implementation Reports, 11(8), mental health nursing, 26(4), 409-417.
415-564.
Cite this article as: Purba, J. M. (2017). Caregivers’ needs in caring for relatives with schizophrenia
in Medan Indonesia: A phenomenological study. Belitung Nursing Journal, 3(6), 656-661

Ningtyas NWR, et al. Belitung Nursing Journal. 2017 December;3(6):662-669
Accepted: 14 March 2017

EFFECTIVENESS OF PROGRESSIVE MOBILIZATION LEVEL I AND II

ON HEMODYNAMIC STATUS AND DECUBITUS ULCER RISK IN
CRITICALLY ILL PATIENTS
Ni Wayan Rahayu Ningtyas*, RR Sri Endang Pujiastuti, Nina Indriyawati
Magister Applied Midwifery, Politeknik Kesehatan Kementrian Kesehatan Semarang, Indonesia
*Correspondence:
Ni Wayan Rahayu Ningtyas S.Tr. Kep
Magister Applied Midwifery, Politeknik Kesehatan Kementrian Kesehatan Semarang, Indonesia
Jl. Tirto Agung, Pedalangan, Banyumanik Kota Semarang, Jawa Tengah, Indonesia (50268)
E-mail: ayuningtyas.niwyn@gmail.com
Abstract
Background: Patient immobility remains to be one of the primary causes of pressure ulcers. Therefore, mobilization is
necessity for patients being treated in the intensive care unit. However, the occurrence of pressure ulcers is not only
dependent on the mobilization, but also depents on the bed itself and the type of mattress. This study used the same mattress
and bed and compared the effectiveness of progressive mobilization with regular mobilization.
Objective: This study aims to examine the effectiveness of progressive mobilization level I and II on hemodynamic status
and decubitus ulcer risk in critically ill patients.
Methods: This was a quasy experimental study using repeated measure design. There were 40 respondents selected using
purposive sampling, which 20 respondents assigned in each group. A Braden scale was used to measure the risk of decubitus
ulcer. Paired t-test and repeated measures anova were performed for data analysis.
Results: Paired t-test showed that there was a significant difference of systolic pressure, diastolic pressure, MAP, heart rate,
and Braden score after given intervention with p-value <0.05. However, repeated anova test showed that diastolic pressure
had p-value >0.05, thus could not be continued to post-hoc test. The progressive mobilization of level I and II in critical
patients can stabilize systolic pressure (52.46%), stabilize MAP (58.43%), stabilize heart rate (68.99%), and reduce the risk
of decubitus (55.03%) for 7 days of recurrent intervention.
Conclusion: The progressive mobilization of level I and II can reduce the risk of decubitus and stabilize the patient's
hemodynamic status in critical patients.
Keywords: Progressive Mobilization Level I and II, Hemodynamic Status, Decubitus Risk
INTRODUCTION
Critical patients are those with dysfunction or delayed weaning of mechanical ventilation
failure in one or multiple body systems with a due to muscle weakness, and development of
life-threatening condition that depends on compressive ulcers (Morton & Fontaine,
monitoring equipment and therapies 2008). Hemodynamic disorders in critical
accompanied by hemodynamic disturbance patients also almost always occur due to organ
where there is still a possibility to be failure or dysfunction, requiring proper
recovered by intensive care, monitoring and monitoring and handling as it greatly affects
treatment at Intensive Care Unit (ICU) the oxygen delivery function in the body,
(Morton & Fontaine, 2008). Short-term which also involves heart function.
impacts for critically ill patients include
Associated Pneumonia Ventilator (VAP),

!
Ningtyas, N. W. R., Pujiastuti, RR. S. E., Indriyawati, N. (2017)!
The development of a compressive or METHODS

decubitus ulcer in a critical patient is the Study Design
result of the use of a mechanical ventilator This research was a quasy experimental study
and the provision of sedation or sedation with repeated measures design. Repeated
which results in a decrease in the patient's measures design is conducted by observing
ability to change the position so that the the same unit repeatedly to increase the
pressure is prolonged. Normally, the skin validity of the experiment by performing
cannot tolerate long pressure so that the more than once treatment (McBurney &
patient with immobilization and prolonged White, 2009).
bed rest has a great risk of skin damage or
decubitus, which will interfere with the blood Settings
supply to the distressed area causing tissue The study was conducted for 10 weeks (from
death. Immobilization is one of the most December 19, 2016 to February 25, 2017) in
significant factors in decubitus incidence the ICU of West Nusa Tenggara Regional
(Setiyawan, 2008). General Hospital and Mataram District
General Hospital.
The presence of physical activity in critical
patients in the early treatment at ICU is Population and Sample
indispensable to the patient. The physical The number of samples in this study were 40
activity aims to improve hemodynamic status respondents selected using purposive
and post-treatment physical morbidity in ICU. sampling technique. The group was divided
One of the interventions that nurses can do is into two groups, namely 20 respondents in the
to mobilize progressively. Progressive intervention group carried out progressive
mobilization is introduced and developed in mobilization of level I & II and 20
2010 by the American Association of Critical respondents in the control group who received
Care Nurses (AACN). Progressive routine mobilization intervention. The number
mobilization is a series of plans designed to of samples was obtained based on the Dahlan
prepare patients to move gradually and sample formula using the mean and SD of the
sustainably, especially in critical patients with previous study, as standard and calculated by
intensive care. the statistical formula obtained the results of
40 respondents (Dahlan Sopiyudin, 2009).
Research conducted by Kathy Stiller to 31 Respondents were selected based on inclusion
patients in the ICU who had received 69 total criteria: a) New patients were treated in ICU
mobilization treatments found a significant with mechanical ventilator, b) Patients with
increase in heart rate and blood pressure minimum adult age of 18 years, c) Patients
(Stiller, Phillips, & Lambert, 2004). with stupor awareness, d) Patients with GCS
According to research conducted by score> 8, e) Patients with systolic blood
Zakiyyah, the number of respondents pressure (SBP) of 90 - 180 mmHg, f) Patients
experiencing decubitus in the control group with mean artery pressure of 55-140, g)
were significantly more than the numbers in Patients with peripheral oxygen saturation
the intervention group, there were 4 (SpO2) of > 90% and the inspired oxygen
respondents (26.7%) identified in the control fraction (FiO2) of <60%. The exclusion
group who were not given progressive criteria included: a) Patients with fractures
mobilization of level 1, with 3 respondents were not consolidated, b) Patients with
experiencing decubitus with braden scores <9 independence changes or dependence of
in 1-3 days, and 1 respondent in 4-7 days independent activity since before being
(Zakiyyah, 2014). However, the occurrence of treated, c) Patients with mechanical
pressure ulcers is not only dependent on the ventilators for more than 7 days or
mobilization, but also depents on the bed postoperative recurrence or cancer therapy
itself and the type of mattress. This study used within 6 months, d). Patients who died before
the same mattress and bed and compared the the 7th day of intervention, starting from day
effectiveness of progressive mobilization with one were designated as a sample.
regular mobilization.

!
Intervention nutrition and friction & friction. The sum of

In this study respondents were given all scores from each subscale on the Braden
treatment for 7 days with 4 times scale is 23 as the highest score, and the lowest
measurement of pretest on the first day, score is 6. The lower the total score obtained
posttest 1 after the intervention of the third by the patient indicated that the patient is
day, posttest 2 after the intervention of the increasingly at risk to suffer dekubitus. The
fifth day, and posttest 3 after the intervention Braden scale has been validated with 10
of the seventh day. The intervention groups in patients with mechanical ventilator, with r-
this study used progressive mobilization value count = 0.942 (r count > 0.878),
interventions of level I & II that progressive indicated that the instrument was reliable. The
mobilization was a series of plans designed to result of validity test showed that 5 of 6 r-
prepare patients to move gradually and values of subscale item on braden scale was >
sustainably. Progressive mobilization of level 0.878, so that item was valid. The six
I consisted of: setting position of Head of Bed subscales included: sensory subscale (r=
300, performing passive ROM 2 times a day, 0.958), humidity (r=0.502), activity (r=0.897),
performing continuous lateraly rotation mobilization (r=0.958), nutrient (r=0.885) and
therapy (CLRT) every two hours by providing frictional (r=0.911).
right sloping and left tilting positions
according to the patient's ability. For the Ethical Consideration
second-level mobilization, patients were given This research has been through two times
passive ROM measures three times per day, ethical test. First, the ethical test conducted in
setting the Head of Bed position 450-650 for the Poltekkes Kemenkes Semarang with
fifteen minutes followed by training the registered code number: 241/KEPK/
patient for 20 minutes. This progressive Poltekkes-SMG/EC/2016, and second was the
mobilization intervention was carried out ethical test by ethics commission of the
daily for 7 days. To find out the increase in General Hospital of NTB Province with code
patient's level II, the patient was assessed in number of ethics: 070.1/08/KEP /2016. Prior
terms of hemodynamic condition remained to data collection, each respondent and family
stable and the patient's level of awareness was given an informed consent to provide the
showed an improvement by seeing the patient basis of an explanation of the medical action
able to open the eyes even though there was as well as the risks associated with the patient.
no good contact. The mobilization was done
by the researcher and the research assistant Data Analysis
who had been selected and qualified as Paired t-test and repeated measures anova
research assistant. The control group received were performed in this study.
regular ICU mobilization of Head of Bed 300
and continuous lateraly rotation therapy RESULTS
(CLRT) every 4 hours. Table 1 shows that there was a significant
effect of progressive mobilization on systolic
Instruments pressure in the experiment group in the
Hemodinamic status was monitored using an posttest 2 (p=0.002) and posttest 3 (p=0.008).
observation sheet while the risk of decubitus There was no significant effect in the control
using the Braden Scale (Bhoki, Mardiyono, & group.
Sarkum, 2014). The Braden scale was one of
the methods used to assess the risk of While Table 2 shows that there was a significant
decubitus ulcer to patients with prolonged bed effect of progressive mobilization on diastolic
rest. In Braden scale there are six subscales to pressure in the experiment group in the posttest 2
determine the level of risk of injury to the (p=0.021) and posttest 3 (p=0.009). There was no
press. These subscales include: sensory significant effect in the control group.
perception, humidity, activity, mobilization,
!
Table 1 Effect of progressive mobilization level 1 and II on systolic pressure before and after intervention in
the experiment and control group (n=40)
Experiment group Control group
Variable
t p t p
Posttest 1 (Day 3) 1.489 0.153 -0.241 0.812
Posttest 2 (Day 5) 3.653 0.002 0.346 0.733
Posttest 3 (Day 7) 2.981 0.008 1.066 0.300
Table 2 Effect of progressive mobilization level 1 and II on diastolic pressure before and after intervention in
the experiment and control group (n=40)
Variable
t p t p
Posttest 1 (Day 3) 0.901 0.379 -0.240 0.813
Posttest 2 (Day 5) 2.524 0.021 -0.080 0.937
Posttest 3 (Day 7) 2.911 0.009 0.737 0.470
Table 3 Effect of progressive mobilization level 1 and II on MAP before and after intervention in the
experiment and control group (n=40)
Variable
t p t P
Posttest 1 (Day 3) 1.237 0.231 -0.450 0.658
Posttest 2 (Day 5) 3.219 0.004 0.074 0.942
Posttest 3 (Day 7) 3.296 0.004 0.902 0.378
As shown in the Table 3, it is indicated that (p=0.004). However, there was no significant
there was a significant effect of progressive effect of progressive mobilization on MAP in
mobilization on MAP in the experiment group the control group.
in the posttest 2 (p=0.004) and posttest 3
Table 4 Effect of progressive mobilization level 1 and II on heart rate before and after intervention in the
experiment and control group (n=40)
Variable
t p t p
Posttest 1 (Day 3) 1.671 0.111 -0.072 0.944
Posttest 2 (Day 5) 3.127 0.006 0.328 0.746
Posttest 3 (Day 7) 4.831 0.000 0.246 0.808
Table 5 Effect of progressive mobilization level 1 and II on risk of decubitus ulcer before and after
intervention in the experiment and control group (n=40)
Variable
Mean ± SD t P Mean ± SD t P
Posttest 1 (Day 3) -3.800 ± 1.673 -10.156 0.000 -2.350 ± 1.872 -5.615 0.000
Posttest 2 (Day 5) -6.450 ± 2.139 -13.484 0.000 -3.850 ± 1.387 -12.414 0.000
Posttest 3 (Day 7) -8.450 ± 1.669 -22.637 0.000 -4.450 ± 1.356 -14.673 0.000
Table 4 shows that there was a significant While Table 5 shows that there was a
effect of progressive mobilization on heart statistically significant effect of progressive
rate in the experiment group in the posttest 2 mobilization level 1 and II on risk of
(p=0.006) and posttest 3 (p=0.000). However, decubitus ulcer in the experiment group as
there was no significant effect of progressive well as in the control group with p-value
mobilization on heart rate in the control <0.05. However there was a higher reduction
group. of decubitus risk in the experiment group (t= -
22.637) compared with the control group (t=-
14.673).

!
Table 6 Comparison of the effect of progressive mobilization on systolic diastolic pressure, MAP, heart rate,
and risk of decubitus in the experiment and control group using Repeated Anova
Df F p
Systolic pressure between experiment 2.79 4.534 0.013
and control group
Diastolic pressure between experiment 2.505 2.738 0.057
and control group
MAP between experiment and control 2.231 4.264 0.014
group
Heart rate between experiment and 1.831 6.345 0.004
control group
Risk of decubitus ulcer between 2.059 307.225 0.000
experiment and control group
Table 6 shows that there was a statistically differences of diastolic pressure (F=2.738, p=
significant difference of systolic pressure in 0.057), MAP (F=4.264, p= 0.014), heart rate
the experiment and control group (F=4.534, (F=6.345, p= 0.004), and risk of decubitus
p= 0.013). Similar with the other variables (F=307.225, p= 0.000) in the experiment and
showed that there were statistically significant control group.
Table 7 Post hoc in systolic pressure between experiment and control group (n=40)
Experiment Control
Group
Mean P Mean P
Pretest - Posttest (Day 3) 5.800 0.226 -1.300 0.784
Pretest - Posttest (Day 5) 13.250* 0.007 1.900 0.686
Posttest (Day 3) – Posttest (Day 5) 7.450* 0.016 3.200 0.286
Posttest (Day 3) – Posttest (Day 7) 7.450 0.131 8.150 0.057
Posttest (Day 5) – Posttest (Day 7) -1.050 0.677 4.950 0.055
Table 8 Post hoc in MAP between experiment and control group (n=40)
Experiment Control
Group
Mean p Mean P
Table 9 Post hoc in heart rate between experiment and control group (n=40)
Experiment Control
Group
Mean p Mean P
Posttest (Day 5) – Posttest (Day 7) 9.050* 0.001 -0.150 0.952
Table 7 revealed that there was a significant 5) (p= 0.007), in the pretest - posttest (day 7)
mean difference of systolic pressure in the (p=0.029), and between posttest (day 3) –
experiment group in the pretest - posttest (day posttest (day 5) (p=0.016).
!
While Table 8 revealed that there was a posttest (day 7) (p=0.000), and between
significant mean difference of MAP in the posttest (day 5) – posttest (day 7) (p=0.001);
experiment group in the pretest - posttest (day and Table 10 shows that there was significant
5) (p= 0.008), in the pretest - posttest (day 7) reduction of risk of decubitus ulcers between
(p=0.015), and between posttest (day 3) – the experiment and control group. However,
posttest (day 5) (p=0.042). the experiment group showed the higher
decrease of decubitus risk compared with the
Table 9 revealed that there was a significant control group. It could be said that the
mean difference of heart rate in the progressive mobilization of level I & II is
experiment group in the pretest - posttest (day more effective in decreasing the risk of
5) (p= 0.008), in the pretest - posttest (day 7) decubitus in critical patients.
(p=0.000), between posttest (day 3) – posttest
(day 5) (p=0.038), between posttest (day 3) –
Table 10 Post hoc in risk of decubitus ulcer between experiment and control group (n=40)
Experiment Control
Group
Mean p Mean P
Pretest - Posttest (Day 3) -3.800* 0.000 -2.350* 0.000
Posttest (Day 3) – Posttest (Day 5) -2.650* 0.000 -1.500* 0.000
DISCUSSION keeping a static position (Coyer, Lewis, &

Effect of progressive mobilization on Tayyib, 2013; Vollman, 2010).
hemodynamic status
Findings of this study revealed that there was In this study most of the respondents were
a statistically significant effect of progressive patients with neurological disorders that were
mobilization on systolic pressure, and MAP almost entirely post-craniotomy. In addition,
with p-value (<0.05). The results of the study the other studies revealed that there is an
indicated that there was 52.46% increase of effectiveness of head up 300 to increase
systolic pressure in the experiment group, cerebral perfusion in post op trepanasi patient,
considered effective to stabilize systolic statistically there were changes in blood
pressure in critical patients. pressure, pupil and MAP (Huda, 2017). The
head up position of 300 also improves the
This study result supports the previous cerebral perfusion pressure (CPP), in which
research explained the significant effect of CPP is the amount of blood flow from the
repeated (69 times) mobilization on systolic systemic circulation required to provide
pressure with p = 0.001 (Stiller et al., 2004). adequate oxygen and glucose for brain
Head of bed as one part of progressive metabolism. With stability of CPP, vital signs
mobilization causes the body perform various will remain constantly improving the flow
ways to adapt psychologically to maintain blood and improve neurological status. The
cardiovascular homeostasis. The other studies suggested that for every 100 head
cardiovascular system will regulate in 2 ways elevation, ICP average decreased by 1 mm
namely by plasma volume shift or by inner Hg, which was associated with a 2 to 3 mm
ear response as a vestibular response that Hg cerebral perfusion pressure (CPP)
affects the cardiovascular system during reduction, with blood pressure to be
position changes. Critical patients usually maintained was 10 - 20 mmHg (Rosner &
have a weak heart beat, a lack of respiratory Coley, 1986).
or low cardiovascular acceptance so that it is
better to be given intervention rather than

!
The most important arterial pressure reflex is rate. There was a change of 68.99%, which
the baroreceptor reflex. An increase in arterial indicated that the intervention was effective in
pressure stretches the walls of the main stabilizing the heart rate level. In this study,
arteries in the chest and neck, in turn the respondents were critical patients with
stimulates baroreceptors. The signals are sent ventilator, which the patient spend long time
to the brainstem vasomotor center, and reflex in bed that will cause changes in the
signals are sent back to the heart and blood cardiovascular system. In the first three days
vessels to slow the heart and dilate the of bedrest, plasma volume was reduced by 8%
vessels, thereby lowering the normal arterial -10%, and in the fourth week of bedrest the
pressure. Thus, baroreceptor reflexes help patient had a loss of 15% -20% plasma
stabilizing arterial pressure. volume (Berney & Denehy, 2003). These
changes resulted in increased heart workload,
Findings of this study showed there was no increased heart rate, decreased stroke volume
significant effectof progressive mobilization and decreased cardiac output. Orthostatic
on diastolic pressure. This result is in contrast hypotension will be worse in the third week if
with previous study which indicated that there the patient is immobilized. Instability can also
was a significant influence between occur because the response of the autonomic
mobilization intervention and diastolic nervous system diminishes, when the body's
pressure of patients (p-value= 0.001) (Stiller gravitational changes, the cardiovascular
et al., 2004). Similar with another study also system adjusts to shift the volume of plasma
showed a significant influence of mobilization transferred to the central nervous system to
with blood pressure (p=0.021). However, the alter the pulse of the blood vessels. As the
magnitude of the change value in previous heart's workload increases, oxygen
studies is relative small (≤10%), few research consumption also increases. The long bedrest
explain the effect of progressive mobilization position will be difficult to adapt in changing
on the diastolic pressure (Olviani, 2015). position, then continuous lateral rotation
therapy (CLRT) can gradually train the
On the other hand, finding of this study patient to tolerate a change of position
showed there was a significant effect of (Banasik & Emerson, 2001).
progressive mobilization on MAP, which
increases 58.43%. It indicates that progressive Effect of progressive mobilization on risk
mobilization level I and II is effective in of decubitus ulcer
stabilizing MAP value in the critical patients. Findings of this study showed that there was a
According to Berney, there were no significant effect of the intervention on the
significant adverse cardiovascular effects of risk of decubitus ulcer in the experiment and
mobilization measures seen from MAP when control group (p<0.05). However, the
applied to a stable patient population in progressive mobilization level 1 & II showed
hospitals with stable hemodynamics. MAP a higher reduction of decubitus risk compared
has no significant changes during the with the intervention in the control group. It
mobilization intervention, which indicated could be said that the progressive
that the mobilization was safe to be performed mobilization of level I & II is more effective
in critical patients, in which the MAP in decreasing the risk of decubitus in critical
measurements were conducted within 20 patients. The results of this study were in line
minutes before and after the mobilization. In with the previous studies that revealed that
contrast to this study, the effect of MAP there was a significant effect of mobilization
improvement began to emerge on the fifth day on the incidence of decubitus in stroke
of the intervention, the MAP was measured patients with p-value of 0.011 (Aini &
on day 1, day 3, day 5, and day 7, showing the Purwaningsih, 2013). It is also revelaed that
improvement of the MAP measurement progressive mobilization achieved the best
results (Berney & Denehy, 2003). effect when performed at least 18 hours per
day in every 2 hours (Vollman, 2010).
Similar with MAP result, the finding of this Besides, the risk of decubitus is based on the
study also revealed that there was a significant level of dependence of patients, patients who
effect of progressive mobilization on heart need a minimum care have no risk for
!
occurrence of decubitus, while those who McBurney, D. H., & White, T. L. (2009). Research
need partial care or total care have the high methods: Cengage Learning.
Morton, P. G., & Fontaine, D. (2008). Critical Care
risk of decubitus (Okatiranti, Sitorus, & Nursing: A Holistic Approach: Lippincott
Tsuawabeh, 2013). Williams & Wilkins.
Okatiranti, O., Sitorus, R. E., & Tsuawabeh, D. (2013).
Risiko Terjadinya Dekubitus Berdasarkan
Tingkat Ketergantungan Pasien di Ruang
CONCLUSION Perawatan Neurologi [Risk of Decubitus
The progressive mobilization interventions of based on the Level of Patient Dependence in
level I and II was effective for stabilizing the Neurology Treatment Ward. Jurnal
systolic pressure, MAP, heart rate, and Keperawatan Padjadjaran, 1(3).
effectively decreasing the risk of decubitus in Olviani, Y. (2015). PENGARUH PELAKSANAAN
MOBILISASI PROGRESIF LEVEL I
critical patients. Therefore, it is suggested that TERHADAP NILAI MONITORING
the implementation of progressive HEMODINAMIK NON INVASIF PADA
mobilization of level I and II for five days can PASIEN CEREBRAL INJURY DI RUANG
be used as an alternative nurse intervention. ICU RSUD ULIN BANJARMASIN
[EFFECT OF LEVEL I PROGRESSIVE
MOBILIZATION IMPLEMENTATION ON
NON INVASIVE HEMODYNAMIC
REFERENCES MONITORING VALUE IN CEREBRAL
Aini, F., & Purwaningsih, H. (2013). Pengaruh Alih INJURY PATIENTS IN ICU of ULIN
Baring Terhadap Kejadian Dekubitus Pada BANJARMASIN HOSPITAL]. Caring, 2(1),
Pasien Stroke Yang Mengalami Hemiparasis 37-48.
di Ruang Yudistira di RSUD Kota Semarang. Rosner, M. J., & Coley, I. B. (1986). Cerebral perfusion
Semarang: STIKES Ngudi Waluyo. pressure, intracranial pressure, and head
Banasik, J. L., & Emerson, R. J. (2001). Effect of lateral elevation. Journal of neurosurgery, 65(5),
positions on tissue oxygenation in the 636-641.
critically ill. Heart & Lung: The Journal of Setiyawan, S. (2008). Hubungan tingkat pengetahuan,
Acute and Critical Care, 30(4), 269-276. sikap dengan perilaku perawat dalam upaya
Berney, S., & Denehy, L. (2003). The effect of pencegahan dekubitus di Rumah Sakit Cakra
physiotherapy treatment on oxygen Husada Klaten [Relationships of knowledge,
consumption and haemodynamics in patients attitude and behavior of nurses in preventing
who are critically ill. Australian Journal of decubitus in the Hospital of Cakra husada
Physiotherapy, 49(2), 99-105. Klaten]. Universitas Muhammadiyah
Bhoki, M. W., Mardiyono, M., & Sarkum, S. (2014). Surakarta.
Braden Scale and Norton in Predicting Risk of Stiller, K., Phillips, A., & Lambert, P. (2004). The safety
Pressure Sores in ICU Room. Jurnal Riset of mobilisation and its effect on
Kesehatan, 3(2), 576-586. haemodynamic and respiratory status of
Coyer, F., Lewis, P., & Tayyib, N. (2013). A intensive care patients. Physiotherapy Theory
prospective observational study of patient and Practice, 20(3), 175-185.
positioning in a Saudi intensive care unit. Vollman, K. M. (2010). Introduction to progressive
Middle East Journal of Nursing, 7(1), 26-34. mobility. Critical Care Nurse, 30(2), S3-S5.
Dahlan Sopiyudin, M. (2009). Besar sampel dan cara Zakiyyah, S. (2014). PENGARUH MOBILISASI
pengambilan sampel [Besar sampel dan cara PROGRESIF LEVEL I TERHADAP RISIKO
pengambilan sampel]: Jakarta: Salemba DEKUBITUS DAN PERUBAHAN SATURASI
Medika. OKSIGEN PADA PASIEN KRITIS
Huda, N. (2017). Efektifitas Elevasi Kepala 30 Dalam TERPASANG VENTILATOR DI RUANG ICU
Meningkatkan Perfusi Serebral Pada Pasien RSUD Dr. MOEWARDI SURAKARTA [Effect
Post Trepanasi di Rumah Sakit Mitra of progressive mobilization level I on
Surabaya [Effectiveness of head up 30 to decubitus risk and oxygen saturation changes
improve cerebral perfusion in patient post op in critical ill patient with ventilator in the
trepanation in Mitra Keluarga Surabaya intensive care unit of the General Hospital of
Hospital]. Jurnal Ilmiah Keperawatan, 12(1), Dr. moewardi Surakarta]. Program
1137-1144. Pascasarjana Undip.
Cite this article as: Ningtyas, N. W. R., Pujiastuti, RR. S. E., Indriyawati, N. (2017). Effectiveness
of progressive mobilization level I and II on hemodynamic status and decubitus ulcer risk in critically
ill patients. Belitung Nursing Journal, 3(6), 662-669.

Timorita YA, et al. Belitung Nursing Journal. 2017 December;3(6):670-676
Accepted: 17 September 2017

THE ASSOCIATION OF ISLAMIC BASED CARING MODEL AND

COMMITMENT TO ORGANIZATION IN STAFF NURSES
Yuda Ayu Timorita1*, Tri Hartiti2, Bambang Edi Warsito1, Suhartini Ismail1
1
Department of Nursing, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
2
Faculty of Nursing, Universitas Muhammadiyah, Semarang, Indonesia
*Correspondence:
Yuda Ayu Timorita
Department of Nursing, Faculty of Medicine, Diponegoro University
Tembalang, Semarang, Central Java 50275, Indonesia
E-mail: ayutimorita@gmail.com
Abstract
Background: Strong organizational commitment is needed by hospitals to attract and retain nursing staffs in order to
consistently deliver good quality of nursing services. The decrease in organizational commitment among nurses can cause
many losses to the organization, including increased organizational spending, breakdown in patient care, and cause
performance trends that appear not for the benefit of the organization or unit, but more for personal self-interest.
Objective: To analyze the relationship of the application of Islamic Based Caring (IBC) model with organizational
commitment among nurses.
Methods: This was a correlation analytic research with cross sectional design. There were 108 nurses selected using a
propotionate stratified random sampling. Islamic Based Caring was measured using a questionnaire developed based on the
theory of Suhartini Ismail (2016), and organizational commitment was measured using a questionnaire developed based on
the concept of Caldwell, O’Reilly & Chatmann (1990) and Mowday, Porter dan Steers (1982) in Asmaningrum (2009).
Logistic regression and forward stepwise (conditional) method were used for data analysis.
Results: There was a statistically significant correlation of a healing presence (p=0.000), caring relationship (p=0.010),
caring environment (p=0.045) and belief in God (p=0.000). Belief in God (Allah SWT) has the highest correlation
(OR=6.660) with organizational commitment among nurses.
Conclusion: There is a positive and significant relationship between the implementation of Islamic Based Caring with the
organization's commitment among nurses.
Keywords: Islamic Based Caring, Caring, Organizational Commitment, Nurse
INTRODUCTION
Development of health and nursing services in commitment to the organization is needed to
hospitals is increasing. People are show good performance and productivity
increasingly critical of the quality of health (Asmaningrum, Keliat, & Hastono, 2011).
services in hospitals. Nursing staff is the
spearhead and backbone of health services in Organizational commitment is a global
hospitals. Nurses become innovators in construction that reflects the affective
providing quality health services. Study said response and the relative strength of an
that 80% of health services are provided by individual's identification and involvement of
nurses (Baumann, 2007); while as many as the entire organization. This is manifested by
40% of health care providers in Indonesia are strong confidence (identification) and
nursing personnel (MOH, 2005). Nursing acceptance (internalization) of the
services are good indicators of poor quality of organization's goals and values, the
hospital health services. Thus, a nurse's high willingness to strive for the achievement of

!
Timorita, Y. A., Hartiti, T., Warsito, B. E., Ismail, S. (2017)!
organizational interests (job involvement) and understanding of norms or rules of work both
a strong desire to maintain the position of an in professional ethics and the dimensions of
organization member (Asmaningrum et al., accountability, then justice and the truth in the
2011). work ethic of Islam will actually carry out its
duties and functions, and further affect
The low commitment of nurses can cause commitment to the profession and
many losses to the organization. Some of organization (Aji, 2016).
these include increased organizational
spending and breakdown of patient care Islamic hospital of Kendal is a hospital that
(Anisah, 2016). The lack of commitment of has a special character with Islamic nuance
nurses has led to a tendency for performance that is reflected in everyday culture. Number
not to be of interest to the organization or to of nurses in this hospital is currently as many
its unit, but rather to private interests as 208 people or 43.4% of the total number of
(Asmaningrum et al., 2011). Borhani employees and 100% are Muslims. This
suggested that there is a positive relationship hospital brings the motto of "Working as a
between organizational climate, worship, goodness in service, proficient in
professionalism, caring with organizational performing actions and putting trust in Allah
commitment (Borhani, Jalali, Abbaszadeh, & SWT". This tells that the hospital has
Haghdoost, 2014). Caring climate of embedded Islamic values in its organization
organization, job satisfaction and which is expected to become individual
organizational commitment can improve staff values for all employees working at this
organizational behavior (Huang, You, & Tsai, hospital.
2012). Caring climate significantly affects
employee performance and influence directly Various efforts to maintain nursing staff in
to organizational commitment through order to increase the commitment of nursing
mediation of job satisfaction (Fu & organizations have been done by the hospital
Deshpande, 2014). management, including the provision of
health insurance for all employees, providing
The impact of caring for nurses is to develop a incentives to nurses either directly or
sense of accomplishment, satisfaction, and indirectly received, the opportunity to
achievement of goals and gratitude as well as continue education, both formal and informal.
to maintain integrity, integrity of functions In addition, large and clean mosque is built to
and responsibilities, and improve self- support the spiritual activities of Islam for
confidence; otherwise, non-caring effects for employees, patients and visitors; while there
nurses, such as nurses become emotional, less are routine morning prayer activities held
caring, feelings of fear and fatigue (Jane Lee- three times a week, such as reading al-qur'an
Hsieh Msn & Chien-Lin Kuo Ms, 2005). and translation, praying together for the
healing of patients and tausyiah / Islamic
Caring in Islam means commitment to helping studies, tahajud prayer culture every month
others (Ismail, Hatthakit, & Chinnawong, regularly, Islamic guidance for all employees,
2015). Employees who strongly support the including nurses. Additionally, the voice of
work ethic of Islam are more committed to Adzan as a call to prayer is always heard
their organization and are more likely to make through the sound system in all rooms, and
changes where the change has no potential to infaq box is provided for each employee.
change the basic values and organizational Thus, it could be said that the Islamic hospital
goals, and is considered to be a benefit to the of Kendal has created a spiritual climate of
organization (Jamil, 2007). Islam in the workplace.
The spiritual climate in the workplace affects However, despite the spiritual climate of
organizational commitment, therefore the Islam and the efforts of the hospital
spiritual workplace needs to be developed to management that has been created, there were
foster a sense of community resulting in self- still problems in the organization's
harmony, environmental harmony and commitment to nurses. It was 40% of nurses
transcendence (Anisah, 2016). The more did not accept and believed in organizational

!
values and goals. The numbers of turn over wards or special units, and nurses who
nurses in 2016 as many as 14 nurses (6.73% ) occupied positions as structural and functional
of 208 nurses, and in January - February 2017 officials at the hospital.
there were 4 nurses resigned. The result of the
evaluation showed the reason for the nurses' Instruments
resignation from this hospital was to move to Islamic based caring questionnaire was used
another hospital which was considered better, to measure the application of Islamic based
and some nurses had to follow their families caring model. This questionnaire was
and husbands. developed based on the concept of Islamic
Based Caring Model (Ismail et al., 2015). It
Given various problems above, researchers consisted of a healing presence, caring
are encouraged to conduct research on the relationship, caring environment and belief in
application of Islamic Based Caring Model God (Allah SWT). There were 37 closed
which includes healing presence, caring questions in the questionnaire in Likert scale
relationship, caring environment, and belief in (5 = strongly agree, 4 = agree, 3 = neutral, 2 =
God according to the theory from Suhartini disagree, and 1 = strongly disagree), with a
Ismail in relating to organizational range of values from 146-178. Its category
commitment to nurses. So, it is expected to consisted of: Poor if value <156.69, and Good
attract and retain nursing staff to show the if value > 156.69, with mean value as a cut of
performance and productivity of good nurses point. The content validity was 0.89. Of 38
so that the quality of nursing services and items, one item (#18) was deleted due to low
patient satisfaction can increase. correlation coefficient (0.230) based on
Pearson product moment; and the rest of
Healing presence is about how nurses build questions ranged from 0.4777-0.780 (with sig
capabilities and strengthen and maintain the 0.05, r table value 0.361). Cronbach alpha was
application of caring. Caring relationships is a 0.941.
relationship in coordination and collaboration
with health teams and relationships with The nurse organizational commitment
patients and families based on Islam, while questionnaire was developed by researchers
caring environmentis an environment that can by adopting the organizational commitment
support spiritual beliefs; and belief in God is a concept of Caldwell, O’Reilly & Chatmann
belief in Allah SWT so that feel satisfaction (1990) and Mowday, Porter dan Steers (1982)
(ridha). in Asmaningrum (2009), which consisted of
identification, internalization, work
involvement and the desire to survive. The
METHODS questionnaire consisted of 15 closed questions
Study design in Likert scale (5 = strongly agree, 4 = agree,
This was a correlation analytic research with 3 = undecided, 2 = disagree and 1 = strongly
cross sectional design to analyze the disagree), with a range of values 57 – 75; and
application of Islamic Based Caring Model in its category consisted of: Poor if value
relation with organizational commitment <61.77, and Good if value > 61.77, with
among staff nurses in 2017. mean value as a cut of point. Correlation
coefficient in all items ranged from 0.601 –
Research subjects 0.926, and Cronbach alpha was 0.931.
The population in this study was the nurses in
the inpatient ward of Islamic hospital of Data analysis
Kendal amounted to 129 nurses. There were There were three types of analysis: (i)
108 nurses selected using a propotionate Univariate analysis was to describe the
stratified random sampling. The inclusion characteristics of nurses based age, sex,
criteria of the sample were nurses who education, length of work experience and
worked more than a year, were not marriage status, the implementation of Islamic
undergoing education, day off, or sick and Based Caring and organizational commitment.
willing to be a respondent. The exclusion (ii) Bivariate analysis was conducted to obtain
criteria included nurses working in outpatient the significance value of the relationship
!
between between individual characteristics RESULTS

with organizational commitment, and the Based on Table 1, the sample of this study
relationship between the implementation of amounted to 108 nurses in inpatient ward of
Islamic Based Caring with organizational the Islamic Hospital of Kendal with age of
commitment. (iii) Multivariate analysis was to respondents ranging between 22 - 39 years,
determine the most dominant application of with confidence interval 95% ranging
Islamic Based Caring related to the dependent between 27.53 - 29.13 years. While the
variable. shortest working experience was 1 year and
the longest was 17 years, with confidence
interval 95% ranging between 4.148 to 5.487
years.
Table 1 Frequency distribution of respondents based on age and length of work experience in the Islamic
Hospital of Kendal in August 2017 (N=108)
Variable Mean SD Min-Max CI 95%
Age (year) 28.33 4.194 22-39 27.53-29.13
Length of work experience (year) 4.818 3.5109 1-17 4.148-5.487
Table 2 Frequency distribution of respondents based on gender, education, and marriage status in the Islamic
Hospital of Kendal in August 2017 (N=108)
Characteristics Frequency (%)
Gender
Male 26 24.1
Female 82 75.9
Education
Diploma III in Nursing 73 67.6
Bechelor degree in Nursing 4 3.7
Ners 31 28.7
Marital status
Single 40 37.0
Married 68 63.0
*Ners: A program after bachelor degree in nursing
Table 2 showed that the frequency nursing, and 31 respondents (28.7%) with
distribution of respondents consisted of 26 Ners program background. Of all participants,
males (24.1%) and 82 females (75.9%). Based 40 respondents (37%) were single and 68
on educational background, 73 respondents respondents (63%) were married.
(67.6%) had Diploma III in nursing, 4
respondents (3.7%) had bachelor degree in
Table 3 Frequency distribution of the application of Islamic based Caring model in the Islamic Hospital of
Kendal in August 2017 (N=108)
Category Frequency Percentage (%)
Poor 60 55.6
Good 48 44.4
Total 108 100.0
Table 3 shows that the application of Islamic categorized as poor (60.2%) and good
based caring model was poor (55.6%) and (39.8%).
44.4% was good; while the organizational
commitment as shown in the Table 4 was

!
Table 4 Frequency distribution of the commitment to organization in the Islamic Hospital of Kendal in August
2017 (N=108)
Organizational
Frequency Percentage (%)
commitment
Poor 65 60.2
Good 43 39.8
Total 108 100.0
Table 5 The relationship between the application of Islamic Based Caring Model with the organization
commitment of nurses in the Islamic Hospital of Kendal in August 2017 using Chi-Square (N=108)
Application of Islamic Based Caring
Variabel p-value
Model
Organizational 0.000
A healing presence
commitment
Caring relationship
commitment
Caring environment
commitment
Belief in God (Allah SWT). Organizational 0.000
commitment
Table 5 shows that all indicators (a healing while Table 6 shows that the variable that has
presence, caring relationship, caring the highest correlation with organizational
environment and belief in God ) of Islamic commitment of nurses was Belief in God
Based Caring Model had a significant (Allah SWT) with the strength of correlation
correlation with the organisational (OR) of 6.660.
commitment of nurses with p-value <0.05;
Table 6 Logistic regression of a healing presence, caring relationship, caring environment and belief in God
with the organisational commitment of nurses in the Islamic Hospital of Kendal in August 2017 using forward
stepwise (conditional) (N=108)
Model Variable Coefficient p-value OR
Step 1 Belief in God 2.068 0.000 7.911 (3.304-18.945)
Constant -1.407 0.000 0.245
Step 2 A healing
1.604 0.002 4.974 (1.847-13.396)
presence
Belief in God 1.896 0.000 6.660
Constant -2.337 0.000 0.097
DISCUSSION
The result of the research shows that there Belief in God (Allah SWT) is closely related
was a significant relationship of healing peace, inner strength, personal well-being,
presence, caring relationship, caring and hope in crisis situations (Ismail et al.,
environment, and belief in God with 2015). According to this theory, nurses are
organizational commitment of nurses with p- able to to maintain a balance between all
value <0.05. Based on Forward Stepwise dimensions through their caring. Ultimately,
analysis, Belief in God was the only variable harmony in life can be achieved. From the
having the highest correlation to the patient side, nurses are encouraged to practice
organizational commitment of nurses. The their beliefs by praying five times a day,
statistical test results obtained an OR (Ex B) dhikr, and reciting the Quran to maintain the
of 6660, which indicated that the strength of balance of body, mind and soul through their
the relationship of the belief in God variable belief in God. In addition, patients and
was 6.660 times in increasing the nurse's families are also encouraged to be patient and
organizational commitment. sincere with the illness experienced and the
risk of death by praying and asking for help
!
from Allah SWT. They were also asked to organizational commitment among nurses has
accept the disease as a form of repentance for never been studied by previous research,
their sins and deaths as part of a journey to though because the IBC model is a new model
meet with Allah SWT. created by Suhartini (2016). The results of
this study indicated that there was a
Universal belief implies that the policies and significant relationship between the
systems applied in hospitals are not based on implementation of Islamic Based Caring
a particular religion or culture (Ismail et al., Model with organizational commitment of
2015). The hospital provides religious figures nurses, therefore this research can be an input
(Ulama in Indonesian term) to help patients for the management of the Islamic hospital of
and their families to support their belief in Kendal in particular or other Islamic hospital
God. Nurses suggest integrating spiritual management in applying the model in order to
needs into nursing care and the hospital attract and retain qualified nursing staff to be
system. consistent in providing professional nursing
service.
The Islamic hospital of Kendal is a hospital
that has a special character with Islamic This study has several limitations included
nuance that is reflected in everyday culture, that theory mentioned several factors
employees who strongly support the work influencing organizational commitment of
ethic of Islam are more committed to the nurses. However, this study did not include all
organization and then more likely to make variables, as the researchers only tested the
changes, which the change does not have the model of Islamic based caring. A cross
potential to change the basic values and sectional design in this study might have a
objectives of the organization and are limitation, which its sampling was done
considered to be beneficial to the organization simultaneously in one time without any direct
(Jamil, 2007). control by the researcher on the independent
variable. As this study only aimed to know the
The spiritual climate in the workplace affects relationship among some variables, further
organizational commitment, therefore the study is needed to analyze cause and effect of
spiritual workplace needs to be developed to the Islamic based caring model or quasi
foster a sense of community resulting in self- experiments or qualitative research methods
harmony, environmental harmony and to gain more comprehensive information on
transcendence (Anisah, 2016). Gain more the application of this model and
understanding of norms or work rules both in organizational commitment, and to examine
professional ethics and the dimensions of this model in relating to nurses' job
accountability, justice and truth in the work satisfaction, nurse's motivation and
ethic of Islam will actually carry out its duties performance, nurse burnout, patient
and functions, which further affecting its satisfaction and patient safety.
commitment to the profession and its
organization (Aji, 2016). It is asserted that
Islam is not only religion, it teaches its CONCLUSION
followers to obey the rules of God and follow It can be concluded that there is a significant
the Prophet of Muhammad SAW in lifestyle relationship between the implementation of
(Ismail et al., 2015). Islam declares that every Islamic Based Caring Model (a healing
action taken will be asked for responsibility presence, caring relationship, caring
both in the world and in the hereafter. Islamic environment, and belief in God) with
values are very influential on the attitude of organizational commitment of nurses. The
an employee to the work so that it can affect most dominant variable associated with
the commitment of employees to the organizational commitment of nurses is belief
organization. in God (Allah SWT). Therefore, it is
recommended that nurse managers may apply
This research has several advantages the Islamic based caring model as the
included: the research of the implementation Standard Operational Procedures (SPO) in
of Islamic Based caring model with

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nursing practice to increase the insurance company. Journal of Business

organizational commitment of nurses. Ethics, 124(2), 339-349.
Huang, C.-C., You, C.-S., & Tsai, M.-T. (2012). A
multidimensional analysis of ethical climate,
job satisfaction, organizational commitment,
REFERENCES and organizational citizenship behaviors. Nurs
Aji, G. (2016). Analisis Pengaruh Etika Kerja Islam Ethics, 19(4), 513-529.
Terhadap Komitmen Organisasi Dengan Ismail, S., Hatthakit, U., & Chinnawong, T. (2015).
Komitmen Profesi Sebagai Variabel Islamic Based Caring in Nursing Science: A
Intervening (Studi Empiris Terhadap Internal Literature Review. Paper presented at the
Auditor Bank Di Jawa Tengah). Economica: ASEAN/Asian Academic Society
Jurnal Ekonomi Islam, 1(2), 93-108. International Conference Proceeding Series.
Anisah, A. (2016). Hubungan Spiritualitas di Tempat Jamil, A. (2007). Pengaruh Etika Kerja Islam Terhadap
Kerja dengan Komitmen Organisasi Perawat Sikap-Sikap Pada Perubahan Organisasi:
di RSI Ibnu Sina Padang Tahun 2016. Komitmen Organisasoi Sebagai Mediator.
Universitas Andalas. Universitas Diponegoro.
Asmaningrum, N., Keliat, B. A., & Hastono, S. P. Jane Lee-Hsieh Msn, R. N., & Chien-Lin Kuo Ms, R. N.
(2011). Pengaruh Penerapan Spiritual (2005). Application and evaluation of a caring
Leadership terhadap Komitmen Perawat pada code in clinical nursing education. Journal of
Organisasi di Rumah Sakit Islam Surabaya. Nursing Education, 44(4), 177.
Jurnal Keperawatan Soedirman, 6(1), 9-19. Mowday, R. T., Porter, L., & Steers, R. Employee-
Baumann, A. (2007). Positive practice environments: Organization Linkages: The Philosophy of
Quality workplaces= quality patient care Commitment, Absenteeism and Turnover.
information and action tool kit', International NewYork: Academic Press. 1982.
Council of Nurses, Geneva. Geneva MOH. (2005). Pedoman Pengembangan Manajemen
(Switzerland) ISBN, 09-95040. Kinerja Perawat dan Bidan. In K. M. K. R. I.
Borhani, F., Jalali, T., Abbaszadeh, A., & Haghdoost, A. N. 836/Menkes/SK/VI/2005 (Ed.): Menteri
(2014). Nurses’ perception of ethical climate Kesehatan Republik Indonesia.
and organizational commitment. Nurs Ethics, Caldwell, D. F., Chatman, J. A., & O'Reilly, C. A.
21(3), 278-288. (1990). Building organizational
Fu, W., & Deshpande, S. P. (2014). The impact of commitment: A multifirm study. Journal of
caring climate, job satisfaction, and Occupational and Organizational Psycho-
organizational commitment on job logy, 63(3), 245-261.
performance of employees in a China’s
Cite this article as: Timorita, Y. A., Hartiti, T., Warsito, B. E., Ismail, S. (2017). The association of
Islamic based caring model and commitment to organizations in staff nurses. Belitung Nursing
Journal, 3(6), 670-676.
!
Sari RP, et al. Belitung Nursing Journal. 2017 December;3(6):677-685

EFFECT OF MULTI MICRONUTRIENT SUPPLEMENTATION ON

HEMOGLOBIN LEVELS IN PREGNANT WOMEN
WITH ANEMIA
Rati Purnama Sari1*, Noor Pramono1, Sri Wahyuni1 , Muchlis Achsan Udji Sofro2,3,
Melyana Nurul Widyawati1
1
Magister Applied Midwifery, Politeknik Kesehatan Kementerian Kesehatan Semarang, Indonesia
2
Department of Internal Medicine, RSUP Dr Kariadi, Semarang, Indonesia
3
Faculty of Medicine, Diponegoro University, Semarang, Indonesia
*Correspondence:
Rati Purnama Sari
Magister Applied Midwifery, Politeknik Kesehatan Kementerian Kesehatan Semarang, Indonesia
E-mail: ratipurnamasariab@gmail.com
Abstract
Background: The coverage of 90 Fe tablets in Semarang in 2015 was 26.619 of 29.490 pregnant women (97%) but the
incidence of anemia in pregnant women was still quite high. One important factor which influences the levels of
hemoglobin is multi micronutrient.
Objective: This study aims to analyze the changes in hemoglobin levels with multi micronutrient supplementation in
pregnant women with anemia.
Methods: A Quasy experimental study with randomized control group pre-post test design. The study samples were 40
pregnant women with gestational age of 20 ± 1 weeks divided into two groups, the intervention group (multi micronutrient
supplementation) and the control group (Fe supplementation) for 6 weeks. The study was conducted from November 2016
to January 2017. The levels of hemoglobin were measured using cyanmethohemoglobin. Paired t test and independent t
test were used for data analyses.
Results: The mean increase in hemoglobin levels after multi micronutrient supplementation was 1.545 (1.292) g/dl,
whereas the mean increase in hemoglobin levels after Fe supplementation was 0.757 (0.742) g/dl. The difference in
hemoglobin levels before and after multi micronutrient supplementation was significantly different (p=0.049). Cohen’s d
effect size test showed value of 0.748.
Conclusion: Multi micronutrient supplementation could improve hemoglobin levels. Increase in the levels of hemoglobin
with multi micronutrient supplementation was higher than Fe supplementation.
Keywords: Multi micronutrient, Fe, Pregnant Women with Anemia
INTRODUCTION
Anemia remains one of the health problems 29.6%, Singapore was 28.5%, Brunei
experienced by most countries in the world, Darussalam was 28.0%, Malaysia was 26.6%,
especially in developing countries. Globally and Vietnam was 23.5% (bank, 2016).
in 2011, according to WHO, anemia was
suffered by 29% of non-pregnant women and The prevalence of anemia in Indonesia is still
38% of pregnant women aged 15-49 years relatively high. Based on Basic Health
(World Health, 2014). According to World Research (Riskesdas), most of pregnant
Data Bank in 2011 pregnant women who were women had hypochromic anemia caused by
anemic in Myanmar was 33.3%, Philippines iron deficiency as much as 59%. While
was 32.3%, Thailand was 30%, Indonesia was macrocytic anemia caused by vitamin B12
BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017 ! 677!

Sari, R.P., Pramono, N., Wahyuni, S., Sofro, M. A. U., Widyawati, M. N. (2017)!
!
deficiency as much as 10.3% (Departemen

Kesehatan, 2008). Based on Riskesdas in Based on the results of a study showed that
2013, the prevalence of anemia in Indonesian there was a correlation between the intake of
population reached 21.7%. The groups at risk folic acid, vitamin B 12, vitamin E, and Cu
of anemia with the greatest prevalence were and the levels hemoglobin (Besuni, Jafar, &
among pregnant women of 31.7%, age 5-12 Indriasari, 2013). The analysis results in
years of 29%, under five children of 28.1%, adolescents showed that there was a
young women aged 13-18 years of 22.7%, as relationship between nutritional deficiency
well as women aged age 15-49 of 22.7% and anemia. Adolescents with folic acid daily
(MOH, 2013). The coverage of pregnant intake of <150 g/day had 2.8 times risk of
women who received Fe tablet in Central Java suffering from anemia. Adolescents with
Province in 2012 was 90.74% (Dinkes, vitamin C intake of <60 mg/day had 1.13
2014). times risk of suffering from anemia
(Tampubolon & Hadi, 2005).
During pregnancy the main factor, which
causes nutritional anemia, is lack of nutrition, Studies on micronutrients showed that
especially iron in the daily diet. Less iron vitamins and minerals had a correlation with
intake and low absorption of iron due to other hemoglobin levels. Study results conducted in
micronutrient deficiencies affect a decrease in pregnant women in South Sulawesi showed
blood hemoglobin levels and cause anemia.5 that hemoglobin levels were associated with
the prevalence of anemia during pregnancy is nutritional status, iron tablet intake and
risky for the mother and baby. Risks that can consumption patterns. The results showed that
occur in the form of complications during the prevalence of anemia among pregnant
pregnancy and childbirth and cause mortality, women reached 41%. Based on this study it
low birth weight, and growth/early was found that the mean of vitamin
development retardation (Ramakrishnan, consumption in pregnant women was only
2000). about 40% of the Nutrient Adequacy Score
(NAS) (Fatimah, Hadju, Bahar, & Abdullah,
One of the government's efforts to overcome 2011).
anemia is the provision of the iron tablet for
pregnant women, teenagers and Women of Results of a study on children in India showed
Fertile Age (WUS) groups. Treatment of that there was a significant increase in the
anemia in pregnancy has been focused on group with micronutrient supplements and
iron. Besides iron, red cell formation process biochemical parameters on the status of iron
requires the other micronutrient substances, and vitamin A. Hemoglobin increased by 0.52
which are necessary as a precursor to the g/dL, retinol by 8.56 mg/dL, ferritin by 108
process of erythropoiesis in the spinal cord. mg/L, iron of 1.27 mg and the prevalence
The presence of micronutrients such as decrease of retinol deficiency was from 51.6%
vitamin A, vitamin B, vitamin C, Zinc, Folic to 28.1%, anemia from 46.0% to 32.6%, iron
acid also plays an important role in helping to deficiency from 66.9% to 51.3 % and iron
improve the absorption of iron in the body. deficiency anemia from 35.2% to 31.0%,
Deficiency of micronutrients such as vitamin while the prevalence in the other two control
A, iron, iodine and folic acid is very common groups showed no significant differences
during pregnancy because of the increased (Kumar, Nirmalan, Erhardt, Rahmathullah, &
nutritional needs of the mother and the fetus Rajagopalan, 2014). A meta-analysis study
development (WHO, 2015). Multi concluded that micronutrient supplementation
micronutrients are naturally found in many in pregnant women was more effective than
fruits and vegetables. But the total diet study iron and folic acid supplementation in
results showed a mean of vegetable and dairy reducing the risk of low birth weight and
consumption per person per day in Indonesian premature birth (Kawai, Spiegelman, Shankar,
population by age group was only 57.1%. The & Fawzi, 2011).
mean of fruit consumption in Indonesia was
still low at only 33.5 grams per person per day Based on data from Semarang Health Office
(Balitbangkes, 2014). in 2015, the incidences of maternal anemia
678!
! BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017 !
were 3.861 of 21.057 pregnant women micronutrient supplementation has not been
(18.34%). The coverage of 90 tablets Fe in done.
Semarang in 2015 was 26.619 of 29.490
pregnant women (97%). Data form 37 Public
Health Centers in Semarang showed that the METHODS
highest incidence of anemia in 2015 was in Research Design
Bangetayu PHC as many as 337 of 1.282 This was a quasy experimental study with
pregnant women (26.29%). Data in 2014 randomized control group pre-post test
showed that anemia among pregnant women design.
in the PHC work area were also high as many
as 311 of 754 pregnant women (41.25%) Setting
(Dinkes, 2014). The study was conducted on November 3,
2016 until January 11, 2017.
Efforts have been made by Semarang Health
Office, among others, the provision of 90 Fe Population and Sample
tablets for pregnant women during pregnancy The study populations were anemic pregnant
(Dinkes, 2014). Other efforts by healthcare women in Bangetayu PHC. For test one tail
workers is by providing counseling on hypothesis with power 95%, significance
nutrition that could help increase the levels of difference in the two groups of 0.05 and 1.28
hemoglobin and proper Fe consumption. literature using the following formula (Dahlan
Monitoring and motivation were also given by Sopiyudin, 2009):
health surveillance officers (Gasurkes) of
health cadres in the community. While multi
n = 2 (Zα+Zβ)2σ2
(µc-µ1) 2
n = Number of samples per group
Zα = the value of the standard normal distribution that is equal to the significance level (for α= 0.05 is
1.64)
Z β = the value of the standard normal distribution that is equal to the significance level (for α= 0.05 is
1.28)
σ = standard deviation of outcome
µc-µ1 = the difference of mean outcome before and after intervention
n = 2 (Zα+Zβ)2σ2
(µc-µ1) 2
n = 2 (1.64+1.28)2(0.78) 2
(0.65)
n = 15.96 = 16 samples
To anticipate drop out, the researchers make corrections to the sample size, by adding a large
number of subjects in order to be fulfilled using the sample was calculated as follows:
!
!! =
1−!
n = sample size calculated
f = estimate of the proportion of dropouts, an estimated 20% (f = 0.2)
!
!! =
1−!
16
!! = = 20
1 − 0.2
To test one-tail hypothesis with 95% power

and significance of 0.05 and using the above Samples that met the inclusion and exclusion
formula, 20 samples were obtained for each criteria were acquired as many as 40 people.
either the intervention group (multi- Inclusion criteria for this study were pregnant
micronutrient supplementation) or the control women with the gestational age of 20 ± 1
group (Fe supplementation). weeks and experienced anemia (hemoglobin

!
levels of 7.0 to 10.5 g/dl). While the exclusion The data in this study were primary data. Data
criteria were pregnant women suffering from collection instrument used cyanmetho-
kidney disease, malaria, intestinal worms hemoglobin examination to measure
based on interviews; there was a family hemoglobin levels with conducted twice,
history of the disease blood disorders such as before given the intervention and 6 weeks
thalassemia and sickle moon; the use of after the intervention.
certain medications which could increase the
levels of hemoglobin (chemotherapy or Ethical Consideration
ARV); had a habit of drinking tea or coffee The process of data collection was performed
during pregnancy; and vegetarian. The drop by doing a home visit and coming to pregnant
out criteria were if the respondent died; women class on 88 pregnant women. This
resigned, missed from the monitoring/changes study has been getting ethical clearance from
in address, and were disobedient in taking the Research Ethics Committee of Heath
supplements of more than 10% of the number Polytechnic of Semarang (No: 212/KEPK
of tablets given. /Poltekkes-Smg/EC/2016). Respondents in
this study have given informed consent about
The sampling technique used simple random this study and willing to participate by signing
sampling, single blind. Randomization was letter of informed consent.
performed by using sealed envelopes to
determine the samples in the intervention Data Analysis
group or the control group and signed Paired t test and independent t test were used
informed consent. for data analysis.
Intervention
Respondents in the intervention group were RESULTS
given multi micronutrient supplementation. Fe Characteristics of the Respondents
supplementation was given for the control All respondents followed the study until the
group. Multi micronutrient supplementation is end and there was no dropout. Characteristics
supplementation in tablets form, each tablet of the respondents in this study consisted of
content of vitamins and minerals (vitamin A age, parity, pregnancy spacing, nutritional
6000 IU, vitamin D 400 IU, vitamin C 100 status and economic status. Each variable was
mg, vitamin B1 10 mg, vitamin B2 2.5 mg, analyzed to see the difference between the
vitamin B6 15 mg, vitamin B12 4 mcg, two groups. Distribution of the respondents’
niacinamide 20 mg, Ca panthothenate 7.5 mg, characteristics is shown in Table 1.
folic acid 1 mg, Fe fumarate 90 mg, Ca lactate
250 mg, iodine 0.1 mg). Fe supplementation The analysis on the respondents’
is supplementation in tablets form, each tablet characteristics obtained non-significant
content of Fe 90 mg and folic acid 0.4 mg. differences in the characteristics (age
Supplementation was given once a day for 42 p=0.457, parity p=0.736, pregnancy spacing
days. Respondents were reminded to p=0.073, nutritional status p=0.849 and
consume supplement via Short Message economic status p=0.723) similar in multi-
Service (SMS) every week. micronutrient supplementation group and Fe
supplementation group. So, the characteristics
Instrument of the respondents had the same effect on the
two groups.
Table 1 Distribution of general characteristics and health characteristics (nutritional status)

MMN Fe
Variable p-value
Supplementation Supplementation
Age (years) (n i=20; n k=20)
- mean (SD) 27.80(4.51) 29.05(5.91) 0.457
- median 27 31
- minimum 21 20
- maximum 37 38
680!
Parity (people) (n i=20; n k=20)

- primigravida 6 7 0.736
- multigravida 14 13
Pregnancy spacing (month) (n i=14; n
k=13) 55.43(25.55) 71.54(29.44) 0.073
- mean (SD) 60 84
- median 14 18
- minimum 84 108
- maximum
Nutritional Status (cm) (n i=20; n k=20)
- mean (SD) 25.20(3.06) 25.03(2.78) 0.849
- median 24.75 24
- minimum 21 21
- maximum 33 32
Economic Status (people) (n i=20; n k=20)
- Under UMK 6 5 0.723
- Above UMK 14 15
Table 2 Hemoglobin Levels before and after supplementation

Group MMN Supplementation Fe Supplementation
Before intervention (gr/dl) (n i=20; n k=20)
- mean(SD) 9.71(0.79) 10.02(0.37)
- median 10.09 9.96
- minimum 8.22 9.33
- maximum 10.50 10.50
After intervention (gr/dl) (n i=20; n k=20)
- mean(SD) 11.26(1.32) 10.77(0.82)
- median 10.96 10.75
- minimum 9.51 9.10
- maximum 13.98 12.54
p=0.0001 p=0.0001
Hemoglobin levels in the multi micronutrient mean of 10.02 (0.37) g/dl and after
supplementation group before supple- supplementation showed the mean of 10.77
mentation showed the mean of 9.71 (0.79) (0.81) g/dl. Hemoglobin levels after multi-
g/dl and the mean after supplementation was micronutrient supplementation was higher
11.26 (1.32) g/dl. Hemoglobin levels before than before multi micronutrient supple-
and after multi micronutrient supplementation mentation. Hemoglobin levels before and
showed significant difference (p=0.0001). after Fe supplementation had significant
difference (p=0.0001). Hemoglobin levels
Hemoglobin levels in the Fe supplementation after Fe supplementation was higher than
group before supplementation showed the before Fe supplementation.
Table 3 The results of difference test of the difference in hemoglobin levels before and after
administration of multi micronutrient supplementation and Fe supplementation
MMN Fe
Group p-value
Supplementation Supplementation
Difference in hemoglobin levels before and after
(gr/dl) (N i=20; N k=20)
- mean(SD) 1.545(1.292) 0.757(0.742) 0.049
- median 1.38 0.71
- minimum 0.20 -0.60
- maximum 5.43 2.14

!
Based on the above table it can be seen that compared to the group that was not given. In
the mean increase in hemoglobin levels after addition the group with multi-micronutrient-
multi-micronutrient supplementation was fortified beverage also experienced an
1.545 (1.292) g/dl, while the mean increase in increase in weight, UAC size and BMI (Hyder
hemoglobin levels after Fe supplementation et al., 2007). Results of a study conducted on
was 0.757 (0.742) g/dl. Difference in pregnant women in China found that Fe
hemoglobin levels before and after the multi- supplementation with a combination of retinol
micronutrient supplementation was and riboflavin vitamins had an increase in
significantly different (p=0.049). The increase hematological status as well as well as
of hemoglobin levels after multi micronutrient oxidative stress and erythrocyte membrane
supplementation was higher than after Fe fluidity. Hematologic status in the form of
supplementation. Based on of Cohen’s d hemoglobin levels increased by 2.18 g/dl
effect size test, in this study was 0.748. compared to the control group. Oxidative
stress parameters was indicated by increased
glutathione peroxidase activity of 87.9 IU/ml
DISCUSSION and the decrease in malondialdehyde levels by
Difference in hemoglobin levels in the 2.56 mmol/l (Ma et al., 2010). Based on the
intervention group study results, it can be concluded that multi-
Hemoglobin levels after multi micronutrient micronutrient supplementation in pregnant
supplementation was higher than before women with anemia could improve
supplementation. Hemoglobin levels in multi hemoglobin levels.
micronutrient supplementation group
experienced a mean increase of 1.545 g/dl. Difference in hemoglobin levels in the
The mean of hemoglobin levels in pregnant control group
women before multi micronutrient Hemoglobin levels after Fe supplementation
supplementation was 9.71 g/dl, considered as was higher than before supplementation.
moderate anemia (<10 g/dl). After the multi- Hemoglobin levels in Fe supplementation
micronutrient supplementation for 6 weeks, group had a mean increase of 0.757 g/dl. The
the mean of hemoglobin levels in pregnant mean of hemoglobin levels in pregnant
women became 11.26 g/dl, categorized as women before Fe supplementation was 10.02
non-anemic. g/dl, categorized as mild anemia (<10 g/dl).
After Fe supplementation for 6 weeks, the
This study is in line with the results of a study mean of hemoglobin levels in pregnant
conducted in China, which showed that the women became 10.77 g/dl, categorized as
combination of vitamin and multi- non-anemic. The study results are consistent
micronutrients was more effectively to with the results of a study on tobacco leaf
increase hemoglobin levels in preschool sorters women in Deli Serdang said that iron
children compared to the provision of Vitamin tablet (Fe) supplementation for 3 months
alone or a combination of Vitamin A and zinc. could increase hemoglobin levels by 2.14
The group that got multi micronutrients had g/dl. The results also showed that the
an increase in the mean of hemoglobin levels hemoglobin level was closely related to with
of 0.635 g/dl (Chen et al., 2012). The factor work productivity (Oppusunggu, 2009).
that influences the increase in hemoglobin is Results of a meta-analysis of three studies
the content of riboflavin, vitamin B-12 and showed that Fe supplementation orally for 4-6
folic acid that play a role in the metabolism of weeks might increase hemoglobin levels mean
iron or hemoglobin synthesis. Vitamin A is of 0.35 g/dl. Results of a study conducted in
directly as a facilitator with an impact in patients after surgery showed that there was
hematopoiesis. Vitamin A has important role an increase in hemoglobin of 2.0 g/dl after Fe
in the regeneration of cells including therapy for 4 weeks (Tay & Soiza, 2015). The
erythrocytes (Chen et al., 2012; Grober, results are consistent with the results of a
2013). A study conducted on female study in Padang, which stated that Fe tablet
adolescents in Bangladesh showed that the supplementation had a relationship with
group who were given multi-micronutrient- anemia status of pregnant women. Fe tablet
fortified beverage had increased serum ferritin
682!
consumption could affect the Fe adequacy of micronutrients, especially iron so that may
pregnant women (Azra & Rosha, 2015). cause the occurrence of hypochromic anemia
(Barasi, 2013). Vitamin B6 plays a role in the
Based on these results it can be concluded that formation of heme precursor in hemoglobin
the Fe supplementation in pregnant women called alpha-delta-aminolevulinic acid
with anemia could improve hemoglobin synthase. In addition, pyridoxine also assists
levels. Fe supplementation that has become a in the process of iron incorporation into heme
government program was proven to increase (Grober, 2013). One major function of
hemoglobin levels. vitamin B12 is in cell metabolism. Vitamin
B12 plays a role in the formation of red blood
Difference in hemoglobin levels in the cells or erythrocytes in the process of cell
intervention group and the control group maturation (Almatsier, 2002).
Based on these results an increase in
hemoglobin levels in multi micronutrient Folic acid along with vitamin B12 affects the
supplementation group was higher than the hemoglobin levels that are required in the
increase in hemoglobin levels in control erythrocytes synthesis. Folic acid plays a role
group. The mean of hemoglobin levels after in the production of heme to form purine and
multi micronutrient supplementation was pyrimidine in the synthesis of DNA and RNA
increased by 1.545 g/dl. The mean of in the erythropoiesis process. Folic acid or
hemoglobin levels after Fe supplementation vitamin B12 deficiency may cause the
was increased by 0.757 g/dl. growing cells are not capable of performing
DNA replication prior to division. So the
Multi micronutrient supplementation is a erythrocytes produced will have larger size
necessary supplement for pregnant women, (megaloblastic) with lower density and
which contains vitamin A, vitamin B1, smaller amounts. So that folic acid deficiency
vitamin B2, vitamin B6, vitamin B12, vitamin can cause megaloblastic anemia and
C, folic acid, and Fe. In the process of macrocytic anemia (Almatsier, 2002).
erythrocytes maturation, the spinal chord
needs many precursors so for effective Vitamin C plays a role to reduce the ferry into
erythropoiesis process. Precursors include the ferrous in the small intestine that
iron, vitamin C, vitamin B1, vitamin B2, facilitates the absorption of iron. Vitamin C
vitamin B12 and oxygen (O2) that are can increase absorption of iron in the form of
required by the erythropoietin hormone non-heme up to four times. Vitamin C plays a
(Hofbrand, Petit, & Moss, 2013). Complete role in the transfer of iron from transferrin in
multi micronutrients are jointly supporting the the plasma into ferritin stored in liver
increasing levels of hemoglobin. Vitamin A is (Almatsier, 2002). Another component, which
important in iron metabolism and the plays a key role in hemoglobin, is iron. Iron
production of hemoglobin. Vitamin A plays a plays a role in oxygen transportation and
role as a facilitator of ferritin use in storage. Iron is a component of hemoglobin
hematopoietic process (Barasi, 2013). that carries oxygen throughout the body. Iron
Vitamin A plays a role in increasing the use of is an essential element in the formation of
iron in hematopoiesis. Vitamin A has a role heme protein composed of porphyrin
related to erythrocytes in the production of protoporphyrin compounds and trivalent Fe
erythrocytes; protein synthesis and iron (Grober, 2013).
transfer both in mobilization and
incorporation. Vitamin A can directly The study results are consistent with the
stimulate erythropoiesis (Grober, 2013). results of a study suggested that between
multi micronutrient supplementation
Other micronutrients contribute indirectly and compared to no multi micronutrient
together act as a coenzyme in the supplementation or placebo, there was a
hematopoietic process. Vitamin B2 helps to significant difference in reducing anemia in
increase the metabolism of folic acid, pregnant women. The group that received
pyridoxine and niacin. Deficiency of vitamin multi micronutrient supplementation
B 2 results in lower absorption of compared to group that received iron and folic

!
acid supplementation might reduce anemia in hemoglobin levels and types of anemia by
pregnant women by 1.23 times (Haider & using accurate laboratory tests and a more
Bhutta, 2006). Another study said that there extensive study site and longer study duration
was a significant difference in the increase in until delivery (time series).
hemoglobin levels between the groups with
iron and vitamin C supplementation compared
to the iron supplementation group. The mean REFERENCES
of hemoglobin levels in women of Almatsier, S. (2002). Prinsip dasar ilmu gizi: Gramedia
childbearing age for 12 weeks in the iron and Pustaka Utama.
Azra, P. A., & Rosha, B. C. (2015). FAKTOR-
vitamin C supplementation group of 1.937 FAKTOR YANG BERHUBUNGAN
g/dl was higher compared to the iron group of DENGAN STATUS ANEMIA IBU HAMIL
1.547 gr/dl (Utama, Listiana, & Susanti, DI WILAYAH KERJA PUSKESMAS AIR
2013). Another study conducted on girls in DINGIN KECAMATAN KOTO TANGAH,
KOTA PADANG. Jurnal Kesehatan
Central Java showed a greater intake of iron, Reproduksi, 6(2), 89-95.
zinc, copper, folic acid and vitamin B 6, the Balitbangkes. (2014). Buku Studi Diet Total: Survei
higher the hemoglobin levels. Zinc is a Konsumsi Makanan Individu Jakarta:
cofactor in the retinol oxidation reaction, thus Balitbangkes Kementerian Kesehatan RI.
zinc indirectly affected the iron metabolism. bank, W. D. (2016). Prevalence of Anemia among
Pregnant Women. from
Copper helps the absorption of iron, helps http://databank.worldbank.org/data/reports.asp
hematopoiesis, and stimulates the release of x?source=2&type=metadata&series=SH.PRG.
ferritin contained in the liver. Folic and ANEM
vitamin B6 also play important role in Barasi, M. (2013). Nutrition at a Glance: John Wiley &
Sons.
hematopoiesis process (Cendani & Besuni, A., Jafar, N., & Indriasari, R. (2013). Hubungan
Murbawani, 2011). Asupan Zat Gizi Pembentuk Sel Darah Merah
dengan Kadar Hemoglobin pada Ibu Hamil di
Results of a study on girls showed that the Kabupaten Gowa. Universitas Hasanuddin.
addition of multi-vitamins on iron supplement Makasar.
Cendani, C., & Murbawani, E. A. (2011). Asupan
with a certain dose taken once a week mikronutrien, kadar hemoglobin dan
compared to the consumption of Fe tablets kesegaran jasmani remaja putri. Media Medika
and the control group (placebo) could Indonesiana, 45(1), 26-33.
significantly improve iron status by using Chen, L., Liu, Y.-F., Gong, M., Jiang, W., Fan, Z., Qu,
P., . . . Li, T.-Y. (2012). Effects of vitamin A,
receptor transferrin serum (STfR) and serum vitamin A plus zinc, and multiple
ferritin (SF) indicators (Besuni et al., 2013). micronutrients on anemia in preschool
Based on the study results it can be concluded children in Chongqing, China. Asia Pacific
that multi-micronutrient supplementation in journal of clinical nutrition, 21(1), 3-11.
pregnant women with anemia could improve Dahlan Sopiyudin, M. (2009). Besar sampel dan cara
pengambilan sampel [Besar sampel dan cara
hemoglobin higher compared to Fe pengambilan sampel]: Jakarta: Salemba
supplementation. Medika.
Departemen Kesehatan, R. I. (2008). Laporan Nasional
Riskesdas 2007. Jakarta: Badan Penelitian
dan Pengembangan Kesehatan Departemen
CONCLUSION Kesehatan Republik Indonesia.
Based on the study results, multi Dinkes. (2014). Health Profile of Central Java Province:
micronutrient supplementation and Fe Department of Health of Central Java.
supplementation could improve hemoglobin Fatimah, S., Hadju, V., Bahar, B., & Abdullah, Z.
levels. An increased level of hemoglobin with (2011). Pola konsumsi dan kadar hemoglobin
pada ibu hamil di Kabupaten Maros, Sulawesi
multi-micronutrient supplementation was 2- Selatan. Makara Kesehatan, 15(1), 31-36.
fold higher than that Fe supplementation, and Grober, U. (2013). Mikronutrien: Penyelarasan
multi-micronutrient supplementation in Metabolik, Pencegahan, dan Terapi. Penerbit
pregnant women should be considered or Buku kedokteran EGC, Jakarta.
Haider, B. A., & Bhutta, Z. A. (2006). Multiple-
proposed compared to only Fe micronutrient supplementation for women
supplementation in the treatment of anemia in during pregnancy. Cochrane Database Syst
pregnant women. Further study is needed to Rev, 4(4).
take into account the recall diet of the Hofbrand, A., Petit, J., & Moss, P. E. (2013). Aspek
respondents, screening for diseases that affect Umum Anemia. Kapita Selekta Hematologi.
684!
Hyder, S. M. Z., Haseen, F., Khan, M., Schaetzel, T., Oppusunggu, R. (2009). Pengaruh pemberian tablet
Jalal, C. S. B., Rahman, M., . . . Mehansho, H. tambah darah (Fe) terhadap produktivitas
(2007). A multiple-micronutrient-fortified tenaga kerja wanita pensortir daun tembakau
beverage affects hemoglobin, iron, and di PT X Kabupaten Deli Serdang [tesis].
vitamin A status and growth in adolescent Medan: Universitas Sumatera Utara.
girls in rural Bangladesh. The Journal of Ramakrishnan, U. (2000). Nutritional anemias: CRC
nutrition, 137(9), 2147-2153. press.
Kawai, K., Spiegelman, D., Shankar, A. H., & Fawzi, Tampubolon, B., & Hadi, H. (2005). Hubungan asupan
W. W. (2011). Maternal multiple zat gizi dengan status besi pada remaja putri
micronutrient supplementation and pregnancy SMU di Kabupaten Jayapura. Universitas
outcomes in developing countries: meta- Gadjah Mada.
analysis and meta-regression. Bull World Tay, H. S., & Soiza, R. L. (2015). Systematic Review
Health Organ, 89(6), 402-411. and Meta-analysis: What is the Evidence for
Kumar, M. V., Nirmalan, P. K., Erhardt, J. G., Oral Iron Supplementation in Treating
Rahmathullah, L., & Rajagopalan, S. (2014). Anaemia in Older People? Paper presented at
An efficacy study on alleviating micronutrient the Age and ageing.
deficiencies through a multiple micronutrient Utama, T. A., Listiana, N., & Susanti, D. (2013).
fortified salt in children in South India. Asia Perbandingan Zat Besi dengan dan Tanpa
Pacific journal of clinical nutrition, 23(3), Vitamin C terhadap Kadar Hemoglobin
413-422. Wanita Usia Subur. Kesmas: National Public
Ma, A. G., Schouten, E. G., Sun, Y. Y., Yang, F., Han, Health Journal, 7(8), 344-348.
X. X., Zhang, F. Z., . . . Kok, F. J. (2010). WHO. (2015). Multiple Micronutrient Supplementation
Supplementation of iron alone and combined During Pregnancy. Retrieved January 12,
with vitamins improves haematological status, 2016, from
erythrocyte membrane fluidity and oxidative http://www.who.int/elena/titles/micronutrients
stress in anaemic pregnant women. British _pregnancy/en/
journal of nutrition, 104(11), 1655-1661. World Health, O. (2014). Global nutrition targets 2025:
MOH. (2013). Riset Kesehatan Dasar; RISKESDAS anaemia policy brief.
(Basic Health Research). Ministry of Health
of the Respublic of Indonesia, Jakarta.
Cite this article as: Sari, R.P., Pramono, N., Wahyuni, S., Sofro, M. A. U., Widyawati, M. N. (2017).
Effect of multi micronutrient supplementation on hemoglobin levels in pregnant women with anemia.
Belitung Nursing Journal, 3(6), 677-685.
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Maharani SI, et al. Belitung Nursing Journal. 2017 December;3(6):686-692

DARK CHOCOLATE’S EFFECT ON MENSTRUAL PAIN IN

LATE ADOLESCENTS
Sandy Isna Maharani1*, Noor Pramono2, Sri Wahyuni3
1
Postgraduate Midwifery Program, Semarang Health Polytechnic, Semarang, Indonesia
2
Medical Faculty of Diponegoro University of Semarang, Indonesia
3
Midwifery Program, Semarang Health Polytechnic, Semarang, Indonesia
*Correspondence:
Sandy Isna Maharani
Postgraduate Midwifery Program, Semarang Health Polytechnic
E-mail: sandyisnam@gmail.com
Abstract
Background: Menstrual pain can be severe enough to interfere with everyday activities for a few day every month,
particualrly in activities in homes and schools for late adolescents. Dark chocolate is considered effective in reducing
menstrual pain. However, little is known about its effect.
Objective: This study aimed to examine the effect of dark chocolate on menstrual pain in late adolescents.
Methods: This was a true experiment study with randomized pretest-posttest with control group design. This study was
conducted from September to November 2016 at the Bhakti Husada Boarding School of Poltekkes Kemenkes Semarang.
There were 50 samples recruited by simple random sampling, with 25 randomly assigned to the experiment and control
group. Numeric Rate Scale (NRS) was used to measure pain. Independent t-test and Mann-whitney were used to examine the
effect of intervention.
Results: There were significant differences in menstrual pain (p <0.001) before and after treatment. The mean of menstrual
pain in the treatment group (2.76 ) was lower than the menstrual pain in the control group (5.36) with p <0.001.
Conclusion: Dark chocolate could reduce menstrual pain significantly in the late adolescents.
Keywords: Adolescent, Menstrual Pain, Dark Chocolate
INTRODUCTION
A teenager is an individual who has already a that menstruation will be faced by teenagers
mature anatomy and reproductive function every month. Discomfort that is felt before the
Adolescent puberty is characterized by menstrual period and at the time of
elevated levels of hormone luteininzing (LH) menstruation will accompany the teenagers
and follicle stimulating hormone (FSH) so despite different cycles and times (Santrock &
that sex hormones are formed (Santrock & Santrock, 2007).
Santrock, 2007). These hormones mature the
reproductive organs such as the ovaries, Menstrual pain or dysmenorrhea is stiffness or
uterus, vagina, breasts, and the appearance of seizures in the lower abdomen due to
secondary sexual features such as the menstruation and production of prostaglandin
appearance of hair on the armpits, genitals, substances that occur at the time of or during
fine hairs on the skin, face and so on. This is menstruation (Widyastuti, Rahmawati, &
also the start of the first menstruation Purnamaningrum, 2009). Usually, pain is felt
(menarche). Conditions that we then know in the day before the menstrual period and

!
Maharani, S. I., Pramono, N., Wahyuni, S. (2017)!
lasts for two days or until the end of community about interventions such as the
menstruation. The prevalence of menstrual example above. However, there is an
pain vary between 15.8 – 89.5%, with the increasing interest in the use of herbs outside
high prevalence is in teenager (Llewellyn- medical therapy derived from traditional
Jones, 2005). Western countries. There is also evidence to
suggest that not all herbs are safe and concern
Data in Indonesia showed that primary about undesirable side effects (Puspitasari &
menstrual pain is experienced by 60-75% of Novia, 2008). One therapy that can be used as
young women, with three-quarters of these an alternative to overcome the pain during
suffering from mild to moderate pain and a premenstruation and menstruation time is dark
further quarter of severe pain. The effects of chocolate.
primary menstrual pain include activity
disorders such as high absence rates from Dark chocolate contains many benefits in the
school work, social life limitations, academic health field. Substances contained in
performance, and sport activities. The chocolate are rich in vitamin A, B1, C, D, and
problem of dysmenorrhoea also affects the vitamin E. In addition, chocolate also contains
decrease of quality of life due to not attending anti-oxidants of phenol and flavonoids, rich in
school or work (Parker, Sneddon, & Arbon, minerals such as calcium, potassium, iron, a
2010). It also affects economic loss in women little omega 3 and 6, and high magnesium
of childbearing age, and affects the national (Nurazizah, Tih, & Suwindere, 2015), which
economic loss due to the decreasing quality of can reduce menstrual pain and premenstrual
life. It can also cause infertility and impaired occurrence in women Chocolate, in all of its
sexual functioning if untreated, depressed, and forms, starts at the same source:
alteration of cardiac autonomic activity the Theobroma cacao tree that has been
(Stoelting‐Gettelfinger, 2010). Severe cultivated over 3,000 years ago by Native
menstrual pain often disrupts women's Americans of Central and North America of
activities and abilities in their daily activities South America (cacaoweb, 2016).
and functions in homes, schools and
workplaces. Dysmenorrhoea can affect The direct effect of magnesium will put
women's reproductive systems for years. In pressure on the blood vessels and will help to
some teenagers, primary dysmenorrhea is a regulate the entry of calcium into the smooth
torture that must be experienced every month, muscle cells in the body, so that it can affect
so adolescents should be able to search the the occurrence of contraction, stress and
right solution to overcome them. relaxation of smooth muscle of the uterus.
Therefore, changes that occur in dietary habits
Some ways can be done to overcome the tend to modulate the metabolic status of
symptoms of discomfort during menstrual individuals who have a free lifestyle that is
period, and the treatment is given by looking closely related to long-term health
at the severity of symptoms caused, usually in consequences. Dark chocolates can reduce
the form of pharmacological and non- menstrual pain because it has a variety of
pharmacological therapy. Some of the things ingredients that qualify as a person
that can be done to deal with the pain of (Arfailasufandi, 2015). Data obtained from
menstruation are using drug therapy, the Community Health Center of Pandanaran
psychotherapy, lifestyle changes, and healthy showed that the incidence of women who
diets such as consumption of vegetables, came with menstrual pain amounted 31
fruits, complex carbohydrates, exercise, patients in 2015. Of the 31 patients, 11
adequate rest, avoidance of alcohol, high-fat patients were teenagers. At the time the
foods, mineral therapy, vitamins and drugs patient check, particularly patients who are
(Elvira, 2010). still in school, must be accompanied by one of
her parents and ask permission not to attend
Science related to dysmenorrhea is still the school. Thus, the perceived pain interferes
inadequate to provide specialized clinics, with their activity. The therapy used is in
examining the potential benefits or risks to the accordance with the standards of the health
center, ie the provision of Fe tablets, Vitamin

!
K and mafenamat acid, but not yet for the measure pain. The 10-point numeric scale
consumption of dark chocolate. ranges from '0' representing one pain
extreme (e.g. “no pain”) to '10' representing
Preliminary study conducted on 20 female the other pain extreme (e.g. “pain as bad as
students living in Bakti Husada Dormitory of you can imagine” or “worst pain
Poltekkes Kemenkes Semarang in March imaginable”) (Judha & Sudarti, 2012). Pain
2016 found that 10 people (50%) said was measured before and after intervention.
experiencing menstrual pain every month,
especially from the first day until the second Intervention
menstrual period. Because they have not Intervention was performed by giving dark
received the materials in the lectures on pain chocolate as much as 40gr / day during the
management and reproductive health, students first 3 days after the menstrual date in the
overcome their pain with sleep, rest and some intervention group, with the assistance of an
people drink yogurt or tamarind. Although the enumerator (a housemother). Dark chocolate
pain does not affect their attendance to school, was given in the form of a bar that has been
but almost all respondents stated that they processed in a chocolate-making factory in
have activity disorder when experiencing Yogyakarta City. Given immediately after the
menstrual pain. Therefore, with this first day menstruation. While control group
phenomenon and the benefit of dark was given 40gr / day of milk chocolate during
chocolate. This study aimed to examine the the first 3 days after the menstrual date.
effect of dark chocolate on menstrual pain in Chocolate milk was given because the milk
teenagers. chocolate provided contains only 20%
chocolate and the rest is made from other
ingredients such as milk, sugar and vegetable
METHODS fat as well as other ingredients.
Study Design
This was a true experiment study with Ethical consideration
randomized pretest-posttest with control Ethical clearance research number: 023 /
group design. KEPK / Poltekkes-SMG / EC / 2017. Prior to
data collection, prospective respondents were
Setting given an explanation of the purpose and
This study was conducted from September to benefits of research, and asked to sign a
November 2016 at the Bhakti Husada written informed consent.
Boarding School of Poltekkes Kemenkes
Semarang. Data Analysis
Descriptive statistics were used in this studty
Research Subjects to describe the mean and frequency
There were 50 samples recruited by simple distribution in the experiment and control
random sampling, with 25 randomly assigned group. Independent t-test and Mann-whitney
to the experiment and control group. The were used to examine the ffect of
inclusion criteria of the samples included: 1) intervention.
young woman aged 18-21 years, 2)
experiencing pre-menstrual pain and
menstrual pain in the last 3 months, 3) regular RESULTS
menstrual cycle, 4) single, 5) not taking Characteristics of the respondents
analgesic medication in the last 24 hours, 6) Table 1 shows that the mean age of the
and willing to be a respondent. The exclusion respondents was 18-19 years old in the
criteria included: young woman diagnosed experiment and control group. There were no
with certain gynecologic disease or secondary significant differences of age, nutrient intake
dysmenorrhea, and allergic to chocolate. and BMI between the two groups with p-value
>0.05. It could be said the characteristics of
Instruments the respondents between the two groups were
Numeric Rate Scale (NRS) was used to homogenous.
!
Table 1 Characteristics of the respondents based on age, nutrient intake, and BMI
Characteristics of respondent Experiment group Control group p-value
Age
Mean (SD) 18.20 (0.408) 18.16 (0.374)
Median 18.00 18.00 0.716
Min 18 18
Max 19 19
Nutrient intake
• Carbohydrate
Mean (SD) 104.18 (26.06) 119.06 (26.38)
Median 112.2 118.9
Min 44.8 56.5 0.074
Max 137.9 187.5
• Magnesium
Mean (SD) 149.75 (72.57) 158.17 (62.36)
Median 124.7 173.1
Min 49.7 51.3 0.614
Max 326.1 254.9
• Calcium
Mean (SD) 211.53 (180.28) 207.84 (96.84)
Median 162.9 201
Min 26.5 30.4 0.404
Max 964.2 399.9
• Phosphor
Mean (SD) 473.01 (158.7) 501.48 (122.3)
Median 406.4 540.1
Minimum 205.9 205.9 0.426
Max 766 667.5
• Iron
Mean (SD) 7.61 (1.07) 6.07 (2.83)
Median 4.6 7.30 0.573
Minimum 2.0 2.0
Max 57.2 11.5
Body Mass index (BMI)
Mean (SD) 19.44 (2.27) 19.91 (2.01)
Median 18.90 19.25 0.347
Minimum 16.42 17.09
Max 24.97 25.89
Table 2 Menstrual pain in the experiment and control group

Frequency
Group Pretest Posttest p
distribution
Experiment Mean (SD) 7.44 (0.92) 2.76 (1.20)
Median 7 3 0.001
Min 6 1
Max 9 6
Control Mean (SD) 6.20 (1.04) 5.36 (1.11)
Median 6 5
Min 5 3
Max 8 7
Table 2 shows that the mean of menstrual experiment group shows a higher decrease of
pain in the experiment group before given pain compared to the control group.
intervention was 7.44 and decreased to 2.76
after given intervention. While in the control
group the mean of menstrual pain before DISCUSSION
given intervention was 6.20 and decreased to Respondent's Characteristic
5.36 after given intervention. There was a The age characteristics of both groups were
significant difference in menstrual pain before the same. The average age was 18.2 years up
and after given intervention in the two groups to 18.16 years. In this study, the respondent's
with p-value 0.001 (<0.05). However, the age was the late adolescent age (18 to 21

!
years). The late adolescents were selected as 158.17 mg in the control group. At the time of
respondents because the age group mostly menstruation occurs, women will lose a
took education in college, and were more number of minerals and micronutrients in the
prone to experiencing pain during body. Magnesium has a natural benefit for
menstruation, with busy activities and easy to reducing menstrual pain. Magnesium can help
stress and lack of a number of nutrients due to smooth muscle contraction in the uterus
have poor diet especially during menstruation, become more relaxed. The need for
especially minerals and micro substances. magnesium in adolescents based on
Menstrual pain also reduces the concentration Nutritional Adequacy Rate (AKG) is 300 mg /
of adolescents in learning and daily activities day. By consuming dark chocolate 69% as
each month. much as 40 grams per day is expected to
increase the amount of magnesium in the
Food intake of respondents was assessed by body and reduce pain during menstruation.
processing the daily menu into the Dose of dark chocolate 69% as much as 40 gr
Nutrisurvey 2007 application in cooperation contains enough magnesium that is equal to
with the nutrition section. The application was 115 mg which will help increase the amount
used to calculate the amount of nutrients of magnesium in body obtained from food. In
especially carbohydrates, magnesium, the previous study we found out that
calcium, iron and phosphorus consumed. The menstrual pain can be overcome by
results obtained show the value or content of consuming magnesium as much as 300 mg
respondent's nutrients in accordance with during pain (Wulandari & Afriliana, 2017).
what is consumed. In this study, the average
carbohydrate intake of respondents was In addition to magnesium, a mineral that is
104.18 g for the treatment group and 119.06 important during menstruation is calsium.
grams for the control group. Carbohydrates in Calsium is able to activate the nerves and
teenagers needed is 309 grams (Indonesia, muscle contraction, blood vessel launched
2013), so it can be seen that the carbohydrate during menstruation, reduce cramps and keep
intake in the respondents was still lacking. balance of body fluids. Giving chocolate to
This is because the respondents who were all the respondent provides additional calcium in
women choose to reduce the rice so that their the body of the respondents amounted 32 mg .
body weight does not rise. Source of While the need for calcium in adolescents
respondent carbohydrate comes from basic according to Nutritional Adequacy Rate
food such as rice, bread interlude, crackers (AKG) is 1100 mg (Wulandari & Afriliana,
and others. In this study, carbohydrate 2017). So consuming dark chocolate in this
consumption of respondents was assessed study did not affect the decrease of menstrual
because carbohydrates is a source of energy pain in the respondents because of the small
that can also contribute high enough calories amount to be consumed. The results of the
and sugar that could inhibit the absorption of analysis of food intake into the assessment
magnesium and calcium needed by the body material again is iron and phosphorus. Iron
during menstruation, so investigated was done and phosphorus become micronutrients that
whether it has a relationship with the aid in transporting or transporting processes
incidence of menstrual pain. However, after for core minerals such as magnesium and
calculated using nutrisurvey2007 application calcium. The results of iron and phosphorus
and processed data using SPSS16, it turns out intake of the respondents were found to be
carbohydrate intake in both respondents from less than the coverage of nutritional needs
the treatment and control group did not have a based on AKG.
significant difference so it can be ascertained
that the carbohydrate intake of the The average of phosphorus was 473.01 mg for
respondents did not interfere with the the treatment group and 501.48 for control
absorption of micronutrients magnesium and group, which was not in accordance with the
calcium. requirement of phosphorus based on AKG
that is 700 mg for phosphorus and 13 mg for
The average of magnesium of respondents for iron. But after having the addition of
the treatment group was 149.75 mg and phosphorus of dark chocolate consumed
!
during menstruation, it was able to add as and increase serotonin levels. L-taurine gives
much as 132 mg of phosphorus and 3.1 mg rise to body-wide relaxation. L-glutamine can
iron. The iron in the treatment group obtained be utilized directly by the brain for energy
amounted to 7.61 mg and 6.07 for the control production in brain cells. Thus it can improve
group. However, the reduction in menstrual brain function and facilitate the utilization of
pain indirectly influenced by the consumption GABA and S-HTP (Smith & Smith, 2012). In
of iron and phosphorus. In addition, theory, magnesium has a direct effect on
respondents who experienced menstrual pain vascular pressure and can regulate the entry of
in this study had normal nutritional status with calcium into the smooth muscle cells of the
an average BMI of 19.44 (treatment) and uterus, so magnesium affects contraction and
19.91 (control). relaxation of smooth muscle of the uterus.
Magnesium can also suppress inflammation
Menstrual Pain in the experiment and by inhibiting the formation of prostaglandins.
control So in the group treated with dark chocolate
The results showed an average of menstrual states menstrual pain is reduced significantly
pain before intervention was 7.44, with (Smith & Smith, 2012).
maximum pain score of 9 and minimum pain
score of 6. After given intervention, the Limitations of the study
average pain was 2.76, with maximum pain The results of this study can only be
score of 6 and minimum pain score of 1. The generalized in Bhakti Husada Dormitory as
mean difference before and after given the setting of the study. At the time of data
intervention was 4.68 in the treatment group collection, menstrual conditions in each
and 0.84 in the control group. respondent were not at the same time so that
data collection could not be done
Pathophysiologically, menstrual pain is also simultaneously. In addition, to diagnose
often accompanied by headache, nausea, secondary menstrual pain was difficult if only
constipation or diarrhea and frequent using anamnesa and screening because it has a
urination, and sometimes until vomiting. low accuracy.
Symptoms and signs of dysmenorrhea are
pain in the lower part that can spread to the
lower back and legs. Pain is felt as a loss of CONCLUSION
cramp or as a continuous dull pain. The giving In conclusion, there was a significant effect of
of dark chocolate decreases menstrual pain in dark chocolate in reducing menstrual pain in
the respondents. This corresponds to the the late adolescents (18-21 years). Therefore,
theory of dark chocolate containing complex the dark chocolate is recommended to reduce
carbohydrates, antioxidants (flavonoid pain in young women during menstruation.
polyphenols), vitamin B6, unsaturated fatty Further study is needed to have bigger sample
acids (omega 3 and omega 6) and minerals size to generalize the results.
(magnesium, calcium, iron) that influence in
regulating menstrual cycle by balance the
levels of the estrogen and progesterone REFERENCES
hormones in the blood during the luteal phase Arfailasufandi, R. (2015). Pengaruh Pemberian Coklat
during the menstrual cycle (Speroff & Fritz, Hitam terhadap Penurunan Nyeri Haid pada
Dismenorhea Primer Mahasiswi PSIK
2005). Muhammadiyah Malang. University of
Muhammadiyah Malang.
In a previous study examining the benefits of cacaoweb. (2016). About cacau beans, cocoa and
dark chocolate to reduce menstrual pain stated chocolate. Retrieved January 16, 2016, from
http://www.cacaoweb.net/cocoa-
that the chocolate content of GABA (Gamma- chocolate.html
Amino Butyric acid) is an amino acid that has Elvira, S. D. (2010). Sindrom Pra-Menstruasi
a major function as a neurotransmitter in the Normalkah. Jakarta: Balai Penerbit FK UI.
central nervous system. Gamma aminobutyric Indonesia, K. K. (2013). Permenkes RI Nomor 75 Tahun
acid inhibits nerve transmission in the brain, 2013 tentang Angka Kecukupan Gizi yang
Dianjurkan bagi Bangsa Indonesia. Jakarta:
calming nervous activity. The 5- Kemenkes RI.
hydroxytryptophan creates a sense of comfort

!
Judha, M., & Sudarti, A. F. (2012). Teori pengukuran Smith, G. Z., & Smith, C. C. (2012). Chocolate candies
nyeri dan nyeri persalinan (Measurement fortified with natural amino acids and/or
theory and labor pain). Nuha Medika, herbal nutrients for relief of insomnia, pms,
Yogyakarta, 1-7. and difficulty concentrating: Google Patents.
Llewellyn-Jones, D. (2005). Setiap Wanita: Panduan Speroff, L., & Fritz, M. A. (2005). Clinical gynecologic
Terlengkap tentang Kesehatan, Kebidanan & endocrinology and infertility: lippincott
Kandungan: Delapratasa Publishing. Williams & wilkins.
Nurazizah, E., Tih, F., & Suwindere, W. (2015). Black Stoelting‐Gettelfinger, W. (2010). A case study and
Chocolate Consumption Reduces Subjective comprehensive differential diagnosis and care
Symptoms in 18-22 Years Old Females with plan for the three Ds of women's health:
Premenstrual Syndrome. Journal of Medicine primary dysmenorrhea, secondary
and Health, 1(1). dysmenorrhea, and dyspareunia. Journal of
Parker, M. A., Sneddon, A. E., & Arbon, P. (2010). The the American Association of Nurse
menstrual disorder of teenagers (MDOT) Practitioners, 22(10), 513-522.
study: determining typical menstrual patterns Widyastuti, Y., Rahmawati, A., & Purnamaningrum, Y.
and menstrual disturbance in a large E. (2009). Kesehatan reproduksi. Yogyakarta:
population‐based study of Australian Fitramaya, 26(66), 2.
teenagers. BJOG: An International Journal of Wulandari, S., & Afriliana, F. D. (2017). THE EFFECT
Obstetrics & Gynaecology, 117(2), 185-192. OF CONSUMPTION DARK CHOCOLATE
Puspitasari, N., & Novia, I. (2008). Faktor Risiko yang AGAINST PRIMARY DISMENORE PAIN
Mempengaruhi Kejadian Dismenore Primer. FOR GIRLS TEENAGER AT KEDIRI 5
Indonesian Journal of Public Health, 4(3). HIGH SCHOOL. Indian Journal of Medical
Santrock, J. W., & Santrock, J. W. (2007). Psikologi Research and Pharmaceutical Sciences, 4, 2.
Pendidikan edisi kedua: Kencana Prenada
Media Group.
Cite this article as: Maharani, S. I., Pramono, N., Wahyuni, S. (2017). Dark chocolate’s effect on
menstrual pain in late adolescents. Belitung Nursing Journal, 3(6), 686-692.
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Muhaji, et al. Belitung Nursing Journal. 2017 December;3(6):693-696

COMPARISON OF THE EFFECTIVENESS OF TWO LEVELS OF SUCTION

PRESSURE ON OXYGEN SATURATION IN PATIENTS WITH
ENDOTRACHEAL TUBE
Muhaji1*, Bedjo Santoso2, Putrono2

1
Postgraduate Nursing Program, Semarang Health Polytechnic, Semarang, Indonesia
2
Semarang Health Polytechnic, Semarang, Indonesia
*Correspondence:
Muhaji
Postgraduate Nursing Program, Semarang Health Polytechnic
E-mail: muhaji57@gmail.com
Abstract
Background: Endotracheal suctioning is one of the common supportive measures in intensive care units (ICU), which may
be related to complications such as hypoxia. However, a questionable efficacy is still identified to choose suctioning pressure
between 130 mmHg and 140 mmHg that is effective for patients with endotracheal tube.
Objective: To compare the effectiveness of 130 mmHg and 140 mmHg suctioning pressure on oxygen saturation in patients
with endotracheal tube.
Methods: This research used a quasy experimental design with pretest and posttest group. The study was conducted from 31
January to 1 March 2017 in the Hospital of Panti Wilasa Citarum and Hospital of Roemani Muhammadiyah Semarang.
There were 30 samples recruited using consecutive sampling, with 15 assigned in the 130 mmHg and 140 mmHg suctioning
pressure group. Pulse oximetry was used to measure oxygen saturation. Paired t-test and Independent t-test were used for
data analysis.
Results: Findings showed that there was a statistically significant effect of 130 and 140 mmHg suctioning pressure on
oxygen saturation in patients with ETT with p-value <0.05. There was a significant mean difference of oxygen saturation
between 130 mmHg and 140 mmHg suctioning pressure group with p-value 0.004 (<0.05). The mean difference of oxygen
saturation between both groups was 13.157.
Conclusion: The 140 mmHg suctioning pressure is more effective compared with 130 mmHg suctioning pressure in
increasing oxygen saturation in patients with ETT.
Keywords: Endotracheal Tube, Pressure Suction, Oxygen Saturation
INTRODUCTION
Suction is the act or process of sucking on the pressure is 100-140 mmHg, for children 95-
airway performed on patients with excess 100 mmHg and for infants 50-95 mmHg with
sputum production where patients are unable duration of 10-15 seconds, while the size of
to do it alone (Hudak & Gallo, 2010). Suction suction catheter is adjusted based on the size
is often performed in critical patients treated of endotracheal tube (Timby, 2009).
in intensive care, especially in patients with
endotracheal tube (ETT) entering into the Endotracheal suction is one of the most
bronchial branching of the airways (Hudak & common nursing actions in the Intensive Care
Gallo, 2010). In addition, the action of Unit (ICU). Patients may require suction 3
suctioning of mucus is done with pressure and times a day. Therefore, suction should be
duration of certain suction. Suction pressure is carefully implemented. Complications that
distinguished by age, for adults the suction may arise from suctioning include hypoxemia,
!
Muhaji., Santoso, B., Putrono. (2017)!
!
airway trauma, nosocomial infections and An effort to minimize the desaturation of

cardiac respiratory artery dysrhythmias, oxygen is by way of choosing the use of
hypertension or hypotension, bronchospasm, pressure, duration and suction the right
pulmonary bleeding, pain and anxiety catheter. Pressure suction used in this research
(Kozier, Erb, Signs, Prevention, & Oral, is 130 mmHg and 140 mmHg, and this fits
2002). with the standard procedure of the Roemani
Muhammadiyah hospital of Semarang. This
The results of Putri’s study showed that the study aimed to examine the effectiveness of
suction pressure of 130 mmHg was more 130 mmHg suctioning pressure compared
effective than the suction pressure of 110 with 140 mmHg on oxygen saturation in
mmHg (Putri, 2015). Supported by Kitong’s patients with endotracheal tube.
study revealed that 13-14 patients using
endotracheal tube month showed an increase
in oxygen saturation (Kitong, Mulyadi, & METHODS
Malara, 2014), however, 50% of ignorance of Research Design
the suction procedure and often the This research used a quasy experimental
implementation is not in accordance with design with pretest and posttest group.
existing procedures.
Setting
Endotracheal Tube (ETT) intubation is a way The study was conducted from 31 January to
of breathing for patients who cannot maintain 1 March 2017 in the Hospital of Panti Wilasa
adequate airways (patients with airway Citarum and Hospital of Roemani
obstruction), for mechanical ventilation, and Muhammadiyah Semarang.
for suctioning of bronchial secretions (Kozier
et al., 2002). Kitong stated that a decrease of Research Subject
SpO2 in size of 12 Fr is more effective than The target population in this study was all
the size of 14 Fr with ETT number of 7 mm. patients treated in the ICU of the Hospital of
If suction is not done in patients with airway Panti Wilasa Citarum and Hospital of
obstruction then the patient will experience Roemani Muhammadiyah Semarang.
hypoxemia, and if O2 supply is not met within Consecutive sampling was used to select the
4 - 6 minutes it can cause damage to sample in this study, and there were 30
permanent brain cells (Kitong et al., 2014). samples recruited, with 15 assigned in the
An easy way to find out hypoxemia is by group of 130 mmHg suctioning pressure and
monitoring oxygen saturation (SpO2) levels the group of 140 mmHg pressure. The
that can measure how much of the O2 inclusion criteria of the sample included:
percentage can be carried by hemoglobin. patients with endotracheal tube size of 7.0
Monitoring oxygen saturation levels is by mm, aged > 25 years; while the exclusion
means of pulse oximetry. By monitoring criteria were: patients with unstable
proper and correct oxygen saturation levels hemodynamics and with cardiac arrest.
during mucus sucking, the hypoxemia case
that can cause respiratory failure to life- Intervention
threatening leads to death can be prevented The intervention was given by the researcher
earlier. using a suction central that has pressure
regulator in mmHg pressure size unit
Oxygen saturation is a measure of how much according to standard procedure of suction
oxygen percentage that hemoglobin can carry with 12F suction size, with duration of 10-15
(Kozier et al., 2002). Pulse oximetry is a non- seconds with pressure of 130 mmHg and 140
invasive tool that measures the oxygen mmHg. The researcher was assisted by
saturation of arterial blood of patients placed enumerators who had diploma nursing
on the fingertips, thumb, nose, ear or forehead background and certification in ICU. The
and pulse oximetry to detect hypoxemia procedure of suctioning included: 1) explain
before signs and symptoms appear. the patient about the purpose of the action to
be performed, 2) preparing the tools, 3)
washing hands, 4) adjusting the patient's
!
position as comfortable as possible, 5) Paired t-test was performed to analyze the

cleaning the thumb / one finger with alcohol, effect of interventions on oxygen saturation,
6) connecting the probe to the patient's finger and Independent t-test was to analyze the
to be installed, 7) pressing power standby – difference between 130 mmHg and 140
ON, 8) pressing the calibration system, 9) mmHg suctioning pressure.
recording the results on nursing sheet, 10)
pressing power standby-OFF, 11) removing
the probe from the patient, 12) preparing the RESULTS
tools in place, and 13) washing hands. Table 1 shows that the mean difference of
oxygen saturation before and after given 130
Instrument mmHg suction was -1.133 with p-value 0.006
Oxygen saturation in this study was measured (<0.05), indicated that there was a statistically
using pulse oxymetry. The normal value of significant effect of 130 mmHg suctioning
oxygen saturation is ≥ 95 - 100%. If oxygen pressure on oxygen saturation; and the mean
saturation <95%, then it is categorized as bad difference of oxygen saturation before and
category. after given 140 mmHg suction was -2.467
with p-value 0.000 (<0.05), indicated that
Ethical Consideration there was a statistically significant effect of
This research has met the requirements or 140 mmHg suctioning pressure on oxygen
ethical conduct of Health Research saturation in patients with ETT.
Commission of POLTEKKES Semarang with
number: 288 / KEPK / Poltekkes-Smg / EC / Table 1 also shows that the mean difference
2016. Prior to data collection, the researcher of oxygen saturation in 140 mmHg group was
gave an explanation to the respondents about higher than the mean in 130 mmHg group. It
the objectives, benefits, and risks that might could be said that 140 mmHg suctioning
arise in the research. Once the respondents pressure was more effective than 130 mmHg
agreed, then they were asked to sign an suctioning pressure.
appropriate informed consent.
Data Analysis
Table 1 Effect of 130 mmHg and 140 mmHg suctioning pressure on oxygen saturation using Paired t-test
Mean T Sig. (2-tailed)
SpO2 Pre-Posttest
-1.133 -3.238 0.006
(130 mmHg)
SpO2 Pre-Posttest
-2.467 -10.435 0.000
(140 mmHg)
Table 2 Difference of oxygen saturation before and after given 130 mmHg and 140 mmHg suctioning pressure
using Independent t-test
Oxygen saturation T Df Sig.(2-tailed)
Mean difference of SpO2 between
130 mmHg and 140 mmHg -3.157 28 0.004
suctioning pressure
Independent t-test as shown in the Table 2 suctioning pressure on oxygen saturation, and
obtained p-value 0.004 (<0.05), which findings of this study revealed that there was a
indicated that there was a significant mean significant effect of 130 mmHg and 140
difference of oxygen saturation between 130 mmHg suctioning pressure on oxygen
mmHg and 140 mmHg suctioning pressure saturation in patients with endotracheal tube
group. The mean difference of oxygen with p-value <0.05.
saturation between both groups was 13.157.
Before given intervention, both groups have
DISCUSSION low oxygen saturation, with 8 respondents
The aim of this study aimed to compare the (26.7%) in the 130 mmHg group and 7
effectiveness of 130 mmHg and 140 mmHg respondents (23.3%) in the 140 mmHg group.

!
This condition is due to the secret This is in contrast with Putri’s study revealed
accumulation on the patient's airway. that 130 mmHg suctioning pressure is
Inadequate airway will cause the supply of effective in increasing oxygen saturation
oxygen to the lungs reduced, so that oxygen to (Putri, 2015). However, that study compared
be channeled throughout the body through with 110 mmHg, which is then concluded that
blood vessels is also reduced, as well as low 140 mmHg is more effective than 130 mmHg
oxygen received by peripheral, thus low and 110 mmHg suctioning pressure.
saturation of oxygen (SpO2) is detected in
pulse oximetry (Kartikawati, 2011).
CONCLUSION
Findings of this study showed that 130 mmHg There was a significant effect of 130 mmHg
suctioning pressure gave a significant effect and 140 mmHg suctioning pressure on
on oxygen saturation, but it was less effective oxygen saturation. However, 140 mmHg
due to its pressure was unable to eliminate the suctioning pressure is more effective
secret as a whole so that secret still obstruct compared with 130 mmHg suctioning
the patient breathing. pressure in increasing oxygen saturation in
patients with ETT.
For 140 mmHg suctioning group, after given
intervention, there were 14 respondents
(46.7%) had good oxygen saturation. This REFERENCES
shows a significant increase in oxygen Hudak, C. M., & Gallo, B. M. (2010). Keperawatan
saturation because 140 mmHg pressure Kritis: Pendekatan Holistik. Jakarta: EGC.
Kartikawati, D. (2011). Buku ajar dasar-dasar
reduces the secret so that the patient's airway keperawatan gawat darurat. Jakarta: Salemba
is clear and contains more oxygen supply to Medika.
the periphery. It could said that an appropiate Kitong, B. I., Mulyadi, N., & Malara, R. (2014).
pressure, 140 mmHg in this study, increase Pengaruh Tindakan Penghisapan Lendir
Endotrakeal Tube (Ett) Terhadap Kadar
airway clearance so that the supply of oxygen Saturasi Oksigen Pada Pasien Yang Dirawat
to the peripheral effective and increase the Di Ruang Icu Rsup Prof. Dr. Rd Kandou
levels of SpO2. Manado. Jurnal keperawatan, 2(2).
Kozier, B., Erb, G., Signs, V., Prevention, F., & Oral, A.
The results also showed that the average of (2002). Kozier and Erb's Techniques in
Clinical Nursing: New Jersey: Pearson
oxygen saturation (SpO2) in the 140 mmHg Education.
group before intervention was 95.60% and Putri, G. F. (2015). Efektivitas Tekanan Suction 110
after intervention increased to 98.07%; and mmHg dan 130 mmHg terhadap Saturasi
the average of oxygen saturation (SpO2) in Oksigen pada pasien yang terpasang
Endotracheal Tube di Ruang ICU RSUD Dr.
the 130 mmHg group before intervention was Moewardi Surakarta. Program Studi Ilmu
94.73% and after intervention increased to Keperawatan. Poltekkes Kemenkes Surakarta.
95.87%. Thus, 140 mmHg suctioning pressure Timby, B. K. (2009). Fundamental nursing skills and
is more effective than the 130 mmHg concepts: Lippincott Williams & Wilkins.
suctioning pressure to increase the oxygen
saturation (SpO2).
Cite this article as: Muhaji., Santoso, B., Putrono. (2017). Comparison of the effectiveness of two
levels of suction pressure on oxygen saturation in patients with endotracheal tube. Belitung Nursing
Journal, 3(6), 693-696.
!
Patty FIT, et al. Belitung Nursing Journal. 2017 December;3(6):697-701

EFFECT OF ACUPRESSURE THERAPY POINT LI 4, SP 6, AND BL 60 ON

DURATION OF THE FIRST STAGE OF LABOR IN PRIMIGRAVIDA AND
NEWBORN’S APGAR SCORE
Fara Imelda Theresia Patty1*, Suhartono2, Ngadiyono1, Mardiyono1
1
2
Postgraduate Epidemiology Program, Diponegoro University, Semarang, Indonesia
*Correspondence:
Fara Imelda Theresia Patty
Postgraduate Midwifery Program, Politeknik Kesehatan Kementrian Kesehatan Semarang
E-mail: fiet.neh@gmail.com
Abstract
Background: The prolonged partus is one of the causes of maternal deaths marked by the slow progress of labor. Induction
of labor and caesarean section is a common procedure performed on long-term partus events to end pregnancy. The birth
acupressure technique is a complementary method to activate the hormone oxytocin at a certain point to use to soften the
cervix and increase contraction.
Objective: To examine the effect of acupressure point LI4, SP6 and BL60 on the duration of the first stage of labor and
APGAR Score of newborn in primigravida.
Methods: This research employed a Quasy experimental study with posttest control group design. It was conducted at the
Public Health Center of Trauma and Public Health Center of Palaran Samarinda, East Kalimantan. There were 40
respondents selected using purposive sampling, which 20 respondents assigned in the experiment and control group. The
duration of the first stage of labor was assessed using partograph and APGAR Score was assessed using APGAR Score
assessment sheets. Mann Whitney test was used for data analysis
Results: Findings showed that the duration of the first stage of labor in the experiment group was 187 minutes and in the
control group was 307 minutes. Mann Whitney test obtained p-value 0.001 (<0.05), which indicated that there was a
statistically significant difference of the duration of the first stage of labor between both groups. However, Mann Whitney
test for APGAR score showed p-value 0.114 (>0.05), which indicated that there was no significant difference of APGAR
score in the experiment and control group.
Conclusion: There was a significant effect of acupressure on the duration of the first stage of labor, but no effect of the
APGAR score. Therefore, acupressure may be recommended to shorten the duration of the first stage of delivery in
primigravida.
Keywords: Acupressure, Duration of Labor, APGAR Score
INTRODUCTION
Pregnancy and childbirth is a natural birth for the mother and baby (Kuswaningrum,
process, but not without risk and a burden for Suwandono, Ariyanti, Hadisaputro, &
a woman (Khomsah, Suwandono, & Ariyanti, Suhartono, 2017). The most common
2017). Some pregnant women will face a mild complications are postpartum hemorrhage,
to severe degree of emergency that can placental abruption, prolonged labor and
provide the danger of discomfort, infection. The prolonged partus is one of the
dissatisfaction, pain, disability and even death causes of maternal mortality. WHO stated that
697
Patty, F. I. T., Suhartono., Ngadiyono., Mardiono. (2017)!
!
prolonged labor caused maternal mortality by information to conclude that what kind of
8%, while in Indonesia reached 9% (Say et acupressure has a significant effect on
al., 2014). The prolonged labor is caused by duration of labor and Apgar score. Thus, this
abnormalities contractions, fetal abnormal- study aimed to examine the effect of
lities, and birth canal disorders. The impact of combining acupressure points LI4, SP6 and
the prolonged labor causes the severity of the BL 60 on the duration of the first stage of
mother and fetus, so that the treatment labor and APGAR score on newborn.
performed is the induction of labor. Induction
of labor has been shown to reduce maternal
and infant mortality, but this induction of METHODS
labor also increases morbidity in mothers and Study Design
infants (National Research, 2013). This was a Quasy experimental study with
posttest control group design. The research
The method of labor induction is divided into was conducted at the Public Health Center of
pharmacological methods and non-pharma- Trauma and Public Health Center of Palaran
cological methods. Pharmacological methods Samarinda, East Kalimantan.
include administration of oxytocin, prostag-
landin and mechanical methods by breaking Population and Sample
the membranes and striping of the There were 40 respondents selected using
membranes. The experience of mothers purposive sampling, which 20 respondents
experiencing labor induction is that they assigned in the experiment and control group.
usually have a psychological impact because
labor induction is considered painful, the main Intervention
problem faced during the pharmacologic Intervention group was given acupressure by
method is that the uterus stimulates very pressing at three acupressure points (LI4, SP6
quickly which in turn causes stress on the and BL60) clockwise (tonic) 30-40 times for
mother and fetus (Prawirohardjo, 2006). one full minute, and then repeated again an
hour later.
In recent years, complementary and herbal
methods have been widely used in medical Instruments
intervention; acupuncture and acupressure are The duration of the first stage of labor was
among the complementary therapies that have assessed using partograph and APGAR Score
been found to have some success possibilities was assessed using APGAR Score assessment
for managing pain in labor and birth. Labor sheets (Apgar, 2015).
acupressure is the induction of labor used to
soften the cervix and increase contraction. Ethical Consideration
The theory of acupressure mechanisms in the Ethical consideration was obtained from the
pressurization of stimulating the uterus Research Ethics Commission of Poltekkes
through hormonal changes and changes in the Kemenkes Semarang with No: 287/KEPK/
nervous system. Acupressure increases the PoltekkesSmg/EC016. The researchers have
release of hormones from the hypothalamus in confirmed that each respondent has signed an
the anterior pituitary system to activate the appropriate informed consent.
hormone oxytocin to stimulate the uterus
(Neri, Monari, Midwife, & Facchinetti, 2014; Data Analysis
Smith, Crowther, & Grant, 2013). Mann Whitney test was used for data analysis
because of non-normal data distribution.
Complementary therapy, especially acu-
pressure, has not been implemented in
government health services, especially RESULTS
acupressure induction of natural labor. Table 1 shows that the mean average of
Although many studies have demonstrated the respondents in the experiment group was 23.5
effectiveness of acupressure on the duration years old and in the control group was 24.7
of labor in the first stage and Apgar score of years old. The majority of the respondents in
newborns, however, there is limited both groups had a senior high school
!
698 TYPE%THE%DOCUMENT%TITLE
background and working. Most of them had 2,689 gram and in the control group was
no narrow hip circumference; with cervics 2,580 gram. All variables obtained p-value
opening average was 5.9 in the experiment >0.05, which indicated that there were no
group and 5 in control group. Fetal weight significant differences of the characteristics of
interpretation in the experiment group was the respondents in both groups.
Table 1 Characteristics of the respondents

Variable P-value
(n=20) (n=20)
Age (Year)
Mean ± SD 23.5 ± 2.37 24.7 ± 2.99 0.186
• <19 - -
• 20 – 35 20 (100%) 20 (100%)
• >35 - -
Education level
• Elementary 10 (50%) 7 (35%) 0.343
• Senior High 10 (50%) 13 (65%)
• University - -
Working status
• Working 11 (55%) 12 (60%) 0.343
• Not working 9 (45%) 8 (40%)
Hip circumference (Mean ± SD) 84.7 ± 2.57 85.9 ± 2.78 0.183
• Narrow - -
• Not narrow 20 (100%) 20 (100%)
Fetal weight interpretation (Mean ± 2689 ± 370.48 2580 ± 363.59 0.356
SD)
• <2500 gram 1 (5%) 1 (5%)
• 2500-4000 gram 19 (95%) 19 (95%)
• >4000 gram - -
Cervical dilation (Mean ± SD) 5.9 ± 0.85 5 ± 0.82 0.114
Table 2 Duration of the first stage of labor and APGAR score of newborns using Mann Whitney test
Mean±SD; Median; Min-Max
Variables Experiment group Control group Z P-Value
(n=20) (n=20)
Duration of the first stage of 187 ± 120.61; 150; 60- 307 ± 108.33; 330; 120- -3.249 0.001
labor (Min) 540 480
APGAR Score 8 ± 0.71; 9; 8-10 8 ± 0.55; 9; 8-10 -0.643 0.114
Table 2 shows that the duration of the first no significant difference of APGAR score in
stage of labor in the experiment group was the experiment and control group.
187 minutes with standard of deviation of
120.61, and in the control group was 307
minutes with standard of deviation of 108.33. DISCUSSION
Mann Whitney test obtained p-value 0.001 Findings of this study showed that the
(<0.05), which indicated that there was a characteristics of respondents including age,
significant difference of the duration of the educational level, working status, hip
first stage of labor between both groups. The circumference, fetal weight interpretation and
experiment group shows a faster duration of cervical opening in the experiment group and
the first stage of labor compared with the the control group were homogeneous, thus
duration in the control group. For APGAR confounding variables can be controlled.
score, Mann Whitney test showed p-value
0.114 (>0.05), which indicated that there was According to literature, the acceleration phase
is the beginning of active phase and lead to
699
!
the maximum slope phase, which the cervix is gestation, revealed that there was no
opening rapidly and increases from 3-4 cm to significant effect of acupressure on Apgar
about 8 cm. Under normal conditions, the score in the treatment group and the control
opening speed of the constant is 3 cm per group (Gregson, Tiran, Absalom, Older, &
hour, with a maximum speed of no more than Bassett, 2015).
1.2 cm per hour in primipara; while the
deceleration phase is the active phase, which Mann Whitney test in this study revealed that
the opening speed slows and the cervix there was a significant effect of acupressure
reaches the cervix dilation of 8 - 10 cm, while on the duration of the first stage of labor; bit
the decrease reaches the maximum speed of no effect on Apgar score. This is in line with
1.6 cm per hour in primipara and normally at research conducted by Akbarzadeh Marzieh et
least 1.0 cm per hour (Cunningham, Leveno, al stated that the length of delivery for those
Bloom, Spong, & Dashe, 2014). who were given acupressure was faster than
the length of delivery in the control group. It
The duration of the first stage of labor in this was 157 minutes of the duration of first stage
study was 180 min in the experiment group of labor for supportive care group, 161
and 307 min in the control group, where the minutes for the acupressure group, and 281
measurements were performed during the first minutes for the control group (Akbarzadeh,
stage of the active phase until complete Masoudi, Zare, & Kasraeian, 2016).
cervical dilation. Although the maximum
value of the experiment group was much As for Apgar score, showed no difference
higher than the control group, but the between acupressure group, supportive care
minimum value was lower than that in the group, and control group. APGAR score is
control group, which was 60 minutes. This used to assess Appearance, Pulse, Grimace,
indicated that the experiment group had a Activity and Respiration at the time of birth
chance to be 120 minutes faster during labor and determine the next action to be performed
than the control group. on the newborn with asphyxia. Newborn
asphyxia is influenced by mother, infant and
This is in line with research conducted by umbilical factors. One of the mother factors is
Rojlin Tigga and Rita Thapa who examined the prolonged labor which the supply of
the effectiveness of acupressure on labor pain oxygen from mother to baby is less so that the
and duration of the first stage of labor where baby has hypoxia.
the results of the length of labor in the
treatment group were faster than the control In this research, there is an effect of
group, which Rojlin divided the duration of acupressure on the duration of the first stage
labor into three categories: 1) 7 - 10 hours (14 of labor. The effect of acupressure
respondents in the treatment group), 2) 10 -13 suppression at points LI4, SP6 and BL60 on
hours (16 respondents in the treatment group), the body meridians will drain energy and the
and 3) 13 to 16 hours (15 respondents in the electron flow that stimulates the central
control group) (Tigga & Thapa, 2016). nervous system, dilates the blood vessels and
activates the Nitric Oxidate that stimulates the
Besides, assessment of Apgar score of pituitary; and anterior hypophysis activates
newborn is used to help health workers in the prolactin hormone at the time of labor
assessing the condition of newborns in through uterine thinning downward and
general and decide to take emergency action upward uterine thickening that serves to help
or not to predict the health and intelligence of push the baby down so that cervical dilatation
the baby in the future. In this study, the Apgar occurs, while the posterior hypophage
score of newborn in the treatment and control activates the hormone oxytocin at the start of
group was the same as the mean score was 8, labor by activating the ligamentun rotundum
with the minimum score of 8 and the and maximizing blood flow resulting in
maximum value of 10. This is in line with the contractions at the time of delivery. So, if the
study conducted by Gregson who examined suppression of acupressure done every one
the induction of labor using acupressure in hour, it can stimulate a good contraction so
primiparous mothers who passed the that the cervical dilatation occurs faster.
!
700 TYPE%THE%DOCUMENT%TITLE
CONCLUSION Kuswaningrum, O., Suwandono, A., Ariyanti, I.,

It can be concluded that there was a Hadisaputro, S., & Suhartono, S. (2017). THE
IMPACT OF CONSUMING
significant effect of acupressure on the AMARANTHUS SPINOSUS L EXTRACT
duration of the first stage of labor, but no ON PROLACTIN LEVEL AND BREAST
effect of the Apgar score. Therefore, MILK PRODUCTION IN POSTPARTUM
acupressure may be recommended to shorten MOTHERS. Belitung Nursing Journal, 3(5),
541-547.
the duration of the first stage of delivery in National Research, C. (2013). Reducing Maternal and
primigravida. Neonatal Mortality in Indonesia: Saving
Lives, Saving the Future: National Academies
Press.
REFERENCES Neri, I., Monari, F., Midwife, C. S., & Facchinetti, F.
(2014). Acupuncture in post-date pregnancy: a
Akbarzadeh, M., Masoudi, Z., Zare, N., & Kasraeian,
pilot study. The Journal of Maternal-Fetal &
M. (2016). Comparison of the Effects of
Neonatal Medicine, 27(9), 874-878.
Maternal Supportive Care and Acupressure (at
Prawirohardjo, S. (2006). Buku acuan nasional
BL32 Acupoint) on Labor Length and Infant's
pelayanan kesehatan maternal dan neonatal
Apgar Score. Global journal of health science,
[National reference book of maternal and
8(3), 236.
neonatal health services]. Jakarta: Yayasan
Apgar, V. (2015). A proposal for a new method of
Bina Pustaka.
evaluation of the newborn infant. Anesthesia
Say, L., Chou, D., Gemmill, A., Tunçalp, Ö., Moller,
& Analgesia, 120(5), 1056-1059.
A.-B., Daniels, J., . . . Alkema, L. (2014).
Cunningham, F., Leveno, K., Bloom, S., Spong, C. Y.,
Global causes of maternal death: a WHO
& Dashe, J. (2014). Williams Obstetrics, 24e:
systematic analysis. The Lancet Global
McGraw-Hill.
Health, 2(6), e323-e333.
Gregson, S., Tiran, D., Absalom, J., Older, L., &
Smith, C. A., Crowther, C. A., & Grant, S. J. (2013).
Bassett, P. (2015). Acupressure for inducing
Acupuncture for induction of labour. The
labour for nulliparous women with post-dates
Cochrane Library.
pregnancy. Complementary therapies in
Tigga, R., & Thapa, R. (2016). EFFECTIVENESS OF
clinical practice, 21(4), 257-261.
ACUPRESSURE ON LEVEL OF PAIN AND
Khomsah, Y. S. b., Suwandono, A., & Ariyanti, I.
DURATION OF LABOUR AMONG
(2017). THE EFFECT OF ACUPRESSURE
PRIMIGRAVIDA MOTHERS DURING
AND EFFLEURAGE ON PAIN RELIEF IN
FIRST STAGE OF LABOUR. Indian Journal
THE ACTIVE PHASE OF THE FIRST
of Applied Research, 6(6), 131-133.
STAGE OF LABOR IN THE COMMUNITY
HEALTH CENTER OF KAWUNGANTEN,
CILACAP, INDONESIA. Belitung Nursing
Journal, 3(5), 508-514.
Cite this article as: Patty, F. I. T., Suhartono., Ngadiyono., Mardiono. (2017). Effect of acupressure
therapy point LI 4, SP 6, and BL 60 on duration of the first stage of labor in primigravida and
newborn’s Apgar score. Belitung Nursing Journal, 3(6), 697-701.
701
Setyowati A, et al. Belitung Nursing Journal. 2017 December;3(6):702-706

EFFECT OF YOGA ON DURATION OF THE SECOND STAGE OF LABOR

AND PERINEAL RUPTURE IN PRIMIGRAVIDA MOTHERS
Ana Setyowati1*, Suhartono2, Ngadiyono1, Rr Sri Endang Pujiastuti1, Dyah1
1
2
Faculty of Medicine, Diponegoro University, Semarang, Indonesia
*Correspondence:
Ana Setyowati
E-mail: anena.nenaza@gmail.com
Abstract
Objective: To determine the effect of yoga on the duration of the second stage of labor and perineal rupture in primigravida
mothers.
Methods: This was a Quasy experimental study with posttest group only design. The study was conducted in the Public
Health Center of Pekalongan, Central Java, Indonesia from December 2016 until January 2017. There were 50 mothers
selected using purposive sampling, which 25 assigned in the experiment and control group. Independent t-test and Chi
Square test were used for data analysis.
Results: There was a statistically significant difference in the duration of second stage of labor (p=0.000) and perineal
rupture (p=0.001) between experiment and control group.
Conclusion: There was a significant effect of yoga on the duration of the second stage of labor and perineal rupture in
primigravida mothers. Therefore, yoga is recommended for midwife to be included in the antenatal care.
Keywords: Yoga, Second Stage of Labor, Perineal Rupture
INTRODUCTION
The process of labor occurs in several stages maternal fatigue and asphyxia and intra
over many hours or even a few days-from uterine fetal death. In addition, the strength of
early labor through delivering the baby and pelvic floor muscles also plays a role in the
the placenta (Varney, Kriebs, & Gegor, 2007). smoothness and comfort of labor, including
During labor, contractions in uterus open the the perineal muscles (Noviatri &
cervix and move the baby into position to be Prihatiningsih, 2015). Lack of its strength
born. The delivery process is also supported leads to perineum rupture. Previous study
by the condition of the fetus, birth canal, labor revealed that spontaneous perineum rupture
and psychological condition of mothers occurred in primigravida (51.6%) and
(Lothian, 2009). multigravida (48.4%) (Noviatri, 2015).
Length of labor is one of indicators of the Spontaneous perineum rupture occurs because
normal birth. The duration of labor that occurs of tension in the vaginal area at the time of
in the second stage is the last phase of a labor, delivery, and a discrepancy between the birth
which if it lasts too long resulting in canal and the fetus as well as psychological
symptoms such as dehydration, infection, burden in facing labor process. This rupture,
!
Setyowati, A., Suhartono, Ngadiyono, Pujiastuti, Rr. S. E., Dyah. (2017)!
without proper management, will result in from December 2016 until January 2017 (6
discomfort, bleeding, including death in weeks).
postpartum mothers (Noviatri, 2015). Yoga is
considered as one of alternative therapies to Research subject
prepare pregnant women physically, mentally The target population in this study was all
and spiritually in facing birth process as well primigravida mothers trimester III in the
as to prevent perineum rupture (Shindu, working area of public health center of
2014). Pekalongan amounted to 74 mothers. There
were 50 mothers selected using purposive
Yoga is also useful to train and master the sampling, which 25 assigned in the
breathing techniques that play a very experiment and control group.
important role during pregnancy and labor. It
is also important to strengthen and maintain The inclusion criteria of the sample included:
elasticity of abdominal wall muscles, a primigravida mother with gestational age
ligaments, basic hip muscles and inner thigh >32 weeks, 20-30 years old, mother with
muscles, thus the process of labor can be single pregnancy, baby’s weight 2500-4000
mastered. The relaxation process will be grams, normal pelvic size, and was not
perfect by doing the contractions and suffering from chronic lung disease, diabetes
relaxation necessary to overcome the tension mellitus and hypertension. The exclusion
or pain during labor. One exercise to criteria were: pregnant women who
strengthen and maintain elasticity is the experienced complications in pregnancy and
exercises of pelvic floor muscles. So, at the labor such as hypertension in pregnancy,
time of straining, the muscle will relax antepartum bleeding, premature rupture of
actively so that the baby's head will come out membranes, narrow pelvis, not a head
easily, thus will facilitate the delivery process presentation, and fetal distress.
(Shindu, 2014).
Intervention
Based on preliminary study conducted at the Yoga was administered in the experiment
Public Health Center of Pekalongan Barat in group once a week for four times, with each
June – July 2016, from 28 primigravida session was performed in 30 minutes. In
mothers, according to the result of partograph, addition, experiment group also got a routine
there were 13 mothers (46.4%) had prolonged antenatal examination. Yoga is a body
second stage of labor and 15 mothers (53.6%) movement performed by primigravida women
did not experience prolonged second stage of at 32 weeks of gestation, consisting of posture
labor. However, the effects of prolonged pranayama (breathing), suryanamaskar
second stage can result in fatigue and bleeding (heating and core), nidhra (deep relaxation)
in mother and impact in the fetus. Of the 28 and dhyana (mind concentration). This
deliveries, 5 mothers (17.9%) had a perineal exercise was guided and trained by a yoga
rupture of grade I, 10 mothers (35.7%) had instructor. While the control group only
perineal rupture of grade II, and 13 mothers received routine antenatal checks.
(46.4%) had perianal rupture of grade III. This
study aimed to examine the effect of yoga on Instrument
the duration of the second stage of labor and The duration of the second stage of labor and
perineal integrity in primigravida mothers. perineal integrity were observed by the
researcher and evaluated in perineal sheets.
The duration was noted in minutes.
METHODS
Study Design Ethical consideration
This was a Quasy experimental study with Ethical clearance of the research was obtained
posttest group only design. from the Ethics Commission of Poltekkes
Kemenkes Semarang No.032 /
Settings KEPK/Poltekkes-Smg / EC / 017. Each
The study was conducted in the Public Health participant signed informed consent prior to
Center of Pekalongan, Central Java, Indonesia data collection.

!
Data analysis 24.36 and the control group was 24.12. The
Shapiro wilk showed a normal data majority of the respondents in both groups
distribution, thus Independent t-test and Chi had a senior high school background, and not
Square test were used to determine the effect working. The mean of baby’s weight in the
of yoga on the duration of labor and perineal experiment group was 3148 gr and the control
rupture. group was 3128 gr. Homogeneity test
obtained p-value >0.05, which indicated that
there was no significant difference in the
RESULTS characteristics of the respondents between
Table 1 shows that the mean age of the experiment and control group.
respondents in the experiment group was
Table 1 Average of characteristics of the respondents based on age, education, occupation and baby’s weight
Group
Variable Experiment Control
p value
(n=25) (n=25)
Age (year) 24.36 24.12
(SD 3.04; Median 24; (SD 2.75; Median 24; 0.771
Min 20 – Max 30) Min 20 – Max 29)
Education
Junior high 11 (44%) 8 (32%) 0.090
Senior high 14 (56%) 17 (68%)
Occupation
Not working 7 (28%) 10 (40%)
Trader 7 (28%) 7 (28%)
0.308
Private employee 7 (28%) 4 (16%)
Entrepreneur 4 (16%) 4 (16%)
Baby’s weight 3148 3128
(Gram) (SD 245.57; Median (SD 259.84; Median
0.781
3250; Min 2700 – 3100; Min 2700 – Max
Max 3600) 3600)
Table 2. The effect of yoga on the duration of second stage of labor and perineal rupture in primigravida
mothers
Group
Variable Control (n=25) Experiment (n=25) P-value
Mean±SD; Median; Min±Max
Duration of second stage of 43.44±15.484;40; 25.32±7.06;26;10±35 0.000a
labor 20±78
Perineal rupture 0.001b
No rupture 0 (0%) 3 (12%)
Rupture grade I 6 (24%) 14 (56%)
Rupture grade II 17 (68%) 8 (32%)
Rupture grade III 2 (8%) 0 (0%)
a
Independent t-test, bChi Square test
Table 2 shows that the mean duration of (32%) mothers with rupture grade II; while
second stage of labor in the experiment group the control group showed 6 (24%) mothers
was 25.32 minutes and the control group was with rupture grade I, 17 (68%) mothers with
43.44 minutes with p-value 0.00 (<0.05), rupture grade II, and 2 (8%) with rupture
which indicated that there was a significant grade III. Chi-square test obtained p-value
difference in the duration of second stage of 0.001 (<0.05), which indicated that there was
labor between both groups. For perineal a significant difference in perineal rupture
rupture variable, the experiment group between the two groups.
showed 3 mothers (12%) with no rupture, 14
(15%) mothers with rupture grade I, and 8
!
DISCUSSION factor, fetus, and the helper. Maternal factors

The results of this study revealed that there include the fragile perineum, primigravida,
was a significant effect of yoga on the pelvic floor narrowing, flexibility of the birth
duration of the second stage of labor and canal, excessive straining, partus prespitatus,
perineal rupture. This finding is in line with and labor with acts such as vacuum
the previous study stated that yoga pregnancy extraction, and forceps (Mochtar, 2011).
exercise can strengthen pelvic and abdominal Factors of the fetus include large fetuses,
muscles to facilitate labor (Khalajzadeh, abnormal positions, and shoulder dystocia;
Shojaei, & Mirfaizi, 2012). Findings in this and the helper factors include the leading
study revealed that the length of the second skills of contraction, how to communicate
stage of labor for mothers who performed with mother, and the skill of holding the
yoga was shorter than those who did not perineum at the expulsion of the fetal head
perform yoga. It is due to breathing exercise and vertical position (Mochtar, 2011).
can affect the power, passanger and
psychology of the maternal mother.
According to previous study, mothers who CONCLUSION
follow yoga on average 2-3 times during It can be concluded that there was a
pregnancy have the short duration of the significant effect of yoga on the duration of
second stage of labor (Rahmawati & Lestari, the second stage of labor and perineal rupture
2016). There was a significant effect of yoga in primigravida mothers. Therefore, yoga is
on the duration of the second stage of labor. recommended for midwife to be included in
The more the mothers do yoga, the shorter the the antenatal care.
duration of labor stage II.
This is also in accordance with the theory said REFERENCES

that pregnant women who do yoga on a Chuntharapat, S., Petpichetchian, W., & Hatthakit, U.
regular basis will benefit from the smooth (2008). Yoga during pregnancy: effects on
maternal comfort, labor pain and birth
process of labor and reduce the occurrence of outcomes. Complementary therapies in
fetal distress at the time of delivery clinical practice, 14(2), 105-115.
(Wiadnyana). The results of this study were Khalajzadeh, M., Shojaei, M., & Mirfaizi, M. (2012).
also supported by research conducted by The effect of yoga on anxiety among pregnant
women in second and third trimester of
Songporn Chutharapat on 74 primigravida in pregnancy. European Journal of Sports and
Thailand revealed that mothers who Exercise Science, 1(3), 85-89.
performed yoga was more comfortable during Lothian, J. A. (2009). Safe, Healthy Birth: What Every
delivery and postpartum, and the duration of Pregnant Woman Needs to Know. The
the second stage of labor was shorter Journal of Perinatal Education, 18(3), 48-54.
doi: 10.1624/105812409X461225
compared with control group (Chuntharapat, Mochtar, R. (2011). Sinopsis Obstetri: obstetri fisiologi,
Petpichetchian, & Hatthakit, 2008). obstetri patologi. Jakarta: EGC.
Noviatri, S. (2015). HUBUNGAN ANTARA PARITAS
Respondents who regularly participate in DENGAN KEJADIAN RUPTUR PERINEUM
SPONTAN DI RSUD KOTA SURAKARTA.
yoga can reduce the occurrence of perineal Program Studi Bidan Pendidik jenjang DIV,
rupture due to yoga can help pelvic floor Sekolah Tinggi Ilmu Kesehatan 'Aisyiyah
muscle elasticity. The yoga technique of Yogyakarta. Retrieved from
breathing, contraction and relaxation is useful http://digilib.unisayogya.ac.id/773/1/NASKA
during the emergence of pain at the time of H PUBLIKASI.pdf
Noviatri, S., & Prihatiningsih, D. (2015). Hubungan
pelvic dilation, and doing a good push Berat Lahir Bayi dengan Kejadian Ruptur
technique at the perfect timing in delivery Perineum pada Persalinan Normal Primipara
once the dilation is complete, so the delivery di RSUD Dr. Soedirman Kebumen Tahun
will have effective results with good perineal 2014. STIKES'Aisyiyah Yogyakarta.
Rahmawati, N. A., & Lestari, S. (2016). HUBUNGAN
integrity. SENAM HAMIL TERHADAP LAMANYA
PROSES PERSALINAN PADA IBU
However, respondents who were regularly BERSALIN DI WILAYAH KERJA
followed yoga but still having perineal PUSKESMAS BAYAT KLATEN. INVOLUSI
rupture, it might be because of maternal

!
Jurnal Ilmu Kebidanan (Journal of Midwifery Wiadnyana, M. S. The Power of Yoga for Pregnancy
Science), 6(11). and Post-Pregnancy: PT Gramedia Pustaka
Shindu, P. (2014). Yoga untuk Kehamilan: Sehat, Utama.
Bahagia, dan Penuh Makna. Qanita..
Bandung.
Varney, H., Kriebs, J. M., & Gegor, C. L. (2007). Buku
ajar asuhan kebidanan. Jakarta: EGC.
Cite this article as: Setyowati, A., Suhartono, Ngadiyono, Pujiastuti, Rr. S. E., Dyah. (2017). Effect
of yoga on duration of the second stage of labor and perineal rupture in primigravida mothers.
!
Anita T, et al. Belitung Nursing Journal. 2017 December;3(6):707-711

EFFECT OF CONSUMING TOMATO (LYCOPERSIUM COMMUNE) JUICE

IN LOWERING BLOOD PRESSURE IN PREGNANT MOTHERS WITH
HYPERTENSION
Theresia Anita1*, Agus Suwandono2, Ida Ariyanti1, Noor Pramono2, Suryati Kumorowulan1
1
2
Medical Faculty of Diponegoro University of Semarang, Indonesia
*Correspondence:
Theresia Anita
E-mail: theresiaanita28@gmail.com
Abstract
Background: High blood pressure during pregnancy can pose significant problems such as preeclampsia, eclampsia, and
premature birth. Thus, early prevention is needed. Consuming tomato (lycopersium commune) juice is considered effective
to reduce blood pressure in pregnant women.
Objective: This study aims to examine the effect of tomato juice on the decrease in blood pressure of pregnant women with
hypertension in pregnancy
Methods: This study was a quasy experiment with pretest-posttest control group. This research was conducted at the
working area of the Community Health Center of Magelang in July 2016 - January 2017. The target population of this study
was pregnant women in trimester I, II, and III with high blood pressure. There were 30 samples selected using consecutive
sampling, with 15 assigned in the experiment and control group. Wilcoxon Test was performed for data analysis.
Results: There was a statistically significant difference in systolic and diastolic blood pressure before and after given tomato
juice with p = 0.001 (<0.05).
Conclusion: Consuming tomato juice can be one of the efforts to reduce blood pressure in pregnant women with
hypertension.
Keywords: Hypertension, Pregnancy, Tomato, Lycopersium Commune
INTRODUCTION
Maternal Mortality Rate (MMR) is the deaths in Central Java Province were
number of maternal deaths resulting from the hypertension including preeclampsia and
process of pregnancy, labor and delivery per eclampsia (26.44%), bleeding (22.9%),
100,000 live births in a given period (Dinkes, circulatory system disorders (4.64%),
2014). In Central Java Province of Indonesia, infections (3.66%) and other causes
maternal mortality rate in the postpartum (unspecified) (42.33%) (Dinkes, 2014).
period was 57.95%, at the time of pregnancy
was 27.00% and at the time of delivery was The first cause of maternal deaths was caused
15.05%. While based on age group, most by preeclampsia and eclampsia during
maternal death incidence was in productive pregnancy, labor and childbirth. The presence
age (20-34 years) of 62.02%, followed by age of preeclampsia and eclampsia begins with
group > 35 years with 30.52%, and age group the ongoing increase in blood pressure during
<20 years with 7,45%. The causes of maternal pregnancy. Increased blood pressure is often

Anita, T., Suwandono, A., Ariyanti, I., Pramono, N., Kumorowulan, S. (2017)!
!
considered normal in pregnant women and blood pressure in pregnant women with
less performed an early stabilization and hypertension.
intensive monitoring (Rukiyah & Yulianti,
2010). METHODS
Study Design
Preeclampsia often occurs suddenly, so early A Quasy experimental study with pretest-
detection is necessary during pregnancy. posttest control group design
Early detection is performed by regular blood
pressure checks at the time of antenatal care. Setting
Routine pregnancy examination is absolutely This research was conducted at the working
necessary to ensure that the risk of area of the Community Health Center of
preeclampsia is detected immediately so that Magelang in July 2016 - January 2017.
no more fatal complications occur.
Examination of blood pressure during Research Subjects
pregnancy should be done carefully and try to The target population of this study was
be done by the same person such as midwife pregnant women in trimester I, II, and III with
or doctor (Rukiyah & Yulianti, 2010). high blood pressure at the working area of the
Community Health Center of Magelang.
In addition to blood pressure monitoring, There were 30 samples selected using
early prevention of preeclampsia can be done consecutive sampling, divided into
with nutritional diet therapy such as experiment (15 samples) and control group
consumption of green vegetables, side dishes (15 samples). The inclusion criteria of the
and fruits. One fruit that can be used in sample included: pregnant women with
therapy to lower blood pressure is tomatoes. systolic blood pressure ≥140 mmHg to <150
Tomatoes have various vitamins and anti- mmHg and diastolic blood pressure ≥ 90
disease compounds that are good for health, mmHg to <100 mmHg; pregnancy trimester I,
especially lycopene. Tomatoes contain low II, II pregnancy and willing to be a
amounts of fat and calories, cholesterol-free, respondent. The exclusion criteria of the
and are a good source of fiber and protein. In sample included: pregnant women who have
addition, tomatoes are rich in vitamins A and diabetes, heart disease, kidney, and thyroid,
C, beta-carotene, potassium and lycopene and have bleeding history during pregnancy.
antioxidants (Ismalia & Zuraida, 2016;
Ramadhian & Hasibuan, 2016). Intervention
A fresh red tomato fruit (lycopersium
From January to June 2016, the total number commune) with potassium levels of 610.14
of pregnant women in the working area of the mg / kg and antioxidant of 5.68 mg / ml was
Community Health Center of Muntilan II was used based on the results of laboratory tests
169 people, while the high risk cases of conducted at the Integrated Research and
hypertension and preeclampsia in pregnant Testing Laboratory of Gajah Madah
women trimester I & II were 9 people, University Yogyakarta (LPPT UGM) on
pregnant women trimester III as many as 3 October 12, 2016 - November 2, 2016. The
people and postpartum mothers were 5 red tomato was formed into 250 ml of juice
people. Based on the interview with midwife made from 200 grams of tomato, 100 ml
coordinator in the community health center of water, 5 grams of dietary sugar. The tomato
Muntilan II stated that there were 506 juice was given 1 time daily for 14
pregnant women who had elevated blood consecutive days; while control group was not
pressure with systolic <140 mmHg and given intervention.
diastolic <90 mmHg during pregnancy, which
is still considered normal and can return to Instruments
normal without doing pharmacological The research instrument used observation
therapy. Therefore, based on this condition sheets and Omron digital brand tension
and the benefits of tomatoes, this study aimed meters. Blood pressure measurements were
to examine the effect of tomatoes in lowering performed at the beginning and end of the
study. Measurement of blood pressure was
!
done after the respondent rested 10 minutes. Data Analysis

Systolic and diastolic blood pressure is stated A normality test was performed using Shapiro
to be normal when diastolic was 70 - ± 80 mm Wilk test because the number of respondents
Hg and systolic was 110 - ≤120 mmHg; while was 30 respondents. The results showed non-
the value of blood pressure of pregnant normal data distribution. Thus, Wilcoxon and
women with hypertension in pregnancy is Mann Whitney Test were performed for data
with diastolic pressure of 90 - ≤100 mmHg analysis.
and systolic of 140 - ≤150 mmHg.
RESULTS
Ethical Consideration Characteristics of the respondents
The ethical approval was obtained from the Table 1 shows that the majority of the
Health Research Ethics Committee of respondents aged between 20-35 years,
Poltekkes Kemenkes Semarang. The multigravida, and multipara. Most of them
researchers have confirmed that all were during pregnancy trimester III and had a
respondents have obtained appropriate history of pre-eclampsia.
informed consents.
Table 1 Characteristics of respondents based on age, gravida, parity, pregnancy span, and preecamplsia
history
Control (n=15) Experiment (n=15)
Characteristics
N % N %
Maternal age (year)
20 – 35 11 73.3 12 80.0
>35 4 26.7 3 40.0
Gravida
Primigravida 3 20.0 2 13.3
Multigravida 12 80.0 13 86.7
Parity
Nulipara 4 26.7 3 20.0
Primipara 4 26.7 6 40.0
Multipara 7 46.7 6 40.0
Pregnancy span
Trimester I 1 6.7 1 6.7
Trimester II 4 26.7 5 33.3
Trimester III 10 66.7 9 60.0
Preeclampsia history
Yes 8 53.3 6 40.0
No 7 46.7 9 60.0
Difference of systolic blood pressure before and after given intervention

Table 2 Difference of systolic blood pressure before and after given intervention in the experiment and
control group using Wilcoxon test
Difference
Pretest Posttest between pretest-
Group p-value
posttest
Mean SD Mean SD Mean SD
Control (n=15) 142.60 1.882 139.47 4.207 3.13 4.627 0.028
Experiment (n=15) 143.91 1.985 135.11 4.724 8.26 5.227 0.001
Table 2 shows that the mean of systolic blood intervention. There was a statistically
pressure in the experiment group before given significant decrease of systolic blood pressure
intervention was 143.91 and decreased to in both experiment group and control group
135.11 after given intervention; while the with p-value <0.05. However, the experiment
mean of systolic blood pressure in the control group showed a higher reduction of systolic
group before given intervention was 142.60 blood pressure (8.26) compared to systolic in
and decreased to 139.47 after given the control group (3.13).

!
Difference of diastolic blood pressure before and after given intervention

Table 3 Difference of diastolic blood pressure before and after given intervention in the experiment and
control group using Wilcoxon test
Difference
Pretest Posttest between pretest-
Group p-value
posttest
Mean SD Mean SD Mean SD
Control (n=15) 95.9 2.439 92.9 3.873 2.81 4.530 0.023
Experiment 95.63 2.249 87.16 2.554 8.06 3.242 0.001
(n=15)
Table 3 shows that the mean of diastolic blood pressure is after the heartbeat or the
blood pressure in the experiment group before time between pulses, the pressure in the
given intervention was 95.63 and decreased to arteries will decrease. Provision of tomato
92.9 after given intervention; while the mean juice can help lower blood pressure for people
of diastolic blood pressure in the control with hypertension. According to the American
group before given intervention was 95.9 and dietetic association, it is stated that potassium
decreased to 92.9 after given intervention. contained in tomatoes if given longer can
There was a statistically significant decrease lower blood pressure even more. Potassium is
of diastolic blood pressure in both experiment the main ion in the intra-cellular fluid.
group and control group with p-value <0.05. Consumption of large amounts of potassium
However, the experiment group showed a increases its concentration in the intra-cellular
higher reduction of diastolic blood pressure fluid, which tends to attract fluid from the
(8.06) compared to systolic in the control cellular portion and lower blood pressure
group (2.81). (Besford & Maw, 1975).
Tomato is one type of vegetables and fruits

DISCUSSION rich in vitamin C, vitamin E, potassium, fiber
Blood pressure is the pressure that works and protein. Potassium in tomatoes can reduce
against the walls of blood vessels. Blood sodium in urine and water by diuretics, so it
pressure is the amount of force given by the can lower blood pressure. Mature tomatoes
blood inside the arteries when blood is contain bioactive nutrients such as
pumped throughout the blood circulation tocopherols, phenolics, glycoalkaloid and
system. Each time the muscles contract, the flavonoids (Sharma et al., 2003). Thus, during
blood is pressed against the blood vessel wall pregnancy, it is advisable to consume foods
and counted as systolic blood pressure (upper containing potassium sources such as
number). When the heart relaxes between bananas, watermelons, melons, oranges, and
pulses, the pressure on the blood vessel wall is tomatoes. Potassium plays a role in supporting
calculated as diastolic blood pressure (bottom the function of muscles, nerves and cells. It
number) (American Heart, 2017). also plays a role to maintain fluid balance and
regulate blood pressure. Pregnant women are
The results of this study using Wilxocon test advised to consume potassium as much as
showed a decrease in systolic and diastolic 2,000 mg per day (Rukiyah, 2009).
blood pressure of pregnant women in the
treatment group after given tomato juice In addition, tomatoes also contain lycopene.
intervention with dose 250 ml / day for 14 Lycopene lowers blood pressure through its
days with p-value 0.001 (<0.05), which role as an antioxidant. Lycopene prevents free
indicated that there was a significant radicals ROS (reactive oxygen species) cause
difference of blood pressure before and after oxidative stress, then triggers the production
given intervention. of nitric oxide in the endothelium and
improves vascular function, resulting in a
Systolic blood pressure is the peak pressure decrease in blood pressure. Antioxidants also
that is reached when the heart contracts and have an effect on preeclampsia (Chauhan,
pumps blood out through the arteries, diastolic Sharma, Agarwal, & Chauhan, 2011; Paran &
!
Engelhard, 2001). However, this study Besford, R. T., & Maw, G. A. (1975). Effect of
provides the evidence that tomatoes juice is potassium nutrition on tomato plant growth
and fruit development. Plant and Soil, 42(2),
effective in lowering blood pressure in 395-412. doi: 10.1007/bf00010015
pregnant mothers with hypertension Chauhan, K., Sharma, S., Agarwal, N., & Chauhan, B.
(2011). LYCOPENE OF TOMATO FAME:
Limitation of the study ITS ROLE IN HEALTH AND DISEASE.
International Journal of Pharmaceutical
This study only examined the levels of Sciences Review and Research, 10(1), 99-115.
antioxidants and potassium, which considered Dinkes. (2014). Health Profile of Central Java Province:
as the limitation of the study. Besides, the Department of Health of Central Java.
psychological factors and daily diet were not Ismalia, N., & Zuraida, R. (2016). Efek Tomat
assessed that may affect maternal blood (Lycopersion esculentum Mill) dalam
Menurunkan Tekanan Darah Tinggi. Jurnal
pressure. In addition, the measurement Majority, 5(4), 107-111.
techniques were only done at the beginning Paran, E., & Engelhard, Y. (2001). P-333: Effect of
and end of study, not recorded every day, tomato's lycopene on blood pressure, serum
which was unable to know the development of lipoproteins, plasma homocysteine and
oxidative sress markers in grade I
changes in blood pressure of respondents hypertensive patients. American Journal of
every day. Further study is needed to deal Hypertension, 14(S1), 141A-141A. doi:
with these issues. 10.1016/S0895-7061(01)01854-4
Ramadhian, M. R., & Hasibuan, N. C. (2016).
Efektivitas Kandungan Kalium dan Likopen
yang Terdapat Dalam Tomat (Solanum
CONCLUSION lycipersicum) Terhadap Penurunan Tekanan
It is concluded that there was a significant Darah Tinggi. Jurnal Majority, 5(3), 124-128.
reduction in systolic and diastolic blood Rukiyah, A. Y. (2009). Asuhan Kebidanan II
pressure of pregnant women in the treatment (Persalinan). Jakarta: x, 195.
Rukiyah, A. Y., & Yulianti, L. (2010). Asuhan
group after given tomato juice. This can be an kebidanan IV (patologi kebidanan). Jakarta:
alternative treatment for midwife in lowering Trans Info Media.
blood pressure in pregnant women. Sharma, J. B., Kumar, A., Kumar, A., Malhotra, M.,
Arora, R., Prasad, S., & Batra, S. (2003).
Effect of lycopene on pre-eclampsia and intra-
uterine growth retardation in primigravidas.
REFERENCES Int J Gynaecol Obstet, 81(3), 257-262.
American Heart, A. (2017). What is high blood
pressure? South Carolina State Documents
Depository.
Cite this article as: Anita, T., Suwandono, A., Ariyanti, I., Pramono, N., Kumorowulan, S. (2017).
Effect of consuming tomato (lycopersium commune) juice in lowering blood pressure in pregnant
mothers with hypertension. Belitung Nursing Journal, 3(6), 707-711.

Wati SH, et al. Belitung Nursing Journal. 2017 December;3(6):712-721

HYPNODIALYSIS FOR ANXIETY RELIEF AND ADHERENCE TO

MEDICATION, KIDNEY DIET AND FLUID INTAKE IN PATIENTS WITH
Siti Hajar Wati*, Mardiyono, Warijan
Postgraduate Nursing Program, Semarang Health Polytechnic, Central Java, Indonesia
*Correspondence:
Siti Hajar Wati, S.Ter.Kep
E-mail: hajarwati.siti@gmail.com
Abstract
Objective: To examine the effectiveness of hypnodialysis on anxiety levels and adherence to medication, kidney diet and
fluid intake in patients with chronic kidney disease.
Methods: This was a randomized controlled trial study conducted from November to December 2016. Thirty respondents
recruited using simple random sampling, which 17 respondents assigned randomly in the experiment and control group. The
Hamilton Anxiety Rating Scale (HARS), Morisky scale, adherence to kidney diet questionnaire, adherence to fluid intake
questionnaire were used as instruments for this study. Paired t-test and repeated ANOVA were used for data analysis.
Results: Findings showed that there was a statistically significant effect of hypnodialysis in reducing anxiety levels and
improving adherence to medication, kidney diet, and fluid intake in patients with chronic kidney disease with p-value 0.000
(<0.05), which its effect started from day 7 (posttest 1).
Conclusion: Hypnodialysis may decrease anxiety levels and improve medication adherence, kidney diet and fluid intake.
Therefore, hypnodialyis can be anlternative treatment for patients with chronic kidney disease.
Keywords: Anxiety, Medication Adherence, Kidney Diet, Fluid Intake, Chronic Kidney Disease
INTRODUCTION
Chronic kidney disease (CKD) is progressive, into the urine and affects the workings of each
irreversible deterioration in renal fucntion in system of the body (Smeltzer et al., 2008).
which the body’s ability to maintain
metabolism and fluid and electrolyte balance Decrease in kidney function or Glomerullar
fails, resulting in uremia and azotemia Fitraton Rate (GFR) less than 15 mL/
(Smeltzer et al., 2008). CKD occurs because minute/1.73 m is called as Chronic kidney
of the number of nephrons are damaged and disease (CKD) stage V. Effect of decreased
stop working. For a while, healthy nephrons renal function in excreting the final product of
can take on the extra work. But if the damage metabolism, acidic substance, will accumulate
continues, more and more nephrons in serum patients and work as toxins
shutdown. Damage from the nephron may (Elizabeth, 2009).
cause a decrease in the Glomerullar Fitraton
Rate (GFR), which the kidneys are incapable Patients with chronic kidney disease often
of filtering blood as renal function decreased, develop sudden changes such as severe
so that the rest of the protein metabolism that acidosis, hyperkalemia, sepsis, pulmonary
should be excreted into the urine accumulates edema or other severe infections that can
cause death, therefore rapid treatment is
!
Wati, S. H., Mardiyono., Warijan. (2017)!
needed. Chronic kidney disease is currently hemodialysis without side effects (Sukandar,
the most important health problem, which is 2006).
not only related to the prevalence and the
increase of incidence rate, but also the high When patiens start hemodialysis, then they
cost of replacement treatment of renal must change all aspects of their life at that
function (Harrison, Wilson, & Kasper, 2005). moment. Patients should do hemodialysis
routinely for 2-3 times a week, dealing with
The number of patients with kidney disorders repeated punctures, medication adherence,
in developed countries is quite high. In the low-protein and salt diet, and limited fluid
United States, the incidence of chronic kidney intake. In addition, hemodyalisis also impacts
was sharply increased, in 2000 there were on psychology of patients, such as anxiety.
372,000 cases, by 2010 the number was Anxiety is an emotion characterized by an
estimated to be more than 650,000 cases, and unpleasant state or reaction to situations
about 6 million to 20 million Americans were perceived as stressful or dangerous
estimated to have early chronic kidney (Syamsiah, 2011).
disease. The similar thing also happened in
Singapore, which there was 2,497 cases in Based on preliminary study with five patients
2012, and increased to 2,518 cases in 2013. In with CKD, it was identified that 2 patients
Malaysia, with a population of 18 million, it is experienced mild anxiety and 3 patients
estimated that there are 1,800 new cases of experienced moderate anxiety; of those five
chronic kidney disease per year (Nicolas, patients, four of them did not follow the diet
2013). and fluid intake. It is however supported by
previous study revealed that from 68 patients,
Treatment of chronic kidney disease consists more than a half of them experienced anxiety,
of 3 stages, namely conservative treatment, which was influenced by several factors, such
symptomatic and replacement therapy of side effects during hemodyalisis, including
kidney function. While handling of chronic muscle cramps, nausea, vomiting, and
kidney disease conservatively consists of the hypotension, as well as the fear of death,
role of kidney diet, which regulates calorie economic change, changes in family function
needs, fluid fulfillment, electrolyte and and lifestyle changes (Lailatushifah, 2012).
mineral. Symptomatic therapy aims to prevent
or reduce kidney damage by administration of In addition, Kartika Sari explained that the
drugs such as antihypertensive and anemia non-adherence of patients in kidney diet and
drugs, while replacement therapy for kidney fluid intake is caused that the patients think
function is by hemodialysis or directly by they are free to consume any food and drink
performing a kidney transplant (Price & just before hemodialysis because the waste of
Wilson, 2005). metabolism in the body will be expelled
during hemodialysis therapy, in fact, body
Hemodyalisis is a kidney replacement therapy weight is gained than recommended (Sari,
often performed in Indonesia. Hemodialysis is 2009). Followed by Desak Putu Kurniawati
a treatment that aims to replace kidney said that 50% -66.7% of patients undergoing
function by using machinery to remove the hemodialysis with non-adherence to fluid
remnants of metabolic products and reduce intake restriction were characterized by
disruption of fluid and electrolyte balance complaints of shortness of breath caused by
when the kidneys are no longer able to carry increased body fluid volume during visit.
out the process with diffusion, osmosis and These indicate that adherence to medication,
ultrafitration principles. General indications of kidney diet, and fluid intake is still quite
hemodialysis in chronic kidney disease is difficult to apply by patients with CKD
when GFR is less than 15 mL/min. undergoing hemodyalisis. Thus, an effort to
Hemodialysis is not a therapy that can cure deal with patient’s adherence is needed
the disease permanently, but hemodialysis (kurniawati, 2014).
helps the patient's survival before transplating
the kidneys. Although hemodialysis is safe Health education, family support, and
and beneficial to patients, it does not mean hypnotherapy are often used as efforts to

!
overcome with patient’s adherence. However, anxiety, medication adherence, adherence to

this study only focused on hypotherapy as an kidney diet and fluid intake through deep
intervention to increase patient’s adherence. suggestion to the patient by taking a deep
Previous study stated that there was an effect breath and exhaling by mouth slowly and
of hypnotherapy on anxiety and adherence to repeatedly over and over until patient is
medication, kidney diet, and fuild intake (Ds, hypnotized, which is characterized by relaxed
Kristiyawati, & Supriyadi, 2014; condition and can be encouraged to follow the
Lailatushifah, 2012; Sari, 2009). therapist's instructions appropriately without
seeing the therapist. Hypnodialysis performed
Therefore, given the phenomena and the by certified therapist for 8 times intervention,
effect of hypnotherapy in previous study, this with 4 times a week performed at each
study aimed to prove the effectiveness of patient’s home in duration of 45 minutes
hypnotherapy (called hypnodialysis) on persession. For the control group, health
anxiety and adherence to medication, kidney education about chronic kidney disease and
diet and fluid intake in patients with chronic kidney diet and fluid intake was given for 8
kidney disease. times intervention, with 4 times a week
performed at each patient’s home in duration
of 45 minutes persession.
METHODS
Study Design Instruments
This was a randomized controlled trial study There were four instruments used in this
conducted from November to December 2016 study, which consisted of:
in the General Hospital of Ungaran and (i) The Hamilton Anxiety Rating Scale
Ambarawa. (HARS) was used to measure anxiety
adopted from previous instrument in
Research Subject Indonesian version (Hargyowati, 2016)
The target population in this study were all in Indonesian version. This scale
patients with chronic kidney disease who consisted of 14 items of questions.
undergone hemodialysis at Ungaran Hospital Cronbach’s alpha was 0.756.
and Ambarawa hospital. In the Ungaran (ii) Morisky scale was used to measure
hospital, there were 39 patients regularly medical adherence adopted from
performed hemodialysis, while in Ambarawa previous instrument in Indonesian
hospital, 40 patients routinely performed version (Puspitasari, 2012). This scale
hemodialysis. The number of sample in this consisted of 8 items of questions.
study was 34 respondents recruited based on Cronbach’s alpha was 0.802.
the number of sample in previous study using (iii) Adherence to kidney diet questionnaire,
RCT design. The number of sample in each adopted from previous instrument in
group was 17 respondents assigned randomly Indonesian version (Relawati,
in the experiment and control group. Simple Kurniawan, Fauzi, & Hadi, 2016). The
random sampling was performed by questionnaire consisted of 26 items of
randomization of patients name lists, which dichotomous questions. KR-20 obtained
even number was included in the experiment a reliable value of 1.17, and coefficient
group and odd number included in the control correlation in all items was >0.6.
group. The inclusion criteria of the sample (iv) Adherence to fluid intake questionnaire,
were patients undergoing hemodyalisis with adopted from from previous instrument
full consciousness, while the exclusion in Indonesian version (Aminoto & Asti,
criteria were patients with interdialytic 2012). It consisted of 20 items of
condition (hypotension, hypoglycemia, and questions with dichotomous options. KR-
shortness of breath). 20 value was 0.645, and coefficient
correlation in all items was >0.6.
Intervention
Hypnodialysis is a holistic therapy by giving a Ethical consideration
hypnosis to patients undergoing hemodialysis Ethical clearance was obtained from Health
which aims to address the problems of both Research Ethics Committee of POLTEKKES
!
Semarang with No. 174/KEPK/Poltekkes- had moderate anxiety and 4 respondents

Smg/EC/2016. The researchers have (23.6%) had mild anxiety, while in the day 12
confirmed that all respondents have signed a (posttest 2) the anxiety level showed 13
written informed consent prior to data respondents (76.4%) had mild anxiety and 3
collection. respondents (17.6%) with no anxiety.
Data analysis For the experiment group, in day 1 (pretest 1)

Paired t-test and repeated ANOVA were used in the first week found 12 respondents
for data analysis. (70.5%) had moderate anxiety and 5
respondents (29.4%) had severe anxiety,
while in the day 7 (posttest 1) the level of
RESULTS anxiety showed 15 respondents (88.3%) had
Table 1 shows that in the control group in day mild anxiety and 2 respondents (11.8%) with
1 (pretest 1) in the first week found that 10 no anxiety. In day 8 (pretest 2) in the second
respondents (58.8%) had severe anxiety and 7 week found 16 respondents (94.6%) had mild
respondents (41.2%) had moderate anxiety, anxiety and 1 respondents (5.9%) had no
while in the day 7 (posttest 1) the level of anxiety, while in the day 12 (posttest 2) the
anxiety showed 9 respondents (52.9%) had anxiety level showed 1 respondents (5.9%)
moderate anxiety and 6 people (47.1%) with had mild anxiety and 16 respondents (17.6%)
mild anxiety. In day 8 (pretest 2) in the with no anxiety.
second week found 13 respondents (76.4%)
Table 1 Frequency distribution of anxiety levels in the control and experiment group (n=34)
Control group Intervention group
Variable
Day 1 Day 7 Day 8 Day 12 Day 1 Day 7 Day 8 Day 12
Anxiety
n % n % n % n % n % n % n % n %
level
Mean ± (29.53± (22.82± (23.82± (16.88± (26.71± (16.06± (16.82± (7.76±
SD 4.611) 3.414) 3.245) 4.285) 3.917) 3.288) 2.765) 3.192)
<14 : No
0 0 0 0 0 0 3 17.6 0 0 2 11.8 1 5.9 16 94.1
anxiety
14-20 :
0 0 6 47.1 4 23.6 13 76.4 0 0 15 88.3 16 94.1 1 5.9
Mild
21-27 :
7 41.2 9 52.9 13 76.4 1 5.9 12 70.5 0 0 0 0 0 0
Moderate
28-41 :
10 58.8 0 0 0 0 0 0 5 29.4 0 0 0 0 0 0
Severe
43-56 :
More 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
severe
Table 2 Frequency distribution of medication adherence in the control and experiment group (n=34)
Variable
Day 1 Day 7 Hari 8 Day 12 Day 1 Hari 7 Day 8 Day 12
Medication
n % n % n % n % n % n % n % n %
adherence
(6.53± (5.47± (6.29± (5.00± (6.35± (3.35± (4.18± (2.06±
Mean±SD
0.874) 0.624) 0.588) 0.791) 0.786) 0.931) 0.951) 0.899)
1-5 : High 3 17.6 10 58.8 1 5.9 12 70.6 3 17.6 17 100 15 88.2 17 100
6-7 :
13 76.4 7 41.2 16 94.1 5 29.4 14 82.3 0 0 2 11.8 0 0
Moderate
8 : Low 3 17.6 0 0 0 0 0 0 0 0 0 0 0 0 0 0

!
Table 2 shows that in the control group in day and 12 respondents (70.6%) with high
1 (pretest 1) in the first week found that 3 medication adherence.
respondents (17.6%) had low medication
adherence, 3 respondents (76.4%) had high For the experiment group, in day 1 (pretest 1)
medication adherence and 13 respondents in the first week found that 14 respondents
(76.4%) had moderate medication adherence, (82.3%) had moderate medication adherence
while in the day 7 (posttest 1) there was no and 3 respondents (17.6%) had high
respondents had low medication adherence, 9 adherence, while in the day 7 (posttest 1)
respondents (41.2%) had moderate medication there was no respondent with low and
adherence, and 10 respondents (58.8%) with moderate medication adherence, all of them
high adherence. In day 8 (pretest 2) in the (100%) had high medication adherence. In
second week found that 16 respondents day 8 (pretest 2) in the second week found
(94.1%) had moderate adherence and 1 that 2 respondents (11.8%) had moderate
respondents (5.9%) had high adherence, while medication adherence and 15 respondents
in the day 12 (posttest 2) there were 5 (88.2%) with high adherence, and in the day
respondents (29.4%) had moderate adherence 12 (posttest 2) all respondents (100%) had
high medication adherence.
Table 3 Frequency distribution of adherence to kidney diet in the control and experiment group (n=34)
Variable
Day 1 Day 7 Hari 8 Day 12 Day 1 Day 7 Hari 8 Day 12
Adherece to
n % n % n % n % n % n % n % n %
kidney diet
(15.59± (13.18± (14.06± (9.06± (15.53± (8.41± (10.94± (3.82±
Mean±SD
1.372) 1.976) 2.512) 13.579) 1.908) 3.020) 2.861) 0.728)
1-13 : Obey 0 0 7 41.2 3 17.7 13 76.5 1 5.9 16 94.1 11 64.7 17 100
14-26:
17 100 10 58.7 14 82.3 4 23.5 16 94.2 1 5.9 6 47.1 0 0
Disobey
Adherence to kidney diet as shown in the For the experiment group, in day 1 (pretest 1)
Table 3 shows that in the control group in day in the first week found that 16 respondents
1 (pretest 1) in the first week found that all (94.2%) disobeyed and 1 respondent (5.9%)
respondents (100%) disobeyed, while in day 7 obeyed, while in the day 7 (posttest 1) there
(posttest 1) found that 10 respondents (58.7%) was 1 respondent disobeyed and 16
disobeyed and 7 respondents (41.2%) obeyed. respondents (94.1%) obeyed. In day 8 (pretest
In day 8 (pretest 2) in the second week found 2) in the second week found that 11
that 14 respondents (82.3%) disobeyed and 3 respondents (64.7%) obeyed and 6
respondents (17.7%) obeyed, in the day 12 respondents (47.1%) disobeyed, and in the
(posttest 2) there were 4 respondents (23.5%) day 12 (posttest 2) all respondents (100%)
disobeyed and 13 respondents (76.5%) obeyed kidney diet.
obeyed.
Table 4 Frequency distribution of adherence to fluid intake in the control and experiment group (n=34)
Variable
Adherence to
n % n % n % n % n % n % n % n %
fluid intake
(5.47±
Mean±SD (14.53± (9.94± (10.53± (7.59± (13.82± (7.76± (3.12±
1.281)
1.375) 1.919) 1.586) 1.543) 1.185) 1.855) 1.11)
1-10 : Obey 0 0 11 64.7 8 47.1 16 94.1 0 0 17 100 15 88.2 17 100
11-20:
17 100 6 35.3 9 52.9 1 5.9 17 100 0 0 2 11.8 0 0
Disobey
!
Adherence to fluid intake as shown in the (94.1%) obeyed and 1 respondent (5.9%)
Table 4 shows that in the control group in day disobeyed. For the experiment group, in day 1
1 (pretest 1) in the first week found that all (pretest 1) in the first week found that all
respondents (100%) disobeyed, while in day 7 respondents (100%) disobeyed, while in the
(posttest 1) found that 11 respondents (64.7%) day 7 (posttest 1) all respondents (100%)
obeyed and 6 respondents disobeyed. In day 8 obeyed. In day 8 (pretest 2) in the second
(pretest 2) in the second week found that 8 week found that 15 respondents (88.2%)
respondents (47.1%) obeyed and 9 obeyed and 2 respondents (11.8%) disobeyed,
respondents (52.9%) disobeyed, in the day 12 and in the day 12 (posttest 2) all respondents
(posttest 2) there were 16 respondents (100%) obeyed fluid intake.
Table 5 Mean difference of anxiety level, medication adherence, adherence to kidney diet and fluid intake in
the control and experiment group using Paired t-test (n=34)
Group N Mean SD P-value
Anxiety level
Experiment group
Day 1 (pretest 1) - Day 12 (posttest 2) 17 18.941 5.942 0.000
Day 1 (pretest 1) - Day 8 (pretest 2) 17 10.176 5.028 0.000
Control group
Medication adherence
Experiment group
Control group
Adherence to Kidney diet
Experiment group
Control group
Adherence to Fluid intake
Experiment group
Control group

!
Table 5 shows that the anxiety level after medication adherence between experiment
given hypnodialysis 8 times for 2 weeks in the and control group.
experiment group decreased by about 33.83%
while health education in the control group Similar with adherence to kidney diet, there
could decrease anxiety level as much as was an improvement of adherence after given
22.59%. Paired t-test obtained p-value 0.000 intervention in the experiment group for about
(<0.05), which indicated there was a 45.03% and the control group was 25.12%;
significant difference in anxiety levels while adherence to fluid intake increased to
between experiment and control group. 53.53% in the experiment group and 34.71%
in the control group. Paired t-test obtained p-
For medication adherence, there was an value 0.000 (<0.05), which indicated that
improvement of medication adherence in the there was a significant difference in adherence
experiment group after given intervention by to kidney diet and fluid intake between
about 53.68%, and also an increase of experiment and control group. Of all those
medication adherence in the control group as variables, the mean of anxiety levels,
much as 19.12%. Paired t-test obtained p- medication adherence and adherence to
value 0.000 (<0.05), which indicated that kidney diet and fluid intake in the experiment
there was a significant difference in group was higher that the mean in the control
group
.
Table 6 Effect of hypnodialysis on anxiety levels in the control and experiment group using repeated
anova and post hoc test (n=34)
Repeated Anova Df Mean F P-value
Anxiety levels 3 108.131 6.529 0.000
Residue 1
Post hoc test
Mean of anxiety levels
Day 1 (Pretest 1): experiment – control group 0.063
Day 7 (Posttest 1): experiment – control group 0.000
Day 12 (posttest 2): experiment – control group 0.000
Table 6 shows that the result of repeated Table 7 shows that the result of repeated
anova obtained p-value 0.00 (<0.05), which anova obtained p-value 0.00 (<0.05), which
indicated that there was a significant effect of indicated that there was a significant effect of
hypnodialysis on anxiety levels with F-value= hypnodialysis in increasing medication
6.529. Post hoc test showed the effect of adherence with F-value= 24.956. Post hoc test
hypnodyalisis started from day 7 (Posttest 1). showed the effect of hypnodyalisis started
from day 7 (Posttest 1).
Table 7 Effect of hypnodialysis on medication adherence in the control and experiment group using repeated
Medication adherence 3 23.487 24.956 0.000
Residue 1
Post hoc test
Mean of medication adherence
!
Table 8 Effect of hypnodialysis on adherence to kidney diet in the control and experiment group using
repeated anova and post hoc test (n=34)
Adherence to kidney diet 3 46.594 13.649 0.000
Residue 1
Post hoc test
Mean of adherence to kidney diet
hypnodialysis in increasing adherence to hypnodialysis in increasing adherence to fluid
kidney diet with F-value= 13.649. Post hoc intake with F-value= 13.649. Post hoc test
test showed the effect of hypnodyalisis started showed the effect of hypnodyalisis started
from day 7 (Posttest 1). from day 7 (Posttest 1).
Table 9 Effect of hypnodialysis on adherence to fluid intake in the control and experiment group using
Adherence to fluid intake 3 35.723 19.005 0.000
Residue 1
Post hoc test
Mean of adherence to fluid intake
DISCUSSION subconscious mind. In this condition, patient

Effectiveness of hypnodialysis on anxiety will enter a deeper hypnotic pattern, so that
levels the original brain waves in the beta wave will
Findings of this study revealed that there was change slowly toward the alha wave. Under
a significant effect of hypnodialysis in alpha conditions, the brain will produce
reducing anxiety levels in patients with serotonim and endorphin hormones that cause
chronic kidney disease with p-value 0.000, the person to feel comfortable, calm and
starting from day 7 (posttest 1). It could be happy. This hormone increase body immune
said that hypnodialysis is very beneficial for system, dilate blood vessels, and the heartbeat
patients chronic kidney disease who undergo becomes stabil and the sensory capacity rises.
hemodialysis with positive suggestions. This At the time an individual in hypnotherapy,
is in line with previous studies stated that there is a stimulation of the activation system
hypnotherapy is proven to deal with a variety of the reticularis in the brain, causing an
of psychological and psychological disorders, autonomic nerve response, ie pulse, breath
such as anxiety, stress, phobia, sleep frequency, blood pressure and controlled
disturbances, mind-set disorders, etc (Golden, feelings, emotion and anxiety (La Kahija,
2012). 2007).
Physiologically, hypnotherapy works through Relaxation will inhibit the sympathetic

brainwashing systems, as La Kahija says that hormone, so the number of hormone that
on hypnotherapy sessions such as induction causes body disregulation can be reduced. The
and deepening, patient will be guided by the parasympathetic nervous system, which has
therapist from the conscious mind to the the opposite work function of the sympathetic

!
nerves, will slow or weaken the workings of that hypnotherapy is a persuasive

the body's internal devices. As a result, there communication art that aims to open a
is a decrease in heart rate, breathing rhythm, person's unconscious gate so that suggestions
muscle tension, blood pressure, and the can be given (Hakim, 2010b).
production of stress-causing hormones (La
Kahija, 2007). The relaxation conditions that Humans have two types of thoughts that are
result from the treatment of hypnosis can one unity, between the subconscious mind.
trigger changes in brain waves where in The role and influence of the conscious mind
hypnotic state the brain will enter the alpha to ourselves as much as 12% while the
wave to tetha. The frequency of the wave subconscious mind reaches 88%. The
becomes more rhythmic and regular so that unconscious and the subconscious mind
the effects that arise on the brain is the actually affect each other and work at a very
production of neurotransmitters such as high speed (Batbual, 2010).
endorphins, GABA, enkefalin and several
other neurotransmitters that serve to reduce During the process of hypnosis, the body of a
the condition of anxiety as well as cause a person will be relax, while his/her mind is
relaxing effect. (Potter & Perry, 2005) very focused and attentive. Like other
relaxation techniques, when the critical factor
Hypnodialysis is one part of therapy to (CF) or reticular activating system (RAS) is
overcome anxiety by distraction therapy. open and unwittingly all information enters
Distraction is a method to relieve anxiety by the unconscious mind without filtering and
turning attention to other things so that the becoming program of life. Conducting a self-
patient will forget the anxiety experienced. A program is to by-pass the critical factor or
pleasant sensory stimulus causes the release penetrate the critical filter and directly
of endorphins that can inhibit anxious stimuli communicate with the subconscious mind. By
resulting in less anxious stimuli being penetrating this critical filter, the conscious
transmitted to the brain (Potter & Perry, mind is deactivated so that suggestions are
2005). nine times effective (Hakim, 2010a).
Findings of this study were consistent with Hypnotherapy can help the patient find "you
previous studies revealed that hypnodialysis own way" or "your own way" to motivate
was effective in decreasing emotional and yourself to immediately start an activity such
anxiety levels. Differences in hypnodialysis as sport, quit smoking, regulate diet and
methods in this study and previous study were improve healthy behavior. This study is in
the hemodialysis was given for 4 times while line with the previous study revealed that
in this study was given for 8 times in 2 there was an increase in medication adherence
weeks. after given Motivational Interviewing and
conseling (Rubak, 2005). In addition, theory
Effectiveness of hypnodialysis on states that hypnotherapy is a healing concept
adherence to medication, kidney diet and that balances the system of harmonizing the
fluid intake body by reorganizing the habits and behavior,
Findings of this study also revealed that there both consciously and unconsciously (Hakim,
was a significant effect of hypnodialysis in 2010a). Thus, there was a change of habit and
improving medication adherence and behavior from low adherence to high
adherence to kidney diet and fluid intake in adherence in this study.
patients with chronic kidney disease with p-
value 0.000, starting from day 7 (posttest 1).
CONCLUSION
Hypnodialysis is a therapy used in the form of It can be concluded that there was a
suggestions through the art of distinctive significant effect of hypnodialysis in reducing
communication, and shown to the anxiety levels and improving medication
subconscious mind with the aim to change adherence and adherence to kidney diet and
thoughts, feelings, and behavior for the better. fluid intake in patients with chronic kidney
This is in accordance with the theory stating disease with p-value 0.000 (<0.05). Thus,
!
hypnodialysis can be an alternative treatment Mengkonsumsi Obat Harian. Retrieved 16

for patients with chronic kidney disease. January, 2017, from fpsi. mercubuana-yogya.
ac. id/wp-content/.../Noor-Kepatuhan... pdf
Nicolas, G. A. (2013). Hemodyalisis Therapy of
Sustained Low Efficiency Daily Dialysis for
REFERENCES patients with Chronic Kidney Disease in
Aminoto, C., & Asti, A. D. (2012). PENGARUH Intensive Care Unit. E-Jurnal Medika
HYPNOTHERAPY TERHADAP Udayana, 2(5), 766-782.
KEPATUHAN DIIT CAIRAN PADA Potter, P. A., & Perry, A. G. (2005). Buku ajar
PASIEN GAGAL GINJAL KRONIS fundamental keperawatan: konsep, proses, dan
RAWAT JALAN DI INSTALASI praktik. Jakarta: EGC, 1.
HEMODIALISA RS PKU Price, S. A., & Wilson, L. M. (2005). Patofisiologi
MUHAMMADIYAH GOMBONG. Jurnal konsep klinis proses-proses penyakit. Jakarta:
Ilmiah Kesehatan Keperawatan, 8(3). EGC, 7.
Batbual, B. (2010). Hypnosis Hypnobirthing: Nyeri Puspitasari, A. W. (2012). Analisis Efektivitas
Persalinan dan Berbagai Metode Pemberian Booklet Obat Terhadap Tingkat
Penanganannya. Yogyakarta: Gosyen Kepatuhan Ditinjau dari Kadar Hemoglobin
Publishing. Terglikasi (HbA1C) dan Morisky Medication
Ds, A. I., Kristiyawati, S. P., & Supriyadi. (2014). Adherence Scale (MMAS)-8 pada Pasien
PENGARUH HIPNOTERAPI TERHADAP Diabetes Melitus Tipe 2 di Puskesmas Pati
PENURUNAN TINGKAT KECEMASAN Jaya Kota Depok. Tesis, Universitas
PADA PASIEN YANG MENJALANI Indonesia, Depok.
KEMOTERAPI DI RS TELOGOREJO Relawati, A., Kurniawan, R., Fauzi, I., & Hadi, R.
SEMARANG. Jurnal Ilmu Keperawatan dan (2016). Gambaran Kepatuhan Diet Pada
Kebidanan. Penderita Gagal Ginjal Kronis do RSUD
Elizabeth, J. C. (2009). Buku Saku Patofisiologi. Tjitrowardoyo Purworejo. Fakultas
Penerbit Buku Kedokteran EGC: Jakarta. Kedokteran dan Ilmu Kesehatan, Universitas
Golden, W. L. (2012). Cognitive hypnotherapy for Muhammadiyah Yogyakarta.
anxiety disorders. American Journal of Rubak, S. (2005). Motivational interviewing in intensive
Clinical Hypnosis, 54(4), 263-274. treatment of type 2 diabetes detected by
Hakim, A. (2010a). Hipnoterapi: Cara Tepat & Cepat screening in general practice. Danish Medical
Mengarasi Stres, Fobia, Trauma, dan Bulletin, 52(32), 54-60.
Gangguan Mental Lainnya: VisiMedia. Sari, L. K. (2009). Faktor-faktor yang berhubungan
Hakim, A. (2010b). Hypnosis in Teaching: Cara dengan kepatuhan dalam pembatasan asupan
Dahsyat Mendidik & Mengajar: VisiMedia. cairan pada klien gagal ginjal kronik yang
Hargyowati, Y. E. (2016). Tingkat Kecemasan yang menjalani terapi hemodialisis diruang
Dilakukan Tindakan Hemodialisa di Ruang hemodialisa RSUP Fatmawati Fakultas
Hemodialisa RSUD Dr. Soehadi Prijonegoro Kedokteran dan Ilmu Kesehatan, UIN Syarif
Sragen. Stikes Kusuma Husada Surakarta. Hidayatullah Jakarta.
Retrieved from Smeltzer, S. C., Bare, B. G., Hinkle, J. L., Cheever, K.
http://stikeskusumahusada.ac.id/digilib/files/di H., Townsend, M. C., & Gould, B. (2008).
sk1/31/01-gdl-yaniekohar-1508-1-yanieko- Brunner & Suddarth’s Textbook of Medical
).pdf Surgical Nursing 12th Edition: Wolters
Harrison, I., Wilson, B. W., & Kasper, M. F. (2005). Kluwer: Lippincott Williams and Wilkins.
Prinsip-prinsip ilmu penyakit dalam [The Sukandar, E. (2006). Gagal ginjal dan panduan terapi
principles of internal medicine]. dialisis. Bandung: Pusat Informasi Ilmiah
kurniawati, D. P. (2014). Edukasi dalam meningkatkan (PII) Bagian Ilmu Penyakit Dalam FK-
kepatuhan intake cairan pasien penyakit UNPAD RS Dr. Hasan Sadikin.
ginjal kronik (PGK) on Hemodialisis. Fakultas Syamsiah, N. (2011). Faktor-faktor yang berhubungan
Keperawatan, Universitas Airlangga. dengan kepatuhan pasien CKD yang
La Kahija, Y. F. (2007). Hipnoterapi: Prinsip-prinsip menjalani hemodialisa di RSPAU DR
dasar praktik psikoterapi: Gramedia Pustaka Esnawan Antariksa Halim Perdana Kusuma
Utama. Jakarta. Program Studi Magister
Lailatushifah, S. N. F. (2012). Kepatuhan Pasien Yang Keperawatan, Fakultas Ilmu Keperawatan,
Menderita Penyakit Kronis Dalam Universitas Indonesia.
Cite this article as: Wati, S. H., Mardiyono., Warijan. (2017). Hypnodialysis for anxiety relief and
adherence to medication, kidney diet and fluid intake in patients with chronic kidney disease. Belitung
Nursing Journal, 3(6), 712-721.

Resmi DC, et al. Belitung Nursing Journal. 2017 December;3(6):722-728

EFFECT OF YOGA AND ACUPRESSURE ON PAIN AND FUNCTIONAL

CAPABILITY OF LOWER BACK IN PREGNANT MOTHERS DURING THE
Dewi Candra Resmi*, Suharyo Hadisaputro, Runjati
*Correspondence:
Dewi Candra Resmi
E-mail: decha_qyut@yahoo.co.id
Abstract
Objective: To examine the effect of yoga and acupressure in lower back pain and functional capability in pregnant women
during the third semester of pregnancy.
Methods: A quasy experimental design with pretest posttest with non-equivalent control group. The research was conducted
at the Community Health Center of Kalikajar I, Selomerto I and Garung I in Wonosobo regency in January 2017. The
samples of this research were 42 pregnant women in trimester III selected using purposive sampling, which 14 samples
assigned in the yoga group, acupressure group, and control group. A Visual Analog Scale (VAS) was used to measure pain
level, and Oswestry Disability Index to measure functional capability of lower back. Data were analyzed using paired t-test
and one-way ANOVA.
Results: Findings showed that there was a statistically significant effect of yoga, acupressure, and pregnancy exercise
(control group) in reducing lower back pain and lower back functional capability with p <0.05. Pregnancy exercise (mean=
-1.43) was more effective in reducing lower back pain compared with yoga (mean=-2.29) and acupressure (mean=-2.71);
and acupressure (mean=-14.29) was more effective in improving lower back functional capability than yoga (mean=-6.57)
and pregnancy exercise (mean= -13.29).
Conclusion: There were significant effects of yoga, acupressure, and pregnancy exercise in reducing pain and in improving
the functional ability of the lower back. It is recommended for midwife to use these interventions as an alternative to deal
with back pain and functional capability in pregnant women, especially in the Community Health Center in Wonosobo
regency.
Keywords: Yoga, Acupressure, Pregnancy Exercise, Pain, Functional Ability
INTRODUCTION
Back pain in pregnancy is a pain that occurs and Israel have spinal pain. While in the
in the lumbosacral area. Back pain intensity Northern America, Africa, the Middle East,
usually increases as the gestational age Norway, Hong Kong and Nigeria have higher
increases. It is because this pain is the result prevalence ranging from 21% to 89.9%
of a shift in the center of gravity and its (Ansari, Hasson, Naghdi, Keyhani, & Jalaie,
posture (Varney, Kriebs, & Gegor, 2007). 2010). Survey conducted by the University of
Improper posture will force additional Ulster in 2014 showed that 70% of a total of
stretching and fatigue in the body, especially 157 pregnant women experienced lower back
in the spinal cord, causing pain or back pain pain (Dase, RphD, BmedsSc, & PgChep,
(Brayshaw, 2007). Previous study revealed 2014). In Indonesia, 60-80% pregnant women
that more than 50% of pregnant women in the experienced lower back pain; and in the
United States, Canada, Iceland, Turkey, Korea Community Health Center of Ungaran
722 BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017 ! !

Resmi, D. C., Hadisaputro, S., Runjati. (2017)!
showed that there were 45 pregnant women in the central nervous system in the backbone
the trimester III had lower back pain (Lebang, 2014; Mander, 2003). While
(Pravikasari, 2014). acupressure emphasis on the trigger point,
where in the case of activating point pain is
Based on preliminary study conducted at the the same as the acupuncture point. This is in
Community Health Center of Kalikajar I, accordance with the theory by previous study
Selomerto I and Garung I in Wonosobo stated that one of the benefits of acupressure
regency, there were 187 pregnant women in is to reduce back pain (Khomsah, Suwandono,
the third trimester from January to May 2016. & Ariyanti, 2017).
An effort to reduce low back pain in pregnant
women in these health centers is by only
providing health education about mobilization METHODS
and following the class of pregnant women to Research Design
do pregnancy exercise. While based on the This was a quasy experimental design with
results of interviews on 16 pregnant women in pretest posttest with non-equivalent control
trimester III revealed that 12 mothers group.
experienced lower back pain, and to reduce
the pain they did more rest and warm Setting
compresses on the lower back area. The research was conducted at the
Community Health Center of Kalikajar I,
The lower back will sometimes spread up to Selomerto I and Garung I in Wonosobo
the pelvis, thighs and down to the legs, regency in January 2017. The research was
sometimes will increase tenderness above conducted for 3 weeks.
pubic sympathetic (Cunningham, Leveno,
Bloom, Spong, & Dashe, 2014). This will Research Subjects
cause pregnant women to have difficulty in The target population in this study was all
performing activities such as standing up after pregnant women in trimester III the
sitting, moving from bed, sitting too long, Community Health Center of Kalikajar I,
standing too long, undressing and removing Selomerto I and Garung I in Wonosobo
clothes, or lifting and moving objects around regency. The samples of this research were 42
(Kozier, 2008). pregnant women in trimester III selected
using purposive sampling, which 14 samples
There are two kinds of treatments to deal with assigned in the yoga group, acupressure
pain and functional ability, namely group, and control group. The inclusion
pharmacology and non-pharmacology. criteria were: pregnant women in trimester III
Considering the impacts of pharmacological who experienced back pain and lower back
therapy, non-pharmacologic therapy should be functional ability, did not have a bad history
implemented to reduce back pain experienced of pregnancy, could communicate well,
by the third trimester pregnant women, those cooperative and willing to be a respondent;
include cutaneous stimulation (massage, hot while the exclusion criteria included: pregnant
and cold application, acupressure, and women with gestational age less than 29
contralateral stimulation), TENS, weeks.
acupuncture, relaxation, imagination,
meditation, hypnosis, aromatherapy, yoga and Intervention
reflexology (Thompson, 2004). This study For the yoga group, yoga was given two times
aimed to apply yoga and acupressure to deal per week for 3 weeks. Yoga was done for 60
with pain and functional capability in minutes per session in the morning in the
pregnant women. Community Health Center of Kalikajar I.
Yoga consisted of warm-up exercises,
Yoga is one of non-pharmacological therapies breathing (pranayama), and the core
that can reduce pain. Yoga is a practical effort movement as a series of yoga asana
in harmonizing body, mind, and spirit, which movement including Tadasana, Baddakosana,
its benefits are to build a strongposture, and Upavistha konasana, Dandasana, Suptha
foster flexible and strong muscles, and purify
BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017 ! 723

!
baddakosana, and savanna. Yoga was done by Suwandono, Ariyanti, Mashoedi, &
an expert for yoga for pregnancy. Fatmasari, 2017), and functional capability of
lower back was measured using Oswestry
For the acupressure group, acupressure was Disability Index (ODI) questionnaire
done for 15 minutes per session, which was (Fairbank & Pynsent, 2000). Back pain and
implemented two times per week for 3 weeks. functional capability were measured during
Acupressure is an emphasis on certain points pretest and posttest.
in the body part of the lower back and legs of
the third trimester pregnant women who Ethical Consideration
experienced lower back pain. The points of The ethical consideration of this research was
acupressure included: BL23 (shenshu), GV 3 obtained from the Ethics Commission of
(yaoyangguan), GV 4 (Mingmen), Ki 3 Poltekkes Kemenkes Semarang
(taixi). The acupressure was performed by an No.141/KEPK/Poltekkes-Smg/EC/017. Prior
acupressure therapist at the Community to data collection, each respondent was signed
Health Center of Selomerto I. a written informed consent.
The control group was given the standard Data Analysis

action of pregnancy exercise performed in 60 Paired t-test was used to determine the mean
minutes per session and done two times per effect before and after intervention. To
week for 3 weeks. Pregnancy exercise is an determine the difference in the three groups,
exercise performed to maintain blood ANOVA test was used and followed by post-
circulation, reduce cramps and stiff hoc test. The homogeneity test used a Levene
complaints. Exercise was done in the form of test, and normality test used Shapiro-wilk test
basic exercises, breathing, and stretching because the number of respondents was less
which is different from breathing techniques than 50.
in Yoga. Poses performed differently, which
more with sitting position upright and
crawling to stretch the lower back muscles. RESULTS
This exercise was done by a midwife in the Normality test
Community Health Center of Garung. The results of Shapiro Wilk test as shown in
the Table 1 indicated that lower back pain and
Instrument functional capabilities in the three groups
Back pain was measured using a Visual were in normal distribution with p-value
Analog Scale (VAS) adopted from (Rosyida, >0.05.
Table 1 Normality test on lower back pain and functional capability before and after given intervention using
Shapiro Wilk
Group
Yoga Acupressure Control
Variable
(p-value) (p-value) (p-value)
Pretest Posttest Pretest Posttest Pretest Posttest
Back Pain 0.251 0.057 0.683 0.504 0.271 0.251
Lower back functional
0.809 0.297 0.120 0.539 0.064 0.223
capability
Homogeneity test F 0.629 and p= 0.893 (>0.05), which

Levene’s test as shown in the Table 2 showed indicated that the group of yoga, acupressure
back pain variable with F = 3.192 and p= and control group were homogenous.
0.052 (>0.052), and functional capability with
Table 2 Homogeneity test on lower back pain and functional capability using Levene’s test
Variable F P-value
Back Pain 3.192 0.052
0.629 0.893
capability
!
Characteristics of respondents
Table 3 Characteristics of respondents based on age, employment status, parity, and body weight
Group
Intervention Control
Variable P-value
Yoga Acupressure Pregnancy exercise
n (%) Mean±SD n (%) Mean±SD n (%) Mean±SD
Age (year)
" <19 0 (0) 1(7.1) 2 (14.3) 0.590
" 20-35 13(92.9) 11(78.6) 10 (71.4)
" >36 1 (7.1) 2 (14.3) 2 (14.3)
Employment status
" Employed 5 (35.7) 6 (42.9) 11 (78.6) 0.253
" Unemployed 9 (64.3) 8 (57.1) 3 (21.4)
Parity
" Primipara 6 (42.9) 6 (42.9) 5 (35.7) 0.906
" Multipara 8 (57.1) 8 (57.1) 9 (64.3)
Body weight 60.164±8.72 61.86±8.67 58.71±4.87 0.102
Table 3 shows that there were no significant (p=0.590), employment status (p=0.253),
differences of the characteristics of parity (p=0.906), and body weight (p=0.102).
respondents in the three groups based on age
Difference of lower back pain before and after given intervention

Table 4 Difference of lower back pain before and after given intervention
Pregnancy
Variable Yoga Acupressure p-value
exercise
Mean±SD Mean±SD
Mean±SD
Lower Pretest 4.14±1.127 4.93±2.056 4.86±1.562 0.3682
back pain Postest 2.71±1.204 2.64±1.646 2.14±1.027 0.4652
p-value 0.0001 0.0001 0.0001
Mean
-1.43±0.852 -2.29±0.914 -2.71±1.069 0.0002
difference
1
Paired T test, 2One Way Anova
Table 4 shows that the mean of lower back

pain in the yoga group before given The mean of lower back pain in the control
intervention was 4.14 ± 1.127, and decreased group before given intervention was 4.86 ±
to 2.71 ± 1.207 after the intervention, and the 1.56, and decreased to 2.14 ± 1.02 after
mean difference of pain levels before and intervention. The mean difference of pain
after intervention was -1.43. The results of level before and after intervention was -2.71.
Paired t-test obtained p-value 0.000, which Paired t-test showed p-value 0.000, which
indicated that there was a significant effect of indicated that there was a significant decrease
yoga in decreasing back pain level. The mean of lower back pain after given pregnancy
of lower back pain in the acupressure group exercise. One way anova test obtained p-
before given intervention was 4.93 ± 2.056, value 0.000, which indicated that yoga,
and decreased to 2.64 ± 1.646 after the accupressure, and pregnancy exercise have a
intervention, and the mean difference between significant effect in reducing lower back pain
pain levels before and after intervention was - in pregnant women. However, the mean
2.29. Paired t-test showed p-value 0.000, difference in pregnancy exercise group
which indicated that there was a significant showed a higher decrease of pain level
effect of acupressure in lowering back pain. compared with yoga and acupressure group.

!
Difference of lower back functional capability before and after given intervention
Table 5 Difference of lower back functional capability before and after given intervention
Pregnancy
Variable Yoga Acupressure P-value
exercise
Mean±SD Mean±SD
Mean±SD
Lower back functional Pretest 32.14±13.091 36.29±12.048 31.14±13.421 0.5392
capability Postest 25.57±10.383 22.00±7.104 17.86±5.736 0.0482
1 1 1
p-value 0.009 0.000 0.000
Mean -6.57±7.978 -14.29±6.510 -13.29±9.15 0.0292
difference
1
Table 4 shows that the mean of lower back capability. One way anova test obtained p-
functional capability in the yoga group before value 0.029, which indicated that yoga,
given intervention was 32.14 ± 13.091, and accupressure, and pregnancy exercise have a
after intervention was 25.57 ± 10.383, and the significant effect in increasing lower back
mean difference of lower back functional functional capability in pregnant women.
capability before and after intervention was - However, the mean difference in accupressure
6.57 ±7.978. The results of Paired t-test group showed a higher increase of back
obtained p-value 0.009, which indicated that functional capability compared with yoga and
there was a significant effect of yoga on lower control group.
back functional capability. While the mean of
lower back functional capability in the Table 6 shows that there was a significant
acupressure group before given intervention difference of pain level between yoga and
was 36.29 ± 12.048, and after intervention pregnancy exercise group with mean value
was 22.00 ± 7.104, and the mean difference 1.500 and p-value 0.000 (<0.05); and between
between lower back functional capability yoga and acupressure group with mean value -
before and after intervention was -14.29 1.071 and p-value 0.013 (<0.05). There was
±6.510. Paired t-test showed p-value 0.000, no significant difference between acupressure
which indicated that there was a significant and pregnancy exercise with p-value 0.697
effect of acupressure on lower back functional (>0.05).
capability.
For lower back functional capability, post hoc
The mean of lower back functional capability test showed a significant difference between
in the control group before given intervention yoga and acupressure with mean 7.714 and p-
was 31.14 ± 13.421, and after intervention value 0.042 (<0.05). There was no significant
was 17.86 ± 5.736. The mean difference of difference between yoga and pregnancy
lower back functional capability before and exercise with mean 6.714 and p-value 0.094
after intervention was -13.29 ±9.15. Paired t- (> 0.05), and between acupressure and
test showed p-value 0.000, which indicated pregnancy exercise with p-value 1.000
that there was a significant effect of (>0.05).
pregnancy exercise on lower back functional
Table 6 Mean difference of lower back pain and functional capability using post hoc test
Mean
Variable Group p-value
Difference
Lower back pain Yoga vs pregnancy exercise 1.500 0.000
Acupressure vs pregnancy exercise 0.429 0.697
Yoga vs acupressure -1.071 0.013
Lower back functional Yoga vs acupressure 7.714 0.042
capability Yoga vs pregnancy exercise 6.714 0.094
Acupressure vs pregnancy exercise -1.000 1.000
!
DISCUSSION poor yoga movements. In addition, different

Effect of yoga on lower back pain and instructors in yoga group and pregnancy
functional capabilities compared with exercise group might be one of factors. In
pregnancy exercise pregnancy exercise, the instructor was the
The results showed that there was a midwife of the health center itself so that the
significant effect of yoga on the decrease of respondents were easily to communicate and
lower back pain. Back pain in pregnancy is more comfortable, while a yoga instructor was
the pain that occurs in the lumbosacral area. not a midwife who was not yet known by the
This is in line with previous study stated that respondents. Pregnancy exercise is one of the
alternative treatments to reduce low back pain activities in the prenatal care service during
in pregnancy were massage (61.4%), pregnancy to provide better pregnancy or
acupuncture (44.6%), yoga (40.6%) and delivery compared with pregnant women who
chiropractic (36.6%) (Wang et al., 2005). do not do pregnancy exercises (Thompson,
Yoga is one form of exercises that can be 2004). This is in accordance with previous
done by pregnant women. Yoga can make the research revealed the effectiveness of
body more flexible and comfortable in pregnancy exercise on decrease of back pain
addition to supporting blood circulation, in pregnant mother at the Community Health
overcoming back pain, waist, aches and Center of inpati Karya Wanita Pekanbaru with
swelling (Kozier, 2008). Doing yoga routinely p-value 0.001 (<0.05) (Lebang, 2014).
can increase ability to stand better, walk
longer, run faster and all done without leaving Effect of acupressure on lower back pain
the pain after doing so. The function and and functional capabilities compared with
efficacy of yoga can overcome problems pregnancy exercise
related to the anatomical functions of the body Findings showed that there was a significant
(Brayshaw, 2007). This study also revealed effect of acupressure on lower back pain and
that there was a significant effect of Yoga in functional capabilities. It proves that
the improvement of lower back functional acupressure is a healing technique by
capability. pressing, massaging, massage the body to
activate the circulation of energy.
However, in this study, pregnancy exercise
was more effective in reducing lower back Acupressure is one of the traditional
pain and improving functional capability in treatments by doing massage on acupuncture
pregnant women compared with yoga. points. Acupressure enhances body relaxation
However, it does not mean that yoga has no and creates positive thoughts (Mander, 2003).
effect to decrease the lower back pain level Acupressure is powerful to alleviate
and increase functional capability, but there discomfort and working greatly in improving
are several factors that can affect the decrease mother’s mental and emotional well being
of pain level in the yoga group, one of which because of the key to learning disorders and
is the environment. The physical environment emotional trauma. Emphasizing in the
has an influence on human thoughts, feelings, acupressure points could improve blood
and behavior. Environment is stimuli from the circulation and stimulate the release of
outside that can be responded by the system endorphin hormones (Khomsah et al., 2017).
of the five senses of human (sight, hearing, This is line with previous study revealed that
tasting, smell and touch), where acupressure could reduce lower back pain by
psychologically potentially form a perception 86%, and more effectively when combined
that indirectly affects the emotional and with psychotherapy (Wang et al., 2005).
human behavior. Supported by another study stated that
acupressure can effectively build a weak body
Physical environment referred to in this study and increase muscle strength and range of
is that during the implementation of yoga upper extremity motion in stroke patients. The
where 14 respondents with a narrow room results of this study revealed that acupressure
will cause uncomfortable feelings, and there was more effective in improving lower back
was a sense of stuffy and hot and lack of functional capability compared with yoga and
ventilation for air circulation that will cause pregnancy exercise (Pravikasari, 2014).

!
CONCLUSION HEALTH CENTER OF KAWUNGANTEN,

It is concluded that there was a significant CILACAP, INDONESIA. Belitung Nursing
Journal, 3(5), 508-514.
effect of yoga and acupressure in reducing Kozier, B. (2008). Fundamentals of nursing: concepts,
lower back pain and improving functional process and practice: Pearson Education.
capability of lower back. Therefore, it is Lebang, E. (2014). Yoga atasi backpain: Puspa Swara.
recommended for midwife to use these Mander, R. (2003). Nyeri persalinan (Labor Pain).
Jakarta: Penerbit Buku Kedokteran EGC.
interventions as an alternative to deal with Pravikasari, N. A. (2014). Perbedaan Senam Hamil dan
back pain and functional capability. Teknik Akupresur Terhadap Penurunan Nyeri
Punggung Bawah pada Ibu Hamil Trimester
III. Program Pascasarjana Undip.
REFERENCES Rosyida, D. A. C., Suwandono, A., Ariyanti, I.,
Mashoedi, I. D., & Fatmasari, D. (2017).
Ansari, N. N., Hasson, S., Naghdi, S., Keyhani, S., &
COMPARISON OF EFFECTS OF
Jalaie, S. (2010). Low back pain during
ABDOMINAL STRETCHING EXERCISE
pregnancy in Iranian women: Prevalence and
AND COLD COMPRESS THERAPY ON
risk factors. Physiotherapy Theory and
MENSTRUAL PAIN INTENSITY IN
Practice, 26(1), 40-48.
TEENAGE GIRLS. Belitung Nursing Journal,
Brayshaw, E. (2007). Senam hamil dan nifas: Jakarta:
3(3), 221-228.
EGC.
Thompson, J. (2004). Kehamilan dari Pembuahan
Hingga Kelahiran: Jakarta: Dian Rakyat.
McGraw-Hill.
Dase, R. N. T., RphD, C. H., BmedsSc, M., & PgChep,
Wang, S.-M., Zinno, P. D., Fermo, L., William, K.,
M. (2014). How do women manage
Caldwell-Andrews, A. A., Bravemen, F., &
pregnancy-related low back and/or pelvic
Kain, Z. N. (2005). Complementary and
pain? Descriptive findings from an online
alternative medicine for low-back pain in
survey. Evidence Based Midwifery, 12(3), 76.
pregnancy: a cross-sectional survey. Journal
Fairbank, J. C. T., & Pynsent, P. B. (2000). The
of Alternative & Complementary Medicine,
Oswestry disability index. Spine, 25(22),
11(3), 459-464.
2940-2953.
Cite this article as: Resmi, D. C., Hadisaputro, S., Runjati. (2017). Effect of yoga and acupressure on
pain and functional capability of lower back in pregnant mothers during the third trimester of
pregnancy. Belitung Nursing Journal, 3(6), 722-728.
!
Nurjannah I, et al. Belitung Nursing Journal. 2017 December;3(6):729-734

CLINICAL INDICATORS OF FEEDING SELF-CARE DEFICIT BASED ON

BARTHEL INDEX MEASUREMENT IN PATIENTS SUFFERING FROM
STROKE
Intansari Nurjannah1*, Vini Febriyani Zulfa2, Dwi Harjanto3, Erna Fitriana4, Ngatini4
1
Associate Professor, Mental Health and Community Department, Faculty of Medicine,Universitas Gadjah Mada, Indonesia
2
Nursing Student, School of Nursing, Faculty of Medicine, Universitas Gadjah Mada, Indonesia
3
Mental Health and Community Department, Faculty of Medicine, Universitas Gadjah Mada, Indonesia
4
Clinical Nurse, Sardjito Central Hospital, Yogyakarta, Indonesia
*Correspondence:
Intansari Nurjannah, S.Kp., MN.Sc., Ph.D
Psychiatric and Community Nursing Department,
Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
E-mail: intansarin@ugm.ac.id
Abstract
Objective: This aim of this research is to describe clinical indicators of feeding self-care deficit based on Barthel Index
measurement in patients with stroke.
Methods: The research used a quantitative description study with cross-sectional design. This research was conducted in one
hospital in Yogyakarta, Indonesia on March – April 2017 with total sampling technique. Instrument was developed based on
clinical indicators of NANDA-I nursing diagnosis of feeding self-care deficit.
Results: There were 28 respondents involved in this study, with males (60.7%) and females (39.3%) with an average age of
57 years. Respondents who suffered from non-hemorrhagic stroke were 60.7% and hemorrhagic stroke were 39.3%. Clinical
indicator items for impaired ability to swallow sufficient amount of food (9.1%) was found in respondents with
independency criteria on Barthel Index. Impaired ability to swallow sufficient amount of food item (25%) and impaired
ability to prepare food (25%) were found in respondents with partial dependency criteria. The most items identified on
respondents with severe dependency criteria were impaired ability to self-feed a complete meal item (53.8%) and impaired
ability to prepare food item (53.8%).
Conclusion: There were different pattern of clinical indicators items found in different level of Barthel index level criteria.
Keywords: Clinical indicators, Nursing Diagnosis, Barthel Index, Stroke
INTRODUCTION
Stroke is rising up in numbers every year Kesehatan Kesehatan RI, 2013). This proved
proportionally with older age and certain risk that stroke cases in Yogyakarta is rising and
factors. Based on Indonesia’s data of basic needs significant attention from healthcare
health research, the prevalence of Indonesian professionals. Between 1990 to 2013, there is
that had been diagnosed as stroke by doctors a rising number of disabilities caused by
were 57.9%. Stroke prevalence in Yogyakarta ischemic stroke and death by ischemic and
is striking in second place (10.3%) after North hemorrhagic stroke (Feigin et al., 2015;
Celebes (10.8%) (Kementerian Kesehatan World Stroke Organization, 2016).
Kesehatan RI, 2013). The Indonesia’s data of
basic health research shows that prevalence of Stroke is caused by interruption of blood
stroke was 7.1% in Yogyakarta (Kementerian supply to the brain, mostly because of the

!
Nurjannah, I., Zulfa, V.F., Harjanto, D., Fitriana, E., Ngatini. (2017)!
!
blood artery either broken or obstructed by Participants

mass on arterial wall causing nutrition and There were 28 samples recruited using total
oxygen supply are disturbed (World Health sampling technique in one hospital in
Organization, 2014). Stroke shows symptoms Yogyakarta. The inclusion criteria of the
such as face muscles paralysis, speaking sample were patients with stroke with
articulation problem, change in consciousness Barthel’s index score 1 in feeding function
status, and visual problem on eyes item. Exclusion criteria of the sample were
(Kementerian Kesehatan Kesehatan RI, unconscious, dysphagia, and patients who left
2013). hospital before they had permission to be
discharged.
Based on prominent symptoms, it is well-
noted that stroke patients definitely will have Measures
many difficulties in doing their daily This study used instruments of Barthel’s
activities, moving from one-point-to-another index and clinical indicator of nursing
and even a simple self-caring for example in diagnosis of feeding self-care. These
feeding themselves (Mark, 2016). Feeding instruments were developed and arranged
difficulty by definition is a difficulty in based on clinical indicators of nursing
fulfilling feeding function independently, diagnosis NANDA-I taxonomy by researchers
including in preparing the food and/or in checklist form and structured interview for
beverages (Klinke, Wilson, Hafsteinsdóttir, & data collecting technique. Total score of
Jónsdóttir, 2013). Self-care is actions that Barthel’s index ranged from 0 to 20,
brings patient to healthier lifestyle, able to consisting of independent, partial dependent,
maintain long-term condition, and to prevent severe dependent, and total dependent level of
from further incoming diseases criteria, with Guttman scale with score 1 for
(Woldemariam, 2013). Self-care deficit on “yes” answer and 0 for “no” of stroke clinical
stroke patients (walking, getting dressed, and indicators on patients. Clinical indicators
eating) happens in daily basis with or without instrument were checked by 3 experts for
help from others. One parameter used for content of validity before data sampling was
calculating the quality of independency of taken, and the result was valid (I-CVI = 1& S-
patients is Barthel’s index. CVI =1). Clinical indicators instrument using
reliability test with formula KR20 and the
Feeding function in stroke patients is based on result was 0.8751, which means this
nursing diagnosis of NANDA-1 as feeding instrument was reliable with value >0.70
self- care deficit. However, in NANDA-I (Sabri, 2013).
taxonomy, nursing diagnosis has clinical
indicator that is different from Barthel’s index Data Collection
in feeding function item. It takes further Data were collected in two months by nurses
research of nursing diagnosis to identify who were working in this stroke unit hospital.
clinical indicator to achieve a more accurate Nurses firstly screen patients using inclusion
nursing diagnosis based on patient’s and exclusion criteria and interview patients
responses. Furthermore, it is still a few using research instrument.
research about clinical indicator of nursing
diagnosis of feeding function (Pascoal et al., Data Analysis
2014). Data analysis in this research using univariate
analysis to recognize respondents
characteristic, the category of stroke,
METHODS respondents grouping into criteria in Barthel’s
Design indexing score, and the frequency distribution
This was a descriptive-quantitative research of clinical indicators of nursing diagnosis
with cross-sectional design. NANDA-I taxonomy feeding self-care deficit.
Data processing was done by computer.
Setting
This study was conducted in one hospital in
Yogyakarta from March to April 2017.
730! BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017

RESULTS hemorrhagic stroke than hemorrhagic stroke

The majority of respondents were males with (see Table 2). The most dominant criteria of
average age of 57.46 years old (SD±12,66). Barthel index was severe dependent followed
Most respondents were government employee by independent and partial dependent (see
with university background (see Table 1). Table 3 and Table 4).
More patients were suffering from non-
Table 1 Frequency distribution of respondents’ characteristic in patients with stroke (n=28)

Characteristic Mean ± SD Frequency (f) Percentage (%)
Age
17 – 25 years old 57.46 ± 12.66 1 3.6
26 – 35 years old 0 0
36 – 45 years old 3 10.7
46 – 55 years old 6 21.4
56 – 65 years old 12 42.9
>65 years old 6 21.4
Sex
Female 11 39.3
Male 17 60.7
Education
College 8 28.6
High school 6 21.5
Junior High 4 14.3
Elementary School 6 21.4
No school 4 14.3
Occupational Status
Employed 15 53.6
Unemployed 13 46.4
Civil status
Single 1 3.6
Married 23 82.1
widowed 1 3.6
widow 3 10.7
Stroke Classification
Hemorrhagic 11 39.3
Non-Hemorrhagic 17 60.7
Total 28 100
Table 2 The percentage of respondents with hemorrhagic and non-hemorrhagic stroke in every criteria of
Bathel’s index in the Stroke unit (n=28)
Criteria of Barthel’s index in Stroke Unit (%)
Severe
Stroke Classification Independent Partial dependent Total
Dependent
(n=11) (n=4) (%)
(n=13)
Stroke Hemorrhagic 27.3 18.2 54.5 100
Stroke Non Hemorrhagic 47.1 11.8 41.2 100
Table 3 Frequency distribution of patients with stroke in each category of Barthel’s index (n=28)
Gender
Indexing criteria of
Score Range of Percentage Number of
Barthel’s index in Mean ± SD
Barthel’s Index (%) respondents
Stroke Unit
M F
Independent 15 – 20 81.8 18.2 11 18.36 ± 1.57
Partial dependent 11 – 14 50 50 4 13± 1.16
Severe dependent 1 – 10 46.2 53.8 13 7.15 ± 2.04
Total dependent 0 0 0 0 0
Total 100 100 28 38.51 ± 4.77

!
Table 4 Average of total score in each criteria of Barthel’s index in stroke classification of patients with
stroke in stroke unit in 2017 (n=28)
Barthel’s index criteria (Mean ± SD)
Stroke
Independen Partial Dependent Severe dependent
Classification
t (n=11) (n=4) (n=13)
Hemorrhagic 18.67 ± 1.15 13 ± 1.41 7.33 ± 2.65
Non-hemorrhagic 18.63 ± 1.51 13 ± 1.41 7 ± 0.58
Table 5 Frequency Distribution of clinical indicators of nursing diagnosis of feeding self-care deficit in
Barthel’s index criteria in patients with stroke
Barthel Index Criteria
No. Items of Clinical indicators Partial Severe
Independent
(%) Dependent (%) dependent (%)
(n=11)
(n=4) (n=13)
1 Inability of eating in acceptable 0 0 0 0 1 7.7
way
2 Inability of eating in enough 1 9.1 1 25 2 15.4
amount of food
3 Inability to manipulate food in 0 0 0 0 3 23.1
the mouth
4 Inability to open food case 0 0 0 0 4 30.8
5 Inability to handle eating tools 0 0 0 0 4 30.8
6 Inability to swallow food 0 0 0 0 0 0
7 Inability to place food in/on 0 0 0 0 5 38.5
food tools
8 Inability to hold the cup 0 0 0 0 5 38.5
9 Inability to take the food and 0 0 0 0 4 30.8
put into mouth
10 Inability in using assist tools 0 0 0 0 4 30.8
11 Inability to finish meal portion 0 0 0 0 7 53.8
12 Inability to chew the food 0 0 0 0 0 0
13 Inability to prepare food to eat 0 0 1 25 7 53.8
DISCUSSION
The number of respondents in this research Stroke classification data shows that
was 28 patients. Most respondents aged respondents suffering from non-hemorrhagic
between 56 to 65 years, male, and married. stroke events were 17 patients (60.7%), and
Data from basic health research (Kementerian from hemorrhagic stroke were 11 patients
Kesehatan Kesehatan RI, 2013) stated that (39.3%). The research of Rachmawati, et al
citizen diagnosed with stroke are increasing shows that most respondents suffered from
accordingly with age (Kementerian Kesehatan non-hemorrhagic stroke, 28 patients (56%),
Kesehatan RI, 2013). Data from Riskesdas and hemorrhagic stroke was 22 patients (44%)
also stated that male and female have the (Rachmawati et al., 2013). Patients who
same prevalence. Married males have bigger suffered from non-hemorrhagic stroke are 171
case incidence of stroke compare with patients and followed by hemorrhagic stroke
females due to gender social experiences such of 70 patients. Non-hemorrhagic stroke is
as marriage history and social economy more common due to lifestyle that harmful to
(Rachmawati, Utomo, & Nauli, 2013). Based health in the community such as high-
on previous research, the highest number of cholesterol consumption, smoking and
stroke patients has college degree and alcohol-drinking habit in long term that will
working employee. Research also shows that cause plaque obstruction in blood vessels that
stroke are more common in society with lower obstruct blood supply (Rachmawati et al.,
education and unemployed (Rachmawati et 2013). One survey shows that high
al., 2013). temperature can be a risk factor for ischemic
or non-hemorrhagic stroke (Wang et al.,

2016). Lower temperature will cause criteria in Barthel’s index, except 2 items of
vasoconstriction, blood pressure and clinical indicators, namely inability to chew
thrombocyte aggregation increasing, and the food and inability to swallow the food.
activation of sympathy neural system that Condition of a few patients with these criteria
cause the increasing risk of stroke (Chen et are still weak including the extremities that
al., 2017). supposed to be helped these patients to eat
their food.
The result of this study shows that criteria of
severe dependent dominantly were on patients One of the causes of this feeding inability is
with hemorrhagic stroke, and independent on hemiparesis (Xiong et al., 2012). Hemiparesis
patients with non-hemorrhagic stroke. No is common in patients with stroke.
respondent was in total dependent since Hemiparesis is a neurological deficit that
researchers put it in the exclusion criteria. causes weakness on one side of the body and
Previous research has respondents of 50 this condition makes the patient unable to
patients and divided Barthel’s index into 5 maintain balance in activities (Dhiman et al.,
criteria and using a modified Barthel’s index 2014). This imbalance will affect patients in
with score between 0 to 100 (Chen et al., sitting, moving from one place to another,
2017). The identified criteria include total joints articulation, and standing straightly
dependent of 39 patients (78%), medium (Dhiman et al., 2014). Sitting position is not a
dependent of 8 patients (16%), and mild functional but it is an essential component that
dependent of 3 patients. No patient was is believed to be able to support another
categorized as independent (Rakhman, 2014). functional activities, such as getting dressed,
Dhiman et al (2014) research on 130 moving, and eating on sitting position
respondents also divided total score of (Morone et al., 2015). Dhiman et al (2014)
Barthel’s index criteria into 4, namely total research shows that there are no differences
dependent (0-4) with 49 respondents, severe between lesion of right hemiparesis or left
dependent (5-9) with 30 respondents, medium one. Each lesion affects patient’s dependency
dependent (10-14) with 34 respondents, and and fulfilling daily activities including eating
mild dependent (15-19) with 17 respondents (Dhiman et al., 2014).
(Dhiman et al., 2014). This research also
shows higher number on respondents with Stroke will lead patients into disability, and
criteria partial dependent. Nevertheless, the disability can be changed if patients change
higher of Barthel score, the lesser are the their lifestyle. Disabilities in stroke patients
respondents (Maselko, Bates, Avendano, & are marked with paralysis on extremities
Glymour, 2009). Observation on Morone et al including hemiparesis, blood pressure
(2015) research shows that patients with increasing, and aging. Disabilities will make
hemorrhagic stroke have better outcome of patients dependent in fulfilling daily activities
functional status based on total score of including feeding activity (Xiong et al., 2012).
Barthel’s index compared with non- Furthermore, stroke patients will increasingly
hemorrhagic stroke patients. This is different show progress on functional status in feeding,
with the result of this research which non- get dressed, go to toilet, and do make-up if
hemorrhagic stroke patients have higher given continuous rehabilitation therapy earlier
percentage in independent criteria than since treated in hospital (Oyewole, Ogunlana,
hemorrhagic stroke patients (Dhiman et al., Oritogun, & Gbiri, 2016).
2014). The research of Xiong et al (2012)
shows that patients with acute ischemic stroke CONCLUSION
or non-hemorrhagic were due to bad There are different patterns of clinical
functional status. indicators based on Barthel index
measurement.
Stroke respondents with independent criteria
show clinical indicators that the same as REFERENCES
respondents with partial dependent criteria in Chen, J., Jiang, H., Wu, L., Liao, X., Lu, Y., Tao, X., . .
Barthel’s index. All clinical indicators item . Huang, H. (2017). Association of ischemic
and hemorrhagic strokes hospital admission
appeared on stroke patients with dependent

!
with extreme temperature in Nanchang, respiratory infection. International journal of

China—A case-crossover study. Journal of nursing knowledge, 25(1), 54-61.
Clinical Neuroscience. Rachmawati, F., Utomo, W., & Nauli, F. (2013).
Dhiman, N., Shah, G., Joshi, D., & Gyanpuri, V. (2014). Gambaran Status Fungsional Pasien Stroke
Relationship between side of hemiparesis and Saat Masuk Ruang Rawat Inap RSUD Arifin
functional independence using activities of Achmad. Jurnal Publikasi. Pekanbaru:
daily living index. Journal of the Anatomical Program Studi Ilmu Keperawatan Universitas
Society of India, 63, S30-S35. Riau.
Feigin, V., Krishnamurthi, R., Barker-Collo, S., Rakhman, A. (2014). Buku Panduan Praktek
Norrving, B., Bennet, D., & Truelsen, T. Laboratorium Ketrampilan Dasar Dalam
(2015). Update on The Global Burden of Keperawatan II (KDDK II: Deepublish.
Ischemic and Hemorrhagic Stroke in 1990- Sabri, S. (2013). Item analysis of student comprehensive
2013 : The GBD 2013 study. test for research in teaching beginner string
Neuroepidemiology, 45(3), 161-176. ensemble using model based teaching among
Kementerian Kesehatan Kesehatan RI. (2013). music students in public universities.
Riskesdas. Riset Kesehatan Dasar. Jakarta: International Journal of Education and
Kesehatan Kementerian Kesehatan. Research, 1(12), 1-14.
Klinke, M., Wilson, M., Hafsteinsdóttir, T., & Wang, X., Cao, Y., Hong, D., Zheng, D., Richtering, S.,
Jónsdóttir, H. (2013). Recognizing new Sandset, E., . . . Salam, A. (2016). Ambient
perspectives in eating difficulties following temperature and stroke occurrence: a
stroke: a concept analysis. Disability and systematic review and meta-analysis.
rehabilitation, 35(17), 1491-1500. International journal of environmental
Mark, V. (2016). Stroke and behavior. Neurologic research and public health, 13(7), 698.
clinics, 34(1), 205-234. Woldemariam, Y. (2013). Exploring of stroke survivors’
Maselko, J., Bates, L., Avendano, M., & Glymour, M. information needs for an Information and
(2009). The intersection of sex, marital status, Communication Technology based home
and cardiovascular risk factors in shaping stroke rehabilitation plan to facilitate self-
stroke incidence: results from the health and care. Master thesis.
retirement study. Journal of the American World Health Organization. (2014). Stroke,
Geriatrics Society, 57(12), 2293-2299. Cerebrovascular accident. 2017, from
Morone, G., Paolucci, S., & Iosa, M. (2015). In What http://www.who.int/topics/cerebrovascular_ac
Daily Activities Do Patients Achieve cident/en/
Independence after Stroke? Journal of Stroke World Stroke Organization. (2016). Face the Facts:
and Cerebrovascular Diseases, 24(8), 1931- Stroke is Treatable. 2017, from
1937. http://www.worldstrokecampaign.org/learn/fa
Oyewole, O., Ogunlana, M., Oritogun, K., & Gbiri, C. ce-the-facts-stroke-is-treatable.html
(2016). Post-stroke disability and its predictors Xiong, L., Leung, H., Chen, X., Han, J., Leung, T., Soo,
among Nigerian stroke survivors. Disability Y., . . . Wong, K. (2012). Preliminary findings
and health journal, 9(4), 616-623. of the effects of autonomic dysfunction on
Pascoal, L., Lopes, M., da Silva, V., Beltrão, B., Chaves, functional outcome after acute ischemic
D., de Santiago, J., & Herdman, T. (2014). stroke. Clinical neurology and neurosurgery,
Ineffective breathing pattern: defining 114(4), 316-320.
characteristics in children with acute
Cite this article as: Nurjannah, I., Zulfa, V.F., Harjanto, D., Fitriana, E., Ngatini. (2017). Clinical
indicators of feeding self-care deficit based on Barthel index measurement in patients suffering from
stroke. Belitung Nursing Journal, 3(6), 729-734.

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Dayyana S, et al. Belitung Nursing Journal. 2017 December;3(6):735-742

EFFECTIVENESS OF MUSIC THERAPY ON ANXIETY AND

Β-ENDORPHIN LEVELS IN PRIMIGRAVIDA DURING THE THIRD STAGE
OF PREGNANCY
Surya Dayyana1*, Suryono2, Melyana Nurul Widyawati1, Syarief Thaufik Hidayat3,
Suryati Kumorowulan1
1
2
Instrumentation and Electronic Laboratory, Physic Department, Faculty of Science and Mathematic, Diponegoro University
of Semarang, Indonesia
3
Medical Staff Group of Obstetry Gynecology Department, Dr. Kariadi Hospital, Semarang, Indonesia
*Correspondence:
Surya Dayyana
Email: suryadayyana44@gmail.com
Abstract
Objective: To examine the effectiveness of music therapy on anxiety levels and β-endorphin levels in primigravida during
the third stage of pregnancy.
Methods: This was a quasy experimental study with pretest-posttest control group design. The research was conducted in
December 2016 - Januari 2017. There were 39 respondents selected using purposive sampling technique, which 13 assigned
in the experiment group 1 (music therapy with a sound pressure of 40 dB), experiment group 2 (music therapy with a sound
pressure of 62 dB) and control group (health counseling). Anxiety levels were measured using the HARS (Hamilton Anxiety
Rating Scale), and β-endorphin hormone levels were measured using ELISA (Enzyme-Linked Immunosorbent Assay)
method. Data analysis used paired t-test, One-Way Anova test with post-hoc bonferroni, and Kruskall Wallis test with post-
hoc Mann Whitney.
Results: Findings revealed that there was a decrease of the mean of anxiety levels in the experiment group 1 from 31.92
(pretest) to 24.69 (posttest), and the experiment group 2 from 34.54 (pretest) to 25 (posttest) with p-value <0.05; and there
was an increase of the mean of β-Endorphin levels in the experiment group 1 from 53.63 (pretest) to 63.24 (posttest), and the
experiment group 2 from 48.55 (pretest) to 64.9 (posttest) with p-value <0.05; however there was no effect of counseling in
the control group on anxiety levels (p=0.413) and β-Endorphin levels (p= 0.394)
Conclusion: Music therapy is effective in reducing anxiety levels and increasing β-endorphin levels. Thus, music therapy
can be used as an alternative treatment for pregnant mothers at home who experienced anxiety.
Keywords: Music Therapy, Anxiety, Β-Endorphin, Pregnant Women
INTRODUCTION
During pregnancy, pregnant women complications during childbirth or after
experience some changes in both physical and delivery. Primigravida Pregnant women have
psychological changes. The changes that more experienced anxiety when compared
occur during pregnancy can cause discomfort with multigravida pregnant women. The
and anxiety during pregnancy. The anxiety anxiety experienced during the first and third
experienced by pregnant women especially trimesters of pregnancy is more severe than
during the third trimester is associated with a anxiety during the second trimester of
sense of worry about maternal and fetal pregnancy (Giakoumaki, Vasilaki, Lili,
health, such as the fear of childbirth, fear if Skouroliakou, & Liosis, 2009; Lee et al.,
the fetus is born disabled and if there are

Dayyana, S., Suryono., Widyawati, N. M., Hidayat, S. T., Kumorowulan, S. (2017)!
!
2007; Teixeira, Figueiredo, Conde, Pacheco, Wong, & Thayala, 2011; Cook & Silverman,
& Costa, 2009). 2013; Hatem, Lira, & Mattos, 2006; Richards,
Johnson, Sparks, & Emerson, 2007). The use
Anxiety accompanied by negative thoughts of music therapy can reduce the anxiety level
can lead to an increase in sympathetic nerve in pregnant women during transvaginal
work, activating the hypothalamus-pituitary to ultrasound examination (Shin & Kim, 2011).
release the hormones cortisol, epinephrine and Moreover, music therapy performed during
adrenaline in the body that trigger the heart to labor can lower the level of anxiety and
pump blood faster and heart rate grows postpartum pain, increased vaginal delivery
stronger and faster (Pawlby, Hay, Sharp, satisfaction and reduced postpartum
Waters, & O'Keane, 2009; Van den Bergh, depression (Simavli et al., 2014).
Van Calster, Smits, Van Huffel, & Lagae,
2008). Uncomfortable feeling, anxiety and The results of preliminary study at the
increased release of stress hormones will Community Health Center of Bandarharjo
adversely affect the health of pregnant women Semarang showed that there were 92
themselves and the health of the fetus, such as primigravida pregnant women in trimester III
increase the risk of delivering babies with low among 395 pregnant women. The results of
birth weight, premature birth, asthma, infant interviews with 10 primigravida pregnant
disease, autism, IUGR (Intrauterine Growth women indicated that there were 7 pregnant
Retardation) and postpartum stress (Ding et women who experienced anxiety with the
al., 2014; Grote et al., 2010; Littleton, Bye, existence of sleep disorders and worried if
Buck, & Amacker, 2010). delivery did not run smoothly. In addition, the
mothers also worried if the baby was not
Secretion of β-endorphin hormone in the body healthy. They also said that midwives had
can improve mood or change the mood, done counseling about labor preparations,
especially in pregnant women in the third however, most of them were still feeling
trimester who experience anxiety. Although anxiety. Therefore, this study aimed to
β-endorphin can be secreted naturally in the examine the effectiveness of music therapy on
body but β-endorphin can also be secreted anxiety levels and β-endorphin levels in
when the body and mind are in a state of primigravida during the third stage of
relaxation. One alternative that can be done to pregnancy.
stimulate the secretion of the hormone β-
endorphin is by doing music therapy
(Haruyama, 2015). METHODS
Study design
Music therapy is the use of music as This was a quasy experimental study with
complementary therapy with the aim to pretest-posttest control group design.
reduce or minimize diseases that affect the
physical, emotional and / or spiritual. Music is Settings
an effective coping mechanism for one's The research was conducted in the working
negative emotions (Hosseini, Bagheri, & area of the Community Health Center of
Honarparvaran, 2013). Musical stimulation is Bandarharjo and the Community Health
processed by and through the brain (the limbic Center of Telogosari Kulon Semarang City in
system), which has a positive effect on nerve December 2016 - Januari 2017.
function and hormonal activity (Boso, Politi,
Barale, & Emanuele, 2006; Todres, 2006). Research Subjects
The calculation of the number of samples
Previous studies revealed that listening to used a paired numerical comparative sample
music in one period could help reduce formula. There were 39 respondents selected
symptoms of depression in adults. In addition, using purposive sampling technique and
music therapy can also improve relaxation, divided into 3 groups (2 groups of
mood, quality of life, and reduce stress and intervention and 1 control group) in which
anxiety. Structure in music can make the each group amounted to 13 respondents. The
patient feel comfortable and peaceful (Chan, distribution of respondents in the working
!
area of the Community Health Center of autonomic symptoms), with Likert scale 0 =
Bandarharjo was assigned as intervention never, 1 = rare, 2 = often, 3 = always. The
groups and respondents in the working area of questionnaire was adopted from previous
the Community Health Center of Telogosari study in Indonesian version with validity of r
Kulon assigned as control group (counseling). value of 0.39-0.79 and cronbach’s alpha was
The inclusion criteria of the sample in this 0.94 (Hawari, 2001). β-endorphin hormone
study were: 1) primigravida pregnant women levels were measured using ELISA (Enzyme-
during the third stage of pregnancy, 2) there Linked Immunosorbent Assay) method, as a
was no physical limitations and hearing biochemical technique mainly used in the
impairments, 3) no consuming cardiovascular field immunologists that utilize specific bonds
drugs, sedatives and related drugs, 4) willing between antibodies and antigens. Normal
to be a respondent. The exclusion criterion of values of β-endorphin hormone levels are
the sample was pregnant women with mental 0.01-100 ng/ml. Measurement of anxiety level
disorders. and β-endorphin hormone levels were done
two times, before and after intervention.
Intervention
Music therapy was given to the experiment Ethical consideration
groups. The experiment group 1 received Ethical approval was obtained from the
music therapy with sound pressure of 40 dB Research Ethics Committee of POLTEKKES
and the experiment group 2 received music Semarang with Number: 272/KEPK/
therapy with sound pressure of 62 dB. The Poltekkes-SMG/EC / 2016. The researchers
implementation of music therapy was done have confirmed that each respondent in this
for 30 minutes per day for 2 weeks at each study has signed an appropriate informed
respondent’s home to minimize the noise consent.
during therapy. The music therapy used Mp3
and speaker containing natural sound. A Data analysis
control group was given a counseling about Data analysis used paired t-test, One way
the inconvenience of a third trimester of Anova test with post hoc bonferroni, and
pregnancy and labor preparation. Counseling Kruskall Wallis test with post hoc Mann
begun with a material explanation by the Whitney.
researchers and then continued question and
answer and discussion between researchers
and respondents. Counseling was done at RESULTS & DISCUSSION
home of each respondent. Figure 1 shows that the average age of
respondents in the experiment group 1 was
Instrument 27.62 years old, experiment group 2 was 23
Anxiety levels were measured using the years old, and the control group was 24.62
HARS (Hamilton Anxiety Rating Scale) years old. This range of age is considered as
questionnaire introduced by Max Hamilton productive age. Thus, it could be said that
(Hamilton, 1960). HARS scale has been pregnant women with productive age had
proven to have high enough validity and more anxiety than pregnant women with
reliability. The questionnaire consisted of 13 unproductive age. However, age is one of the
items (feelings of anxiety, tension, fear, sleep factors that affect anxiety. Young age is more
disturbances, intelligence disorders, depressed prone to stress than old age (Akiki, Avison,
feelings, somatic symptoms, sensory Speechley, & Campbell, 2016; Thiagayson et
symptoms, cardiovascular symptoms, al., 2013). Homogeneity test showed p-value
respiratory symptoms, gastrointestinal >0.05 indicated that there was no different
symptoms, urogenital symptoms, and characteristic of respondent based on age.

!
30% 27.62%
23% 24.62%
25%
20%
15%
Age%(Year)%
10%
5%
0%
Experiment%1% Experiment%2% Control%
Figure 1 Characteristic of respondents based on age
Educational+level+
Elementary/Junior% Senior%high%school/University%level%
7% 8% 7%
6% 5% 6%
Figure 2 Characteristic of respondents based on educational level
Figure 2 shows that the respondents in the respondents in the control group had
experiment group 1 had elementary/junior elementary/junior high school background (6
high school background (7 people) and senior people) and senior high school and university
high school and university level (6 people), level (7 people). Homogeneity test showed p-
while respondents in the experiment group 2 value >0.05 indicated that there was no
had elementary/junior high school different characteristic of respondent based on
background (8 people) and senior high school educational level.
and university level (5 people), and
Family+income+
<%Rp%1.909.000% ≥%Rp%1.909.000%
9% 8%
6% 7%
4% 5%
Figure 3 Characteristic of respondents based on family income
Figure 3 shows that the majority of Homogeneity test showed p-value >0.05
respondents (24 people) in the three groups indicated that there was no different
had family income ≥ Rp. 1.909.000. characteristic of respondent based on family
!
income. Literature stated that educational because the three groups were homogeneous,
levels and family income are mediators that so the characteristics of respondents did not
affect maternal anxiety levels (Brandon et al., affect the outcome of this study.
2008; Lancaster et al., 2010). However,
Table 1 Effect of music therapy on anxiety levels of primigravida during the third stage of pregnancy using
paired t-test
Group n Mean ± !" (min-max) p-value
Pretest 13 31.92 ± 0.57 21-42
Experiment 1 0.001
Posttest 13 24.69 ± 0.67 14-39
Pretest 13 34.54 ± 0.64 22-48
Experiment 2 0.000
Posttest 13 25 ± 0.65 14-39
Pretest 13 35.15 ± 2.7 23-53
Control 0.413
Posttest 13 40.49 ± 0.83 16-54
The results of paired t-test of anxiety level as anxiety levels from 34.54 (pretest) to 25
shown in the Table 1 showed there was a (posttest), with p-value <0.05, which
decrease of the mean of anxiety levels in the indicated that there was a statistically
experiment groups. The experiment group 1 significant effect of music therapy on anxiety
showed a decrease of anxiety levels from levels. There was no effect of counseling in
31.92 (pretest) to 24.69 (posttest), and the the control group on anxiety levels with p-
experiment group 2 showed a decrease of value 0.413 (>0.05)
Table 2 Effect of music therapy on β-Endorphin levels of primigravida during the third stage of pregnancy
using paired t-test
Pretest 13 53.63 ± 1.39 29.61-80.25
Experiment 1 0.027
Posttest 13 63.24 ± 1.42 34.15-92.14
Pretest 13 48.55 ± 1.61 24.58-99.31
Experiment 2 0.003
Posttest 13 64.9 ± 2.7 30.72-162.3
Pretest 13 56.14 ± 1.39 30.85-90.41
Control 0.394
Posttest 13 50.59 ± 1.24 27.74-90.88
The results of paired t-test of β-Endorphin control group was -1.23. It seems that the
levels as shown in the Table 2 showed there experiment group had a greater mean than the
was an increase of the mean of β-Endorphin other groups. P-value was 0.001 (<0.05)
levels in the experiment groups. The indicated that there was a significant
experiment group 1 showed an increase of β- difference of mean difference in anxiety
Endorphin levels from 53.63 (pretest) to 63.24 levels among the three groups.
(posttest), and the experiment group 2 showed
an increase of β-Endorphin levels from 48.55 While Kruskal Wallis test as shown in the
(pretest) to 64.9 (posttest), with p-value Table 3 shows that the mean difference of β-
<0.05, which indicated that there was a Endorphin levels before and after intervention
statistically significant effect of music therapy in the experiment group 1 was -7.23, the
on β-Endorphin levels. There was no effect of experiment group 2 was -10.85, and the
counseling in the control group on β- control group was -1.23. It seems that the
Endorphin levels with p-value 0.394 (>0.05). experiment group had a greater mean than the
other groups. P-value was 0.019 (<0.05)
While One way Anova test as shown in the indicated that there was a significant
Table 3 shows that the mean difference of difference of mean difference in β-Endorphin
anxiety levels before and after intervention in levels among the three groups.
the experiment group 1 was -7.23, the
experiment group 2 was -10.85, and the

!
Table 3 Mean difference of Effect of music therapy on anxiety levels and β-Endorphin levels of primigravida
during the third stage of pregnancy
Variable Group n Mean ± !" (min-max) p-value
Experiment 1 13 -7.23 ± 0.45 -15 – 2
Mean difference of
Experiment 2 13 -10.85 ± 0.52 -21 – 4 0.001
anxiety levels
Control 13 -1.23 ± 0.4 -12 – 6
Experiment 1 13 9.66 ± 1.06 -10.60 – 38.76
Mean difference of Β- Experiment 2 13 16.34 ± 1.24 -3.27 – 62.98 0.019
Endorphin level
Control 13 -5.53 ± 1.73 -30.68 – 40.76
post hoc bonferroni
Variable Group n Mean Different p-value
Experiment 2 13 3.615 0.410
Experiment 1
Control 13 -6.000 0.048
Experiment 1 13 -3.615 0.410
Anxiety levels Experiment 2
Control 13 -9,615 0.001
Experiment 1 13 6.000 0.048
Control
Experiment 2 13 9.615 0.001
using post hoc Mann Whitney
Variable Group p value
Experiment 1 Experiment 2 0.287
β-Endorphin
Experiment 1 Control 0.034
levels
Table 4 shows that there was no significant anxiety and endocrine system work. The
difference of the effect of intervention in the stimulation of music captured by the five
experiment group 1 and 2 (p=<0.05), while senses will be transmitted to the brain, which
there was a significant difference between the will affect the autonomic nervous system to
effect of intervention between the control decrease the work of the sympathetic nervous
group and experiment group 1 and 2 system and enhance the work of the
(p=>0.05); while Table 5 shows that there was parasympathetic system. So music can make a
no significant difference of the effect of person feel more relaxed and comfortable. In
intervention in the experiment group 1 and 2 addition, stimulation of music in the brain
with p-value 0.287 (>0.05), while there was a also affects the anterior pituitary work to
significant difference between the effect of suppress the production of catecholamine or
intervention between the control group and stress hormones (Chanda & Levitin, 2013;
experiment group 1 (p=0.034) and experiment Krout, 2007).
group 2 (p=0.012) on β-Endorphin levels.
The results of this study were in line with
The results of this study revealed that there previous research in which music therapy
was a significant effect of music therapy with could reduce the level of anxiety in pregnant
sound pressure of 40 dB and 62 dB on anxiety women, and postpartum mothers. The results
levels and β-Endorphin levels. Music therapy of previous studies showed that maternal
proved to be effective compared with anxiety levels were lower after given music
counseling in the control group in reducing therapy and there was a significant difference
anxiety levels and increasing the levels of β- in anxiety levels between the intervention and
Endorphin levels. control group (Chang, Chen, & Huang, 2008;
Lai et al., 2006; Shin & Kim, 2011; Simavli et
As literature stated that music therapy is one al., 2014; Yusuf et al., 2017).
of the non-pharmacological therapies that can
be used as one of the relaxation techniques This study provides the insight of evidence
that have a positive influence on the level of that music therapy with natural sound with
!
sound pressure 40 dB and 62 dB for 30 Giakoumaki, O., Vasilaki, K., Lili, L., Skouroliakou,
minutes in 2 weeks could reduce anxiety M., & Liosis, G. (2009). The role of maternal
anxiety in the early postpartum period:
levels and β-Endorphin levels in primigravida screening for anxiety and depressive
during the third stage of pregnancy. However, symptomatology in Greece. Journal of
further research is needed to examine the Psychosomatic Obstetrics & Gynecology,
variation of music pressure levels, duration 30(1), 21-28.
Grote, N. K., Bridge, J. A., Gavin, A. R., Melville, J. L.,
and frequency of the treatment. Iyengar, S., & Katon, W. J. (2010). A meta-
analysis of depression during pregnancy and
the risk of preterm birth, low birth weight, and
CONCLUSION intrauterine growth restriction. Archives of
It can be concluded that there was a general psychiatry, 67(10), 1012-1024.
Hamilton, M. (1960). A rating scale for depression.
significant effect of music therapy in reducing Journal of Neurology, Neurosurgery &
anxiety levels and increasing β-Endorphin Psychiatry, 23(1), 56-62.
levels in in primigravida during the third stage Haruyama, S. (2015). The miracle of endorphin: Mizan
of pregnancy. Thus, music therapy is Qanita.
Hatem, T. P., Lira, P. I. C., & Mattos, S. S. (2006). The
recommended to be an alternative treatment therapeutic effects of music in children
for pregnant mothers at home who following cardiac surgery. Jornal de pediatria,
experienced anxiety. 82(3), 186-192.
Hawari, D. (2001). Manajemen stress, cemas dan
depresi: Fakultas Kedokteran Universitas
Indonesia.
REFERENCES Hosseini, S. E., Bagheri, M., & Honarparvaran, N.
Akiki, S., Avison, W. R., Speechley, K. N., & (2013). Investigating the effect of music on
Campbell, M. K. (2016). Determinants of labor pain and progress in the active stage of
maternal antenatal state-anxiety in mid- first labor. Eur Rev Med Pharmacol Sci,
pregnancy: Role of maternal feelings about the 17(11), 1479-1487.
pregnancy. Journal of affective disorders, 196, Krout, R. E. (2007). Music listening to facilitate
260-267. relaxation and promote wellness: Integrated
Boso, M., Politi, P., Barale, F., & Emanuele, E. (2006). aspects of our neurophysiological responses to
Neurophysiology and neurobiology of the music. The Arts in Psychotherapy, 34(2), 134-
musical experience. Functional neurology, 141.
21(4), 187. Lai, H.-L., Chen, C.-J., Peng, T.-C., Chang, F.-M.,
Brandon, A. R., Trivedi, M. H., Hynan, L. S., Hsieh, M.-L., Huang, H.-Y., & Chang, S.-C.
Miltenberger, P. D., Labat, D. B., Rifkin, J. B., (2006). Randomized controlled trial of music
& Stringer, C. A. (2008). Prenatal depression during kangaroo care on maternal state anxiety
in women hospitalized for obstetric risk. The and preterm infants’ responses. Int J Nurs
Journal of clinical psychiatry, 69(4), 635. Stud, 43(2), 139-146.
Chan, M. F., Wong, Z. Y., & Thayala, N. V. (2011). The Lancaster, C. A., Gold, K. J., Flynn, H. A., Yoo, H.,
effectiveness of music listening in reducing Marcus, S. M., & Davis, M. M. (2010). Risk
depressive symptoms in adults: a systematic factors for depressive symptoms during
review. Complementary therapies in medicine, pregnancy: a systematic review. American
19(6), 332-348. journal of obstetrics and gynecology, 202(1),
Chanda, M. L., & Levitin, D. J. (2013). The 5-14.
neurochemistry of music. Trends in cognitive Lee, A. M., Lam, S. K., Lau, S. M. S. M., Chong, C. S.
sciences, 17(4), 179-193. Y., Chui, H. W., & Fong, D. Y. T. (2007).
Chang, M. Y., Chen, C. H., & Huang, K. F. (2008). Prevalence, course, and risk factors for
Effects of music therapy on psychological antenatal anxiety and depression. Obstetrics &
health of women during pregnancy. J Clin Gynecology, 110(5), 1102-1112.
Nurs, 17(19), 2580-2587. Littleton, H. L., Bye, K., Buck, K., & Amacker, A.
Cook, E. L., & Silverman, M. J. (2013). Effects of music (2010). Psychosocial stress during pregnancy
therapy on spirituality with patients on a and perinatal outcomes: a meta-analytic
medical oncology/hematology unit: a mixed- review. Journal of Psychosomatic Obstetrics
methods approach. The Arts in Psychotherapy, & Gynecology, 31(4), 219-228.
40(2), 239-244. Pawlby, S., Hay, D. F., Sharp, D., Waters, C. S., &
Ding, X.-X., Wu, Y.-L., Xu, S.-J., Zhu, R.-P., Jia, X.- O'Keane, V. (2009). Antenatal depression
M., Zhang, S.-F., . . . Tao, F.-B. (2014). predicts depression in adolescent offspring:
Maternal anxiety during pregnancy and prospective longitudinal community-based
adverse birth outcomes: a systematic review study. Journal of affective disorders, 113(3),
and meta-analysis of prospective cohort 236-243.
studies. Journal of affective disorders, 159, Richards, T., Johnson, J., Sparks, A., & Emerson, H.
103-110. (2007). The effect of music therapy on
patients' perception and manifestation of pain,

!
anxiety, and patient satisfaction. Medsurg prevalence and screening. General hospital
Nursing, 16(1), 7. psychiatry, 35(2), 112-116.
Shin, H. S., & Kim, J. H. (2011). Music therapy on Todres, I. D. (2006). Music is medicine for the heart.
anxiety, stress and maternal-fetal attachment Jornal de pediatria, 82(3), 166-168.
in pregnant women during transvaginal Van den Bergh, B. R. H., Van Calster, B., Smits, T.,
ultrasound. Asian nursing research, 5(1), 19- Van Huffel, S., & Lagae, L. (2008). Antenatal
27. maternal anxiety is related to HPA-axis
Simavli, S., Kaygusuz, I., Gumus, I., Usluogulları, B., dysregulation and self-reported depressive
Yildirim, M., & Kafali, H. (2014). Effect of symptoms in adolescence: a prospective study
music therapy during vaginal delivery on on the fetal origins of depressed mood.
postpartum pain relief and mental health. Neuropsychopharmacology, 33(3), 536-545.
Journal of affective disorders, 156, 194-199. Yusuf, N., Hadisaputro, S., Runjati, R., Suwondo, A.,
Teixeira, C., Figueiredo, B., Conde, A., Pacheco, A., & Mashoedi, I. D., & Supriyana, S. (2017). THE
Costa, R. (2009). Anxiety and depression EFFECTIVENESS OF COMBINATION OF
during pregnancy in women and men. Journal KANGAROO MOTHER CARE METHOD
of affective disorders, 119(1), 142-148. AND LULLABY MUSIC THERAPY ON
Thiagayson, P., Krishnaswamy, G., Lim, M. L., Sung, S. VITAL SIGN CHANGE IN INFANTS WITH
C., Haley, C. L., Fung, D. S. S., . . . Chen, H. LOW BIRTH WEIGHT. Belitung Nursing
(2013). Depression and anxiety in Journal, 3(4), 352-359.
Singaporean high-risk pregnancies—
Cite this article as: Dayyana, S., Suryono., Widyawati, N. M., Hidayat, S. T., Kumorowulan, S.
(2017). Effectiveness of music therapy on anxiety and β-endorphin levels in primigravida during the
third stage of pregnancy. Belitung Nursing Journal, 3(6), 735-742.
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Sulistiyo Y, et al. Belitung Nursing Journal. 2017 December;3(6):743-749

EFFECT OF PSYCHOEDUCATION ON ANXIETY IN PATIENTS WITH

CORONARY HEART DISEASE
Yuli Sulistiyo1*, Bedjo Santoso1, Shobirun1, Soeharyo Hadisaputro2, Leni Latifah3,
Rr Sri Endang Pujiastuti1
1
2
Postgraduate Program, Master of Applied Science, Semarang Health Polytechnic, Semarang, Indonesia
3
BPP GAKI Litbangkes Kemenkes Magelang, Indonesia
*Correspondence:
Yuli Sulistiyo, S.ST., M.Tr. Kep
Jl. Tirto Agung, Pedalangan, Banyumanik, Semarang, Central Java, Indonesia (50268).
E-mail: yulisulistiyo1984@gmail.com
Abstract
Background: Cardiovascular heart disease still remains high in Indonesia. Various interventions have been implemented as
an effort to deal with cardiovascular disease. However, little is known about intervention to reduce anxiety in patients with
cardiovascular disease although anxiety is related to angina attack in this patient. Psychoeducation is considered effective in
decreasing anxiety.
Objective: To examine the effect of psychoeducation in decreasing anxiety in patients with coronary heart disease (CHD) at
the General Hospital of Semarang.
Methods: This was a quasy experimental design with pretest posttest control group design. The study was conducted in the
inpatient wards of the General Hospital of Semarang on January 17 until March 8, 2017. Fifty-six respondents were recruited
using consecutive sampling, with 28 assigned in the experiment and control group. Hamilton Anxiety Rating Scale (HARS)
was used to measure anxiety levels. Paired t-test and Independent t-test were used for data analysis.
Results: Paired test showed that there was a statistically significant effect of psychoeducation on anxiety level in the
experiment group with p-value 0.001 (<0.05), and significant effect of given a brochure of CHD on the anxiety level in the
control group with p-value 0.001 (<0.05). Independent t-test showed a statistically significant difference of anxiety level
after intervention in the experiment and control group with p-value 0.001 (<0.05). The mean anxiety level in the experiment
group (22.46) was lower than the mean anxiety level in the control group (41.54).
Conclusion: Psychoeducation is effective in reducing anxiety levels in patients with CHD. It is suggested that
psychoeducation can be used as one of nursing intervention in an effort to reduce anxiety in patients with CHD.
Keywords: Psychoeducation, Anxiety, Coronary Heart Disease
INTRODUCTION
Cardiovascular disease, such as coronary heart disease causes 70% of global deaths,
heart disease (CHD) is one of the leading and considered as the first rank cause
causes of death, not only in developed (Mahdavi, Abbasi, & Mohammadi, 2015).
countries but also in developing countries, According to the American Heart Association
including Indonesia (Berndt et al., 2012). This (AHA) in Heart Stroke Statistic 2010,
disease is responsible for more than 25% of indicated that every 25 seconds there is one
all deaths worldwide (Cole, Smith, Hart, & person has coronary heart disease and every
Cupples, 2011). In the United Kingdom, for minute there is one death caused by CHD
example, over 90,000 people die from CHD (Dalusung‐Angosta, 2013). In the countries of
every year (Kones, 2011). According to the West Asia, especially in Iran, cardiovascular
World Health Organization (WHO), coronary disease exists 7-10 years earlier than in other

Sulistiyo, Y., Santoso, B., Shobirun., Hadisaputro, S., Latifah. L., Pujiastuti, RR. S. E. (2017)!
!
countries (Khayyam-Nekouei, Neshatdoost, daily life (Stuart, 2014). Patients tend to

Yousefy, Sadeghi, & Manshaee, 2013). experience anxiety conditions either as
independent or interrelated (e.g. anxiety leads
By 2015, the estimated death rate caused by to chronic illness, and/or chronic disease
heart disease and blood vessels increases to 20 causes anxiety) (DeJean, Giacomini,
million (MOH, 2013). In Indonesia, Vanstone, & Brundisini, 2013). In recent
prevalence of CHD based on a doctor's years, cases of cardiovascular disease,
diagnosis is 0.5%, or an estimated 883,447 especially CHD, are handled holistically by
people; and based on symptoms is 1.5% or an the Bio-Psycho-Cultural-Spiritual-Cognitive-
estimated 2,650,340 people; whereas, the Social approach (Dossey, 2008; Dossey,
prevalence of heart failure based on a doctor's Certificate, Keegan, & Co-Director
diagnosis in Indonesia is 0.13% (MOH, International Nurse Coach, 2012; Greco,
2015), and based on a physician or symptom 2013) in psycho-education to reduce anxiety
diagnosis is 0.3%. In Central Java, the (Aghayusefi, Mirzahoseini, Khazaeli, &
proportion of new cases of non-communicable Assarnia, 2016).
diseases of heart disease ranks fourth by
4.77% after hypertension 57.89%, diabetes In addition, studies show less anxiety after
mellitus 16.53%, and asthma bronchial given a psychological treatment approach,
11.61% (Dinkes, 2014). CHD complication such as cognitive-behavioral therapy, PPe
and risk factors not only increase mortality, (Guo et al., 2013; Tarr et al., 2014). The
but also reduce productivity and increase majority of studies on PPe have been
disability and healthcare costs (Sadeghi et al., performed on patients with psychiatric
2009; von Känel, 2008). disorders. However, little is known about the
impact of this program on patients with
Treatment with drugs is routinely used as the physical disorders such as cardiovascular
preferred method for CHD (Indonesia, 2006). disease. Thus, a nurse as an educator plays an
In addition, patients with CHD are confronted important role in assisting the patient in
with some psychological problems (Reid, Ski, increasing knowledge, decreasing anxiety,
& Thompson, 2013; von Känel, 2008). and understanding the symptoms of the illness
Studies have shown that 40%-65% of those and the action given through psycho-
patients have anxiety symptoms education program, which will impact to the
(Hashemzadeh, Garooci Farshi, Halabianloo, behavioral changes of the patients. It is also
& Maleki Rad, 2011). This problem occurs found that the treatment of patients with CHD
due to lack of social support, which among is not only from the physical aspects, but also
other things have the most adverse effects and psychosocial aspect needs to achieve a normal
the most common psychological responses in life (McGillion, Arthur, Victor, Watt-Watson,
patients with cardiovascular disease, but also & Cosman, 2008). This study aimed to
the recurrence of the disease. Studies show examine the influence of psychoeducation on
that anxiety and psychological problems are anxiety in patients with coronary heart disease
reduced through the use of psychological (CHD) in the General Hospital of Semarang
treatments, such as behavioral cognitive- City.
therapy and psycho-education programs (PPe)
(Dehdari, Heidarnia, Ramezankhani, METHODS
Sadeghian, & Ghofranipour, 2009; Tarr, Study design
Launay, & Dunbar, 2014). More recently, This was a quasy experimental design with
researchers have focused on using PPe pretest posttest control group design. The
methods as a basic treatment for the patient's study was conducted in the inpatient wards of
with psychological problems (Ågren, the General Hospital of Semarang on January
Evangelista, Hjelm, & Strömberg, 2012). 17 until March 8, 2017.
Patients with CHD will be accompanied by
anxiety, which will add pain such as angina Research subjects
attacks. Angina is a stressor or a threat to Consecutive sampling was used for this study
one's integrity including physiological to recruit 56 respondents. Twenty-eight
inability and decreased capacity to perform respondents were assigned in the experiment
!
and control group. The inclusion criteria of The intervention was given by the researcher
the sample were: patients with CHD, in first about psychoeducation. While the control
or recurrent CHD events, able to group was given a brochure of CHD only.
communicate verbally, not in the emergency
condition or mental disorder, have been Ethical consideration
treated for at least 1x24 hours, and have Ethical clearance of the research was obtained
family support assistance. from the ethics commission of Poltekkes
Kemenkes Semarang with No.054 / KEPK /
Instruments Poltekkes-Smg / ec / 2017. Each respondent
Anxiety was measured using Hamilton signed the informed consent prior to the data
Anxiety rating Scale (HARS) (Yazici, Demir, collection. The researcher explained about the
Tanriverdi, Karaagaoglu, & Yolac, 1998), objective and procedures of the research
which was developed by Max Hamilton in
1959 with good validity and reliability. The Data analysis
scale consisted of 14 items with 5 levels of Paired t-test and independent t-test were
score (between 0-4). The anxiety level was performed for data analysis.
classified based the number of score summed.
It refers to no anxiety if score <14, mild RESULTS
anxiety if score 14-20, moderate anxiety if Based on Table 1, the average age of
score 21-27, and severe anxiety if score > 28. respondents in the experiment group was
Anxiety was measured before and after given 54.68 and control group was 50.75. The
intervention. majority of respondents were males (57.1%),
with senior high school background (42.9%),
Intervention and working as entrepreneur (experiment
Psychoeducation was implemented for 3 days group=42.9%, control group=46.4%).
in five sessions, with 30 minutes in each Homogeneity test showed p-value >0.05,
session. It was performed in the inpatient which indicated that both groups were
ward of the General Hospital of Semarang. homogeneous.
Table 1 Characteristics of respondents based on age, gender, educational level and type of jobs
Group
Variable
Experiment Control
n (28) % n (28) %
Age (year)
26-35 2 7.1 2 7.1
36-45 5 17.9 6 21.4
46-55 9 32.1 13 46.4
56-65 7 25 4 14.3
>65 5 17.9 3 10.8
Mean= 54.68 Mean= 50.75
Mean age
(min 30 – max 80) (min 30 – max 76)
Gender
Male 16 57.1 16 57.1
Female 12 42.9 12 42.9
Education level
Elementary 10 35.7 5 17.9
Junior high 6 21.4 11 39.3
Senior high 12 42.9 12 42.9
Type of jobs
Labor 8 28.6 9 32.1
Housewife 4 14.3 3 10.7
Trader 2 42.9 3 10.7
Retired 1 3.6 0 0
Civil servant 1 3.6 0 0
Entrepreneur 12 42.9 13 46.4

!
Table 2 Anxiety levels before and after given intervention in the experiment and control group
Group
Total
Anxiety level Experiment Control
f % f % n %
Pretest
Severe 28 50 28 50 56 100
Moderate 0 0 0 0 0 0
Mild 0 0 0 0 0 0
Posttest
Severe 0 0.00 25 44.6 25 44.6
Moderate 23 41.1 3 5.40 26 46.5
Mild 5 8.90 0 0.00 5 8.9
Table 2 shows that all respondents before Kolmogorov smirnov test as shown in the
given intervention in the experiment and Table 3 shows p-value >0.05, which indicated
control group experienced severe anxiety that the experiment and control group were in
(100%), while after given intervention there normal distribution; while Levene’s test as
was a decrease of anxiety level to moderate shown in the Table 4 obtained p-value >0.05,
(41.1%) and mild level (8.90%) in the which indicated that the experiment and
experiment group; but there was only slight control group were homogeneous.
difference in the control group that 44.6% of
respondents still had severe anxiety and
5.40% had moderate anxiety.
Table 3 Normality test of respondents based on anxiety level in the experiment and control group using
Kolmogorov Smirnov (n=56)
Group
Anxiety level
Experiment Control
Pretest .502 .450
Posttest .713 .362
Table 4 Homogeneity test of respondents based on anxiety level in the experiment and control group using
Levene’s test (n=56)
Anxiety level P-value
Pretest .461
Posttest .090
Table 5 Effect of psychoeducation on anxiety level before and after given intervention in the experiment and
control group using paired t-test
Anxiety level n Mean ± SD t p
Experiment group
Pretest 28 41.54 ±4.426 22.083 0.001
Posttest 28 22.46 ±2.236
Control group
Pretest 28 41.54 ± 4.426 20.937 0.001
Posttest 28 22.46 ± 2.236
Table 5 shows there was a statistically given a brochure of CHD on the anxiety level
significant effect of psychoeducation on in the control group with p-value 0.001
anxiety level in the experiment group with p- (<0.05).
value 0.001 (<0.05), and significant effect of
!
Table 6 mean differences of anxiety levels before and after given intervention in the experiment and control
group using Independent t-test
Mean difference Group n Mean SD t p-value
Experiment 28 19.07 4.570
Pretest - posttest 9.017 0.001
Control 28 10.14 2.563
Independent t-test as shown in the table 6 Table 7 shows that there was a statistically
shows p-value 0.001, which indicated that significant difference of anxiety level after
there was a statistically significant difference intervention in the experiment and control
of anxiety level before and after intervention group with p-value 0.001 (<0.05). The mean
in the experiment and control group. anxiety level in the experiment group (22.46)
However, the experiment group shows the was lower than the mean anxiety level in the
greater mean difference (19.07) compared control group (41.54).
with the mean in the control group (10.14).
Table 7 Anxiety levels after given intervention in the experiment and control group using Independent t-test
Anxiety level Group n Mean ± SD t p-value
Experiment 28 22.46 ± 2.236
Posttest 20.937 0.001
Control 28 41.54 ± 4.426
DISCUSSION
Findings of this study showed that there was a posttest in control group indicated a positive
significant effect of psychoeducation on the effect of providing brochures to improve the
anxiety level in patients with CHD. ability of patients to overcome anxiety. Study
Differences in anxiety levels after given stated that every human has the ability to
intervention indicated a positive effect of learn from birth until the end of life
psychoeducation. Psychoeducation can (Dalimunthe, Se, & Heldy, 2007). Health
improve the patient's ability to overcome education in this study will increase the
anxiety. This is in accordance with previous knowledge of the respondents and may
study stated that psychoeducation is one way influence the behavior. However, the
that nurses can be carried out in community, increased knowledge is influenced by various
especially in hospitals in solving factors.
psychological problems related to family
physical problems (Stuart, 2014). By doing In this study, providing a brochure of CHD is
psychoeducation, a nurse will be able to less effective compared with psychoeducation
directly provide effective service and efficient for patients with CHD. This is consistent with
to solve problems. Another study also shows previous studies revealed that psycho-
that psychoeducation therapy could reduce education therapy is much better in reducing
psychosocial problems due to physical illness. anxiety in patients with cancer compared with
It is also effective for the prevention of health education. It could be said that health
emotional expression and the burden of education using brochure may be less
treating patients with the first episode of effective in lowering anxiety.
psychosis (Nurbani, 2009). Furthermore, it is
supported by previous study proved the
effectiveness of psychoeducation in the CONCLUSION
development of psychosocial health and It can be concluded that there was a
family performance in patients with significant effect of psychoeducation on
schizophrenia in China (Chien & Wong, anxiety level in patients with CHD, and
2007). psychoeducation is effective compared with
providing brochure of CHD only. Therefore,
This study also revealed that there was a it is suggested that psychoeducation can be
significant effect of given a brochure of CHD used as one of nursing intervention in an
in reducing anxiety levels of patients with effort to reduce anxiety.
CHD. Differences in anxiety levels in the

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REFERENCES patients undergoing radiotherapy. Health and

Aghayusefi, A., Mirzahoseini, H., Khazaeli, M., & quality of life outcomes, 11(1), 121.
Assarnia, A. (2016). The Effect of Hashemzadeh, A., Garooci Farshi, M., Halabianloo, G.,
Psychoeducational Interventions on Illness & Maleki Rad, A. (2011). The study of
Management in Families of Schizophrenic effectiveness of relaxation and distraction
Patients. Practice in Clinical Psychology, techniques training in anxiety reduction in
4(2), 129-135. cardiac patients. Arak Med Univ J, 14(56), 97-
Ågren, S., Evangelista, L. S., Hjelm, C., & Strömberg, 105.
A. (2012). Dyads affected by chronic heart Indonesia, D. (2006). Pharmaceutical Care Untuk
failure: a randomized study evaluating effects Penyakit Hipertensi: Direktorat Bina Farmasi
of education and psychosocial support to Komunitas dan Klinik Ditjen Bina
patients with heart failure and their partners. Kefarmasian dan Alat Kesehatan, Jakarta
Journal of cardiac failure, 18(5), 359-366. Indonesia.
Berndt, N., Bolman, C., Lechner, L., Mudde, A., Khayyam-Nekouei, Z., Neshatdoost, H., Yousefy, A.,
Verheugt, F. W. A., & de Vries, H. (2012). Sadeghi, M., & Manshaee, G. (2013).
Effectiveness of two intensive treatment Psychological factors and coronary heart
methods for smoking cessation and relapse disease. ARYA atherosclerosis, 9(1), 102.
prevention in patients with coronary heart Kones, R. (2011). Primary prevention of coronary heart
disease: study protocol and baseline disease: integration of new data, evolving
description. BMC cardiovascular disorders, views, revised goals, and role of rosuvastatin
12(1), 33. in management. A comprehensive survey.
Chien, W. T., & Wong, K.-F. (2007). A family Drug design, development and therapy, 5,
psychoeducation group program for Chinese 325.
people with schizophrenia in Hong Kong. Mahdavi, M., Abbasi, I., & Mohammadi, N. (2015).
Psychiatric services, 58(7), 1003-1006. Effect of Cardiac Rehabilitation Program on
Cole, J. A., Smith, S. M., Hart, N., & Cupples, M. E. Quality of Life in Patients Undergoing
(2011). Systematic review of the effect of diet Coronary Artery Bypass Graft Surgery. The
and exercise lifestyle interventions in the Horizon of Medical Sciences, 21(2), 67-74.
secondary prevention of coronary heart McGillion, M., Arthur, H., Victor, J. C., Watt-Watson,
disease. Cardiology Research and Practice, J., & Cosman, T. (2008). Effectiveness of
2011. psychoeducational interventions for improving
Dalimunthe, R. F., Se, M., & Heldy, B. Z. (2007). symptoms, health-related quality of life, and
Pengaruh Motivasi Intrinsik Terhadap Kinerja psychological well being in patients with
Perawat Pelaksana di Instalasi Rawat Inap stable angina. Current Cardiology Reviews,
RSU Dr. Pirngadi Medan Tahun 2007. 4(1), 1-11.
Dalusung‐Angosta, A. (2013). CHD knowledge and risk MOH. (2013). Riset Kesehatan Dasar; RISKESDAS
factors among Filipino‐Americans connected (Basic Health Research). Ministry of Health
to primary care services. Journal of the
MOH. (2015). Pusat data dan Informasi: Ministry of
American Association of Nurse Practitioners,
Health of Indonesia.
25(9), 503-512.
Nurbani. (2009). Pengaruh Psikoedukasi keluarga
Dehdari, T., Heidarnia, A., Ramezankhani, A.,
terhadap masalah psikososial: ansietas dan
Sadeghian, S., & Ghofranipour, F. (2009).
beban keluarga (caregiver) dalm merawat
Effects of progressive muscular relaxation
pasien stroke di RS Jakarta Pusat Dr. Cipto
training on quality of life in anxious patients
Mangunkusumo. Faculty of Nursing,
after coronary artery bypass graft surgery.
Universitas Indonesia. Retrieved from
DeJean, D., Giacomini, M., Vanstone, M., & Brundisini,
http://lib.ui.ac.id/file?file=digital/2016-
F. (2013). Patient experiences of depression
11/125192-Nurbani.pdf
and anxiety with chronic disease: a systematic
Reid, J., Ski, C. F., & Thompson, D. R. (2013).
review and qualitative meta-synthesis. Ontario
Psychological interventions for patients with
health technology assessment series, 13(16),
coronary heart disease and their partners: a
1.
systematic review. PLoS ONE, 8(9), e73459.
Dinkes. (2014). Health Profile of Central Java Province:
Sadeghi, S. M., Razmjouei, N., Ebadi, A., Najafi, M. S.,
Department of Health of Central Java.
Asadi, L. M., & Bozorgzad, P. (2009). Effect
Dossey, B. M. (2008). Theory of integral nursing.
of applying continuous care model on quality
Advances in nursing science, 31(1), E52-E73.
of life of patients after coronary artery bypass
Dossey, B. M., Certificate, C.-D. I. N. C., Keegan, L., &
graft.
Co-Director International Nurse Coach, A.
Stuart, G. W. (2014). Principles and Practice of
(2012). Holistic nursing: Jones & Bartlett
Publishers.
Sciences.
Greco, A. (2013). Effects of Music on Anxiety and Pain
Tarr, B., Launay, J., & Dunbar, R. I. M. (2014). Music
in the Diagnosis and Treatment of Patients
and social bonding:“self-other” merging and
With Breast Cancer.
neurohormonal mechanisms. Frontiers in
Guo, Z., Tang, H.-y., Li, H., Tan, S.-k., Feng, K.-h.,
psychology, 5.
Huang, Y.-c., Jiang, W. (2013). The benefits
of psychosocial interventions for cancer
!
von Känel, R. (2008). Psychological Distress and Yazici, M. K., Demir, B., Tanriverdi, N., Karaagaoglu,
Cardiovascular Risk: Journal of the American E., & Yolac, P. (1998). Hamilton anxiety
College of Cardiology. rating scale: interrater reliability and validity
study. Turk Psikiyatri Derg, 9(2), 114-117.
Cite this article as: Sulistiyo, Y., Santoso, B., Shobirun., Hadisaputro, S., Latifah. L., Pujiastuti, RR.
S. E. (2017). Effect of psychoeducation on anxiety in patients with coronary heart disease. Belitung

Wati SH, et al. Belitung Nursing Journal. 2017 December;3(6):712-721

HYPNODIALYSIS FOR ANXIETY RELIEF AND ADHERENCE TO

MEDICATION, KIDNEY DIET AND FLUID INTAKE IN PATIENTS WITH
Siti Hajar Wati*, Mardiyono, Warijan
*Correspondence:
Siti Hajar Wati, S.Ter.Kep
E-mail: hajarwati.siti@gmail.com
Abstract
Objective: To examine the effectiveness of hypnodialysis on anxiety levels and adherence to medication, kidney diet and
fluid intake in patients with chronic kidney disease.
Methods: This was a randomized controlled trial study conducted from November to December 2016. Thirty respondents
recruited using simple random sampling, which 17 respondents assigned randomly in the experiment and control group. The
Hamilton Anxiety Rating Scale (HARS), Morisky scale, adherence to kidney diet questionnaire, adherence to fluid intake
questionnaire were used as instruments for this study. Paired t-test and repeated ANOVA were used for data analysis.
Results: Findings showed that there was a statistically significant effect of hypnodialysis in reducing anxiety levels and
improving adherence to medication, kidney diet, and fluid intake in patients with chronic kidney disease with p-value 0.000
(<0.05), which its effect started from day 7 (posttest 1).
Conclusion: Hypnodialysis may decrease anxiety levels and improve medication adherence, kidney diet and fluid intake.
Therefore, hypnodialyis can be anlternative treatment for patients with chronic kidney disease.
Keywords: Anxiety, Medication Adherence, Kidney Diet, Fluid Intake, Chronic Kidney Disease
INTRODUCTION
Chronic kidney disease (CKD) is progressive, into the urine and affects the workings of each
irreversible deterioration in renal fucntion in system of the body (Smeltzer et al., 2008).
which the body’s ability to maintain
metabolism and fluid and electrolyte balance Decrease in kidney function or Glomerullar
fails, resulting in uremia and azotemia Fitraton Rate (GFR) less than 15 mL/
(Smeltzer et al., 2008). CKD occurs because minute/1.73 m is called as Chronic kidney
of the number of nephrons are damaged and disease (CKD) stage V. Effect of decreased
stop working. For a while, healthy nephrons renal function in excreting the final product of
can take on the extra work. But if the damage metabolism, acidic substance, will accumulate
continues, more and more nephrons in serum patients and work as toxins
shutdown. Damage from the nephron may (Elizabeth, 2009).
cause a decrease in the Glomerullar Fitraton
Rate (GFR), which the kidneys are incapable Patients with chronic kidney disease often
of filtering blood as renal function decreased, develop sudden changes such as severe
so that the rest of the protein metabolism that acidosis, hyperkalemia, sepsis, pulmonary
should be excreted into the urine accumulates edema or other severe infections that can
cause death, therefore rapid treatment is
!
needed. Chronic kidney disease is currently hemodialysis without side effects (Sukandar,
the most important health problem, which is 2006).
not only related to the prevalence and the
increase of incidence rate, but also the high When patiens start hemodialysis, then they
cost of replacement treatment of renal must change all aspects of their life at that
function (Harrison, Wilson, & Kasper, 2005). moment. Patients should do hemodialysis
routinely for 2-3 times a week, dealing with
The number of patients with kidney disorders repeated punctures, medication adherence,
in developed countries is quite high. In the low-protein and salt diet, and limited fluid
United States, the incidence of chronic kidney intake. In addition, hemodyalisis also impacts
was sharply increased, in 2000 there were on psychology of patients, such as anxiety.
372,000 cases, by 2010 the number was Anxiety is an emotion characterized by an
estimated to be more than 650,000 cases, and unpleasant state or reaction to situations
about 6 million to 20 million Americans were perceived as stressful or dangerous
estimated to have early chronic kidney (Syamsiah, 2011).
disease. The similar thing also happened in
Singapore, which there was 2,497 cases in Based on preliminary study with five patients
2012, and increased to 2,518 cases in 2013. In with CKD, it was identified that 2 patients
Malaysia, with a population of 18 million, it is experienced mild anxiety and 3 patients
estimated that there are 1,800 new cases of experienced moderate anxiety; of those five
chronic kidney disease per year (Nicolas, patients, four of them did not follow the diet
2013). and fluid intake. It is however supported by
previous study revealed that from 68 patients,
Treatment of chronic kidney disease consists more than a half of them experienced anxiety,
of 3 stages, namely conservative treatment, which was influenced by several factors, such
symptomatic and replacement therapy of side effects during hemodyalisis, including
kidney function. While handling of chronic muscle cramps, nausea, vomiting, and
kidney disease conservatively consists of the hypotension, as well as the fear of death,
role of kidney diet, which regulates calorie economic change, changes in family function
needs, fluid fulfillment, electrolyte and and lifestyle changes (Lailatushifah, 2012).
mineral. Symptomatic therapy aims to prevent
or reduce kidney damage by administration of In addition, Kartika Sari explained that the
drugs such as antihypertensive and anemia non-adherence of patients in kidney diet and
drugs, while replacement therapy for kidney fluid intake is caused that the patients think
function is by hemodialysis or directly by they are free to consume any food and drink
performing a kidney transplant (Price & just before hemodialysis because the waste of
Wilson, 2005). metabolism in the body will be expelled
during hemodialysis therapy, in fact, body
Hemodyalisis is a kidney replacement therapy weight is gained than recommended (Sari,
often performed in Indonesia. Hemodialysis is 2009). Followed by Desak Putu Kurniawati
a treatment that aims to replace kidney said that 50% -66.7% of patients undergoing
function by using machinery to remove the hemodialysis with non-adherence to fluid
remnants of metabolic products and reduce intake restriction were characterized by
disruption of fluid and electrolyte balance complaints of shortness of breath caused by
when the kidneys are no longer able to carry increased body fluid volume during visit.
out the process with diffusion, osmosis and These indicate that adherence to medication,
ultrafitration principles. General indications of kidney diet, and fluid intake is still quite
hemodialysis in chronic kidney disease is difficult to apply by patients with CKD
when GFR is less than 15 mL/min. undergoing hemodyalisis. Thus, an effort to
Hemodialysis is not a therapy that can cure deal with patient’s adherence is needed
the disease permanently, but hemodialysis (kurniawati, 2014).
helps the patient's survival before transplating
the kidneys. Although hemodialysis is safe Health education, family support, and
and beneficial to patients, it does not mean hypnotherapy are often used as efforts to

!
overcome with patient’s adherence. However, anxiety, medication adherence, adherence to

this study only focused on hypotherapy as an kidney diet and fluid intake through deep
intervention to increase patient’s adherence. suggestion to the patient by taking a deep
Previous study stated that there was an effect breath and exhaling by mouth slowly and
of hypnotherapy on anxiety and adherence to repeatedly over and over until patient is
medication, kidney diet, and fuild intake (Ds, hypnotized, which is characterized by relaxed
Kristiyawati, & Supriyadi, 2014; condition and can be encouraged to follow the
Lailatushifah, 2012; Sari, 2009). therapist's instructions appropriately without
seeing the therapist. Hypnodialysis performed
Therefore, given the phenomena and the by certified therapist for 8 times intervention,
effect of hypnotherapy in previous study, this with 4 times a week performed at each
study aimed to prove the effectiveness of patient’s home in duration of 45 minutes
hypnotherapy (called hypnodialysis) on persession. For the control group, health
anxiety and adherence to medication, kidney education about chronic kidney disease and
diet and fluid intake in patients with chronic kidney diet and fluid intake was given for 8
kidney disease. times intervention, with 4 times a week
performed at each patient’s home in duration
of 45 minutes persession.
METHODS
Study Design Instruments
This was a randomized controlled trial study There were four instruments used in this
conducted from November to December 2016 study, which consisted of:
in the General Hospital of Ungaran and (i) The Hamilton Anxiety Rating Scale
Ambarawa. (HARS) was used to measure anxiety
adopted from previous instrument in
Research Subject Indonesian version (Hargyowati, 2016)
The target population in this study were all in Indonesian version. This scale
patients with chronic kidney disease who consisted of 14 items of questions.
undergone hemodialysis at Ungaran Hospital Cronbach’s alpha was 0.756.
and Ambarawa hospital. In the Ungaran (ii) Morisky scale was used to measure
hospital, there were 39 patients regularly medical adherence adopted from
performed hemodialysis, while in Ambarawa previous instrument in Indonesian
hospital, 40 patients routinely performed version (Puspitasari, 2012). This scale
hemodialysis. The number of sample in this consisted of 8 items of questions.
study was 34 respondents recruited based on Cronbach’s alpha was 0.802.
the number of sample in previous study using (iii) Adherence to kidney diet questionnaire,
RCT design. The number of sample in each adopted from previous instrument in
group was 17 respondents assigned randomly Indonesian version (Relawati,
in the experiment and control group. Simple Kurniawan, Fauzi, & Hadi, 2016). The
random sampling was performed by questionnaire consisted of 26 items of
randomization of patients name lists, which dichotomous questions. KR-20 obtained
even number was included in the experiment a reliable value of 1.17, and coefficient
group and odd number included in the control correlation in all items was >0.6.
group. The inclusion criteria of the sample (iv) Adherence to fluid intake questionnaire,
were patients undergoing hemodyalisis with adopted from from previous instrument
full consciousness, while the exclusion in Indonesian version (Aminoto & Asti,
criteria were patients with interdialytic 2012). It consisted of 20 items of
condition (hypotension, hypoglycemia, and questions with dichotomous options. KR-
shortness of breath). 20 value was 0.645, and coefficient
correlation in all items was >0.6.
Intervention
Hypnodialysis is a holistic therapy by giving a Ethical consideration
hypnosis to patients undergoing hemodialysis Ethical clearance was obtained from Health
which aims to address the problems of both Research Ethics Committee of POLTEKKES
!
Semarang with No. 174/KEPK/Poltekkes- had moderate anxiety and 4 respondents

Smg/EC/2016. The researchers have (23.6%) had mild anxiety, while in the day 12
confirmed that all respondents have signed a (posttest 2) the anxiety level showed 13
written informed consent prior to data respondents (76.4%) had mild anxiety and 3
collection. respondents (17.6%) with no anxiety.
Data analysis For the experiment group, in day 1 (pretest 1)

Paired t-test and repeated ANOVA were used in the first week found 12 respondents
for data analysis. (70.5%) had moderate anxiety and 5
respondents (29.4%) had severe anxiety,
while in the day 7 (posttest 1) the level of
RESULTS anxiety showed 15 respondents (88.3%) had
Table 1 shows that in the control group in day mild anxiety and 2 respondents (11.8%) with
1 (pretest 1) in the first week found that 10 no anxiety. In day 8 (pretest 2) in the second
respondents (58.8%) had severe anxiety and 7 week found 16 respondents (94.6%) had mild
respondents (41.2%) had moderate anxiety, anxiety and 1 respondents (5.9%) had no
while in the day 7 (posttest 1) the level of anxiety, while in the day 12 (posttest 2) the
anxiety showed 9 respondents (52.9%) had anxiety level showed 1 respondents (5.9%)
moderate anxiety and 6 people (47.1%) with had mild anxiety and 16 respondents (17.6%)
mild anxiety. In day 8 (pretest 2) in the with no anxiety.
second week found 13 respondents (76.4%)
Table 1 Frequency distribution of anxiety levels in the control and experiment group (n=34)
Variable
Day 1 Day 7 Day 8 Day 12 Day 1 Day 7 Day 8 Day 12
Anxiety
n % n % n % n % n % n % n % n %
level
Mean ± (29.53± (22.82± (23.82± (16.88± (26.71± (16.06± (16.82± (7.76±
SD 4.611) 3.414) 3.245) 4.285) 3.917) 3.288) 2.765) 3.192)
<14 : No
0 0 0 0 0 0 3 17.6 0 0 2 11.8 1 5.9 16 94.1
anxiety
14-20 :
0 0 6 47.1 4 23.6 13 76.4 0 0 15 88.3 16 94.1 1 5.9
Mild
21-27 :
7 41.2 9 52.9 13 76.4 1 5.9 12 70.5 0 0 0 0 0 0
Moderate
28-41 :
10 58.8 0 0 0 0 0 0 5 29.4 0 0 0 0 0 0
Severe
43-56 :
More 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
severe
Table 2 Frequency distribution of medication adherence in the control and experiment group (n=34)
Variable
Medication
n % n % n % n % n % n % n % n %
adherence
(6.53± (5.47± (6.29± (5.00± (6.35± (3.35± (4.18± (2.06±
Mean±SD
0.874) 0.624) 0.588) 0.791) 0.786) 0.931) 0.951) 0.899)
1-5 : High 3 17.6 10 58.8 1 5.9 12 70.6 3 17.6 17 100 15 88.2 17 100
6-7 :
13 76.4 7 41.2 16 94.1 5 29.4 14 82.3 0 0 2 11.8 0 0
Moderate
8 : Low 3 17.6 0 0 0 0 0 0 0 0 0 0 0 0 0 0

!
Table 2 shows that in the control group in day and 12 respondents (70.6%) with high
1 (pretest 1) in the first week found that 3 medication adherence.
respondents (17.6%) had low medication
adherence, 3 respondents (76.4%) had high For the experiment group, in day 1 (pretest 1)
medication adherence and 13 respondents in the first week found that 14 respondents
(76.4%) had moderate medication adherence, (82.3%) had moderate medication adherence
while in the day 7 (posttest 1) there was no and 3 respondents (17.6%) had high
respondents had low medication adherence, 9 adherence, while in the day 7 (posttest 1)
respondents (41.2%) had moderate medication there was no respondent with low and
adherence, and 10 respondents (58.8%) with moderate medication adherence, all of them
high adherence. In day 8 (pretest 2) in the (100%) had high medication adherence. In
second week found that 16 respondents day 8 (pretest 2) in the second week found
(94.1%) had moderate adherence and 1 that 2 respondents (11.8%) had moderate
respondents (5.9%) had high adherence, while medication adherence and 15 respondents
in the day 12 (posttest 2) there were 5 (88.2%) with high adherence, and in the day
respondents (29.4%) had moderate adherence 12 (posttest 2) all respondents (100%) had
high medication adherence.
Table 3 Frequency distribution of adherence to kidney diet in the control and experiment group (n=34)
Variable
Day 1 Day 7 Hari 8 Day 12 Day 1 Day 7 Hari 8 Day 12
Adherece to
n % n % n % n % n % n % n % n %
kidney diet
(15.59± (13.18± (14.06± (9.06± (15.53± (8.41± (10.94± (3.82±
Mean±SD
1.372) 1.976) 2.512) 13.579) 1.908) 3.020) 2.861) 0.728)
1-13 : Obey 0 0 7 41.2 3 17.7 13 76.5 1 5.9 16 94.1 11 64.7 17 100
14-26:
17 100 10 58.7 14 82.3 4 23.5 16 94.2 1 5.9 6 47.1 0 0
Disobey
Adherence to kidney diet as shown in the For the experiment group, in day 1 (pretest 1)
Table 3 shows that in the control group in day in the first week found that 16 respondents
1 (pretest 1) in the first week found that all (94.2%) disobeyed and 1 respondent (5.9%)
respondents (100%) disobeyed, while in day 7 obeyed, while in the day 7 (posttest 1) there
(posttest 1) found that 10 respondents (58.7%) was 1 respondent disobeyed and 16
disobeyed and 7 respondents (41.2%) obeyed. respondents (94.1%) obeyed. In day 8 (pretest
In day 8 (pretest 2) in the second week found 2) in the second week found that 11
that 14 respondents (82.3%) disobeyed and 3 respondents (64.7%) obeyed and 6
respondents (17.7%) obeyed, in the day 12 respondents (47.1%) disobeyed, and in the
(posttest 2) there were 4 respondents (23.5%) day 12 (posttest 2) all respondents (100%)
disobeyed and 13 respondents (76.5%) obeyed kidney diet.
obeyed.
Table 4 Frequency distribution of adherence to fluid intake in the control and experiment group (n=34)
Variable
Adherence to
n % n % n % n % n % n % n % n %
fluid intake
(5.47±
Mean±SD (14.53± (9.94± (10.53± (7.59± (13.82± (7.76± (3.12±
1.281)
1.375) 1.919) 1.586) 1.543) 1.185) 1.855) 1.11)
1-10 : Obey 0 0 11 64.7 8 47.1 16 94.1 0 0 17 100 15 88.2 17 100
11-20:
17 100 6 35.3 9 52.9 1 5.9 17 100 0 0 2 11.8 0 0
Disobey
!
Adherence to fluid intake as shown in the (94.1%) obeyed and 1 respondent (5.9%)
Table 4 shows that in the control group in day disobeyed. For the experiment group, in day 1
1 (pretest 1) in the first week found that all (pretest 1) in the first week found that all
respondents (100%) disobeyed, while in day 7 respondents (100%) disobeyed, while in the
(posttest 1) found that 11 respondents (64.7%) day 7 (posttest 1) all respondents (100%)
obeyed and 6 respondents disobeyed. In day 8 obeyed. In day 8 (pretest 2) in the second
(pretest 2) in the second week found that 8 week found that 15 respondents (88.2%)
respondents (47.1%) obeyed and 9 obeyed and 2 respondents (11.8%) disobeyed,
respondents (52.9%) disobeyed, in the day 12 and in the day 12 (posttest 2) all respondents
(posttest 2) there were 16 respondents (100%) obeyed fluid intake.
Table 5 Mean difference of anxiety level, medication adherence, adherence to kidney diet and fluid intake in
the control and experiment group using Paired t-test (n=34)
Group N Mean SD P-value
Anxiety level
Experiment group
Control group
Medication adherence
Experiment group
Control group
Adherence to Kidney diet
Experiment group
Control group
Adherence to Fluid intake
Experiment group
Control group

!
Table 5 shows that the anxiety level after medication adherence between experiment
given hypnodialysis 8 times for 2 weeks in the and control group.
experiment group decreased by about 33.83%
while health education in the control group Similar with adherence to kidney diet, there
could decrease anxiety level as much as was an improvement of adherence after given
22.59%. Paired t-test obtained p-value 0.000 intervention in the experiment group for about
(<0.05), which indicated there was a 45.03% and the control group was 25.12%;
significant difference in anxiety levels while adherence to fluid intake increased to
between experiment and control group. 53.53% in the experiment group and 34.71%
in the control group. Paired t-test obtained p-
For medication adherence, there was an value 0.000 (<0.05), which indicated that
improvement of medication adherence in the there was a significant difference in adherence
experiment group after given intervention by to kidney diet and fluid intake between
about 53.68%, and also an increase of experiment and control group. Of all those
medication adherence in the control group as variables, the mean of anxiety levels,
much as 19.12%. Paired t-test obtained p- medication adherence and adherence to
value 0.000 (<0.05), which indicated that kidney diet and fluid intake in the experiment
there was a significant difference in group was higher that the mean in the control
group
.
Table 6 Effect of hypnodialysis on anxiety levels in the control and experiment group using repeated
Anxiety levels 3 108.131 6.529 0.000
Residue 1
Post hoc test
Mean of anxiety levels
hypnodialysis on anxiety levels with F-value= hypnodialysis in increasing medication
6.529. Post hoc test showed the effect of adherence with F-value= 24.956. Post hoc test
hypnodyalisis started from day 7 (Posttest 1). showed the effect of hypnodyalisis started
from day 7 (Posttest 1).
Table 7 Effect of hypnodialysis on medication adherence in the control and experiment group using repeated
Medication adherence 3 23.487 24.956 0.000
Residue 1
Post hoc test
Mean of medication adherence
!
Table 8 Effect of hypnodialysis on adherence to kidney diet in the control and experiment group using
Adherence to kidney diet 3 46.594 13.649 0.000
Residue 1
Post hoc test
Mean of adherence to kidney diet
hypnodialysis in increasing adherence to hypnodialysis in increasing adherence to fluid
kidney diet with F-value= 13.649. Post hoc intake with F-value= 13.649. Post hoc test
test showed the effect of hypnodyalisis started showed the effect of hypnodyalisis started
from day 7 (Posttest 1). from day 7 (Posttest 1).
Table 9 Effect of hypnodialysis on adherence to fluid intake in the control and experiment group using
Adherence to fluid intake 3 35.723 19.005 0.000
Residue 1
Post hoc test
Mean of adherence to fluid intake
DISCUSSION subconscious mind. In this condition, patient

Effectiveness of hypnodialysis on anxiety will enter a deeper hypnotic pattern, so that
levels the original brain waves in the beta wave will
Findings of this study revealed that there was change slowly toward the alha wave. Under
a significant effect of hypnodialysis in alpha conditions, the brain will produce
reducing anxiety levels in patients with serotonim and endorphin hormones that cause
chronic kidney disease with p-value 0.000, the person to feel comfortable, calm and
starting from day 7 (posttest 1). It could be happy. This hormone increase body immune
said that hypnodialysis is very beneficial for system, dilate blood vessels, and the heartbeat
patients chronic kidney disease who undergo becomes stabil and the sensory capacity rises.
hemodialysis with positive suggestions. This At the time an individual in hypnotherapy,
is in line with previous studies stated that there is a stimulation of the activation system
hypnotherapy is proven to deal with a variety of the reticularis in the brain, causing an
of psychological and psychological disorders, autonomic nerve response, ie pulse, breath
such as anxiety, stress, phobia, sleep frequency, blood pressure and controlled
disturbances, mind-set disorders, etc (Golden, feelings, emotion and anxiety (La Kahija,
2012). 2007).
Physiologically, hypnotherapy works through Relaxation will inhibit the sympathetic

brainwashing systems, as La Kahija says that hormone, so the number of hormone that
on hypnotherapy sessions such as induction causes body disregulation can be reduced. The
and deepening, patient will be guided by the parasympathetic nervous system, which has
therapist from the conscious mind to the the opposite work function of the sympathetic

!
nerves, will slow or weaken the workings of that hypnotherapy is a persuasive

the body's internal devices. As a result, there communication art that aims to open a
is a decrease in heart rate, breathing rhythm, person's unconscious gate so that suggestions
muscle tension, blood pressure, and the can be given (Hakim, 2010b).
production of stress-causing hormones (La
Kahija, 2007). The relaxation conditions that Humans have two types of thoughts that are
result from the treatment of hypnosis can one unity, between the subconscious mind.
trigger changes in brain waves where in The role and influence of the conscious mind
hypnotic state the brain will enter the alpha to ourselves as much as 12% while the
wave to tetha. The frequency of the wave subconscious mind reaches 88%. The
becomes more rhythmic and regular so that unconscious and the subconscious mind
the effects that arise on the brain is the actually affect each other and work at a very
production of neurotransmitters such as high speed (Batbual, 2010).
endorphins, GABA, enkefalin and several
other neurotransmitters that serve to reduce During the process of hypnosis, the body of a
the condition of anxiety as well as cause a person will be relax, while his/her mind is
relaxing effect. (Potter & Perry, 2005) very focused and attentive. Like other
relaxation techniques, when the critical factor
Hypnodialysis is one part of therapy to (CF) or reticular activating system (RAS) is
overcome anxiety by distraction therapy. open and unwittingly all information enters
Distraction is a method to relieve anxiety by the unconscious mind without filtering and
turning attention to other things so that the becoming program of life. Conducting a self-
patient will forget the anxiety experienced. A program is to by-pass the critical factor or
pleasant sensory stimulus causes the release penetrate the critical filter and directly
of endorphins that can inhibit anxious stimuli communicate with the subconscious mind. By
resulting in less anxious stimuli being penetrating this critical filter, the conscious
transmitted to the brain (Potter & Perry, mind is deactivated so that suggestions are
2005). nine times effective (Hakim, 2010a).
Findings of this study were consistent with Hypnotherapy can help the patient find "you
previous studies revealed that hypnodialysis own way" or "your own way" to motivate
was effective in decreasing emotional and yourself to immediately start an activity such
anxiety levels. Differences in hypnodialysis as sport, quit smoking, regulate diet and
methods in this study and previous study were improve healthy behavior. This study is in
the hemodialysis was given for 4 times while line with the previous study revealed that
in this study was given for 8 times in 2 there was an increase in medication adherence
weeks. after given Motivational Interviewing and
conseling (Rubak, 2005). In addition, theory
Effectiveness of hypnodialysis on states that hypnotherapy is a healing concept
adherence to medication, kidney diet and that balances the system of harmonizing the
fluid intake body by reorganizing the habits and behavior,
Findings of this study also revealed that there both consciously and unconsciously (Hakim,
was a significant effect of hypnodialysis in 2010a). Thus, there was a change of habit and
improving medication adherence and behavior from low adherence to high
adherence to kidney diet and fluid intake in adherence in this study.
patients with chronic kidney disease with p-
value 0.000, starting from day 7 (posttest 1).
CONCLUSION
Hypnodialysis is a therapy used in the form of It can be concluded that there was a
suggestions through the art of distinctive significant effect of hypnodialysis in reducing
communication, and shown to the anxiety levels and improving medication
subconscious mind with the aim to change adherence and adherence to kidney diet and
thoughts, feelings, and behavior for the better. fluid intake in patients with chronic kidney
This is in accordance with the theory stating disease with p-value 0.000 (<0.05). Thus,
!
hypnodialysis can be an alternative treatment Mengkonsumsi Obat Harian. Retrieved 16

for patients with chronic kidney disease. January, 2017, from fpsi. mercubuana-yogya.
ac. id/wp-content/.../Noor-Kepatuhan... pdf
Nicolas, G. A. (2013). Hemodyalisis Therapy of
Sustained Low Efficiency Daily Dialysis for
REFERENCES patients with Chronic Kidney Disease in
Aminoto, C., & Asti, A. D. (2012). PENGARUH Intensive Care Unit. E-Jurnal Medika
HYPNOTHERAPY TERHADAP Udayana, 2(5), 766-782.
KEPATUHAN DIIT CAIRAN PADA Potter, P. A., & Perry, A. G. (2005). Buku ajar
PASIEN GAGAL GINJAL KRONIS fundamental keperawatan: konsep, proses, dan
RAWAT JALAN DI INSTALASI praktik. Jakarta: EGC, 1.
HEMODIALISA RS PKU Price, S. A., & Wilson, L. M. (2005). Patofisiologi
MUHAMMADIYAH GOMBONG. Jurnal konsep klinis proses-proses penyakit. Jakarta:
Ilmiah Kesehatan Keperawatan, 8(3). EGC, 7.
Batbual, B. (2010). Hypnosis Hypnobirthing: Nyeri Puspitasari, A. W. (2012). Analisis Efektivitas
Persalinan dan Berbagai Metode Pemberian Booklet Obat Terhadap Tingkat
Penanganannya. Yogyakarta: Gosyen Kepatuhan Ditinjau dari Kadar Hemoglobin
Publishing. Terglikasi (HbA1C) dan Morisky Medication
Ds, A. I., Kristiyawati, S. P., & Supriyadi. (2014). Adherence Scale (MMAS)-8 pada Pasien
PENGARUH HIPNOTERAPI TERHADAP Diabetes Melitus Tipe 2 di Puskesmas Pati
PENURUNAN TINGKAT KECEMASAN Jaya Kota Depok. Tesis, Universitas
PADA PASIEN YANG MENJALANI Indonesia, Depok.
KEMOTERAPI DI RS TELOGOREJO Relawati, A., Kurniawan, R., Fauzi, I., & Hadi, R.
SEMARANG. Jurnal Ilmu Keperawatan dan (2016). Gambaran Kepatuhan Diet Pada
Kebidanan. Penderita Gagal Ginjal Kronis do RSUD
Elizabeth, J. C. (2009). Buku Saku Patofisiologi. Tjitrowardoyo Purworejo. Fakultas
Penerbit Buku Kedokteran EGC: Jakarta. Kedokteran dan Ilmu Kesehatan, Universitas
Golden, W. L. (2012). Cognitive hypnotherapy for Muhammadiyah Yogyakarta.
anxiety disorders. American Journal of Rubak, S. (2005). Motivational interviewing in intensive
Clinical Hypnosis, 54(4), 263-274. treatment of type 2 diabetes detected by
Hakim, A. (2010a). Hipnoterapi: Cara Tepat & Cepat screening in general practice. Danish Medical
Mengarasi Stres, Fobia, Trauma, dan Bulletin, 52(32), 54-60.
Gangguan Mental Lainnya: VisiMedia. Sari, L. K. (2009). Faktor-faktor yang berhubungan
Hakim, A. (2010b). Hypnosis in Teaching: Cara dengan kepatuhan dalam pembatasan asupan
Dahsyat Mendidik & Mengajar: VisiMedia. cairan pada klien gagal ginjal kronik yang
Hargyowati, Y. E. (2016). Tingkat Kecemasan yang menjalani terapi hemodialisis diruang
Dilakukan Tindakan Hemodialisa di Ruang hemodialisa RSUP Fatmawati Fakultas
Hemodialisa RSUD Dr. Soehadi Prijonegoro Kedokteran dan Ilmu Kesehatan, UIN Syarif
Sragen. Stikes Kusuma Husada Surakarta. Hidayatullah Jakarta.
Retrieved from Smeltzer, S. C., Bare, B. G., Hinkle, J. L., Cheever, K.
http://stikeskusumahusada.ac.id/digilib/files/di H., Townsend, M. C., & Gould, B. (2008).
sk1/31/01-gdl-yaniekohar-1508-1-yanieko- Brunner & Suddarth’s Textbook of Medical
).pdf Surgical Nursing 12th Edition: Wolters
Harrison, I., Wilson, B. W., & Kasper, M. F. (2005). Kluwer: Lippincott Williams and Wilkins.
Prinsip-prinsip ilmu penyakit dalam [The Sukandar, E. (2006). Gagal ginjal dan panduan terapi
principles of internal medicine]. dialisis. Bandung: Pusat Informasi Ilmiah
kurniawati, D. P. (2014). Edukasi dalam meningkatkan (PII) Bagian Ilmu Penyakit Dalam FK-
kepatuhan intake cairan pasien penyakit UNPAD RS Dr. Hasan Sadikin.
ginjal kronik (PGK) on Hemodialisis. Fakultas Syamsiah, N. (2011). Faktor-faktor yang berhubungan
Keperawatan, Universitas Airlangga. dengan kepatuhan pasien CKD yang
La Kahija, Y. F. (2007). Hipnoterapi: Prinsip-prinsip menjalani hemodialisa di RSPAU DR
dasar praktik psikoterapi: Gramedia Pustaka Esnawan Antariksa Halim Perdana Kusuma
Utama. Jakarta. Program Studi Magister
Lailatushifah, S. N. F. (2012). Kepatuhan Pasien Yang Keperawatan, Fakultas Ilmu Keperawatan,
Menderita Penyakit Kronis Dalam Universitas Indonesia.
Cite this article as: Wati, S. H., Mardiyono., Warijan. (2017). Hypnodialysis for anxiety relief and
adherence to medication, kidney diet and fluid intake in patients with chronic kidney disease. Belitung

Resmi DC, et al. Belitung Nursing Journal. 2017 December;3(6):722-728

EFFECT OF YOGA AND ACUPRESSURE ON PAIN AND FUNCTIONAL

CAPABILITY OF LOWER BACK IN PREGNANT MOTHERS DURING THE
Dewi Candra Resmi*, Suharyo Hadisaputro, Runjati
*Correspondence:
Dewi Candra Resmi
E-mail: decha_qyut@yahoo.co.id
Abstract
Objective: To examine the effect of yoga and acupressure in lower back pain and functional capability in pregnant women
during the third semester of pregnancy.
Methods: A quasy experimental design with pretest posttest with non-equivalent control group. The research was conducted
at the Community Health Center of Kalikajar I, Selomerto I and Garung I in Wonosobo regency in January 2017. The
samples of this research were 42 pregnant women in trimester III selected using purposive sampling, which 14 samples
assigned in the yoga group, acupressure group, and control group. A Visual Analog Scale (VAS) was used to measure pain
level, and Oswestry Disability Index to measure functional capability of lower back. Data were analyzed using paired t-test
and one-way ANOVA.
Results: Findings showed that there was a statistically significant effect of yoga, acupressure, and pregnancy exercise
(control group) in reducing lower back pain and lower back functional capability with p <0.05. Pregnancy exercise (mean=
-1.43) was more effective in reducing lower back pain compared with yoga (mean=-2.29) and acupressure (mean=-2.71);
and acupressure (mean=-14.29) was more effective in improving lower back functional capability than yoga (mean=-6.57)
and pregnancy exercise (mean= -13.29).
Conclusion: There were significant effects of yoga, acupressure, and pregnancy exercise in reducing pain and in improving
the functional ability of the lower back. It is recommended for midwife to use these interventions as an alternative to deal
with back pain and functional capability in pregnant women, especially in the Community Health Center in Wonosobo
regency.
Keywords: Yoga, Acupressure, Pregnancy Exercise, Pain, Functional Ability
INTRODUCTION
Back pain in pregnancy is a pain that occurs and Israel have spinal pain. While in the
in the lumbosacral area. Back pain intensity Northern America, Africa, the Middle East,
usually increases as the gestational age Norway, Hong Kong and Nigeria have higher
increases. It is because this pain is the result prevalence ranging from 21% to 89.9%
of a shift in the center of gravity and its (Ansari, Hasson, Naghdi, Keyhani, & Jalaie,
posture (Varney, Kriebs, & Gegor, 2007). 2010). Survey conducted by the University of
Improper posture will force additional Ulster in 2014 showed that 70% of a total of
stretching and fatigue in the body, especially 157 pregnant women experienced lower back
in the spinal cord, causing pain or back pain pain (Dase, RphD, BmedsSc, & PgChep,
(Brayshaw, 2007). Previous study revealed 2014). In Indonesia, 60-80% pregnant women
that more than 50% of pregnant women in the experienced lower back pain; and in the
United States, Canada, Iceland, Turkey, Korea Community Health Center of Ungaran
722 BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017 ! !

showed that there were 45 pregnant women in the central nervous system in the backbone
the trimester III had lower back pain (Lebang, 2014; Mander, 2003). While
(Pravikasari, 2014). acupressure emphasis on the trigger point,
where in the case of activating point pain is
Based on preliminary study conducted at the the same as the acupuncture point. This is in
Community Health Center of Kalikajar I, accordance with the theory by previous study
Selomerto I and Garung I in Wonosobo stated that one of the benefits of acupressure
regency, there were 187 pregnant women in is to reduce back pain (Khomsah, Suwandono,
the third trimester from January to May 2016. & Ariyanti, 2017).
An effort to reduce low back pain in pregnant
women in these health centers is by only
providing health education about mobilization METHODS
and following the class of pregnant women to Research Design
do pregnancy exercise. While based on the This was a quasy experimental design with
results of interviews on 16 pregnant women in pretest posttest with non-equivalent control
trimester III revealed that 12 mothers group.
experienced lower back pain, and to reduce
the pain they did more rest and warm Setting
compresses on the lower back area. The research was conducted at the
Community Health Center of Kalikajar I,
The lower back will sometimes spread up to Selomerto I and Garung I in Wonosobo
the pelvis, thighs and down to the legs, regency in January 2017. The research was
sometimes will increase tenderness above conducted for 3 weeks.
pubic sympathetic (Cunningham, Leveno,
Bloom, Spong, & Dashe, 2014). This will Research Subjects
cause pregnant women to have difficulty in The target population in this study was all
performing activities such as standing up after pregnant women in trimester III the
sitting, moving from bed, sitting too long, Community Health Center of Kalikajar I,
standing too long, undressing and removing Selomerto I and Garung I in Wonosobo
clothes, or lifting and moving objects around regency. The samples of this research were 42
(Kozier, 2008). pregnant women in trimester III selected
using purposive sampling, which 14 samples
There are two kinds of treatments to deal with assigned in the yoga group, acupressure
pain and functional ability, namely group, and control group. The inclusion
pharmacology and non-pharmacology. criteria were: pregnant women in trimester III
Considering the impacts of pharmacological who experienced back pain and lower back
therapy, non-pharmacologic therapy should be functional ability, did not have a bad history
implemented to reduce back pain experienced of pregnancy, could communicate well,
by the third trimester pregnant women, those cooperative and willing to be a respondent;
include cutaneous stimulation (massage, hot while the exclusion criteria included: pregnant
and cold application, acupressure, and women with gestational age less than 29
contralateral stimulation), TENS, weeks.
acupuncture, relaxation, imagination,
meditation, hypnosis, aromatherapy, yoga and Intervention
reflexology (Thompson, 2004). This study For the yoga group, yoga was given two times
aimed to apply yoga and acupressure to deal per week for 3 weeks. Yoga was done for 60
with pain and functional capability in minutes per session in the morning in the
pregnant women. Community Health Center of Kalikajar I.
Yoga consisted of warm-up exercises,
Yoga is one of non-pharmacological therapies breathing (pranayama), and the core
that can reduce pain. Yoga is a practical effort movement as a series of yoga asana
in harmonizing body, mind, and spirit, which movement including Tadasana, Baddakosana,
its benefits are to build a strongposture, and Upavistha konasana, Dandasana, Suptha
foster flexible and strong muscles, and purify

!
baddakosana, and savanna. Yoga was done by Suwandono, Ariyanti, Mashoedi, &
an expert for yoga for pregnancy. Fatmasari, 2017), and functional capability of
lower back was measured using Oswestry
For the acupressure group, acupressure was Disability Index (ODI) questionnaire
done for 15 minutes per session, which was (Fairbank & Pynsent, 2000). Back pain and
implemented two times per week for 3 weeks. functional capability were measured during
Acupressure is an emphasis on certain points pretest and posttest.
in the body part of the lower back and legs of
the third trimester pregnant women who Ethical Consideration
experienced lower back pain. The points of The ethical consideration of this research was
acupressure included: BL23 (shenshu), GV 3 obtained from the Ethics Commission of
(yaoyangguan), GV 4 (Mingmen), Ki 3 Poltekkes Kemenkes Semarang
(taixi). The acupressure was performed by an No.141/KEPK/Poltekkes-Smg/EC/017. Prior
acupressure therapist at the Community to data collection, each respondent was signed
Health Center of Selomerto I. a written informed consent.
The control group was given the standard Data Analysis

action of pregnancy exercise performed in 60 Paired t-test was used to determine the mean
minutes per session and done two times per effect before and after intervention. To
week for 3 weeks. Pregnancy exercise is an determine the difference in the three groups,
exercise performed to maintain blood ANOVA test was used and followed by post-
circulation, reduce cramps and stiff hoc test. The homogeneity test used a Levene
complaints. Exercise was done in the form of test, and normality test used Shapiro-wilk test
basic exercises, breathing, and stretching because the number of respondents was less
which is different from breathing techniques than 50.
in Yoga. Poses performed differently, which
more with sitting position upright and
crawling to stretch the lower back muscles. RESULTS
This exercise was done by a midwife in the Normality test
Community Health Center of Garung. The results of Shapiro Wilk test as shown in
the Table 1 indicated that lower back pain and
Instrument functional capabilities in the three groups
Back pain was measured using a Visual were in normal distribution with p-value
Analog Scale (VAS) adopted from (Rosyida, >0.05.
Table 1 Normality test on lower back pain and functional capability before and after given intervention using
Shapiro Wilk
Group
Yoga Acupressure Control
Variable
(p-value) (p-value) (p-value)
Pretest Posttest Pretest Posttest Pretest Posttest
Back Pain 0.251 0.057 0.683 0.504 0.271 0.251
0.809 0.297 0.120 0.539 0.064 0.223
capability
Homogeneity test F 0.629 and p= 0.893 (>0.05), which

Levene’s test as shown in the Table 2 showed indicated that the group of yoga, acupressure
back pain variable with F = 3.192 and p= and control group were homogenous.
0.052 (>0.052), and functional capability with
Table 2 Homogeneity test on lower back pain and functional capability using Levene’s test
Variable F P-value
Back Pain 3.192 0.052
0.629 0.893
capability
!
Table 3 Characteristics of respondents based on age, employment status, parity, and body weight
Group
Intervention Control
Variable P-value
Yoga Acupressure Pregnancy exercise
n (%) Mean±SD n (%) Mean±SD n (%) Mean±SD
Age (year)
" <19 0 (0) 1(7.1) 2 (14.3) 0.590
" 20-35 13(92.9) 11(78.6) 10 (71.4)
" >36 1 (7.1) 2 (14.3) 2 (14.3)
Employment status
" Employed 5 (35.7) 6 (42.9) 11 (78.6) 0.253
" Unemployed 9 (64.3) 8 (57.1) 3 (21.4)
Parity
" Primipara 6 (42.9) 6 (42.9) 5 (35.7) 0.906
" Multipara 8 (57.1) 8 (57.1) 9 (64.3)
Body weight 60.164±8.72 61.86±8.67 58.71±4.87 0.102
Table 3 shows that there were no significant (p=0.590), employment status (p=0.253),
differences of the characteristics of parity (p=0.906), and body weight (p=0.102).
respondents in the three groups based on age
Difference of lower back pain before and after given intervention

Table 4 Difference of lower back pain before and after given intervention
Pregnancy
Variable Yoga Acupressure p-value
exercise
Mean±SD Mean±SD
Mean±SD
Lower Pretest 4.14±1.127 4.93±2.056 4.86±1.562 0.3682
back pain Postest 2.71±1.204 2.64±1.646 2.14±1.027 0.4652
p-value 0.0001 0.0001 0.0001
Mean
-1.43±0.852 -2.29±0.914 -2.71±1.069 0.0002
difference
1
Table 4 shows that the mean of lower back

pain in the yoga group before given The mean of lower back pain in the control
intervention was 4.14 ± 1.127, and decreased group before given intervention was 4.86 ±
to 2.71 ± 1.207 after the intervention, and the 1.56, and decreased to 2.14 ± 1.02 after
mean difference of pain levels before and intervention. The mean difference of pain
after intervention was -1.43. The results of level before and after intervention was -2.71.
Paired t-test obtained p-value 0.000, which Paired t-test showed p-value 0.000, which
indicated that there was a significant effect of indicated that there was a significant decrease
yoga in decreasing back pain level. The mean of lower back pain after given pregnancy
of lower back pain in the acupressure group exercise. One way anova test obtained p-
before given intervention was 4.93 ± 2.056, value 0.000, which indicated that yoga,
and decreased to 2.64 ± 1.646 after the accupressure, and pregnancy exercise have a
intervention, and the mean difference between significant effect in reducing lower back pain
pain levels before and after intervention was - in pregnant women. However, the mean
2.29. Paired t-test showed p-value 0.000, difference in pregnancy exercise group
which indicated that there was a significant showed a higher decrease of pain level
effect of acupressure in lowering back pain. compared with yoga and acupressure group.

!
Difference of lower back functional capability before and after given intervention
Table 5 Difference of lower back functional capability before and after given intervention
Pregnancy
Variable Yoga Acupressure P-value
exercise
Mean±SD Mean±SD
Mean±SD
Lower back functional Pretest 32.14±13.091 36.29±12.048 31.14±13.421 0.5392
capability Postest 25.57±10.383 22.00±7.104 17.86±5.736 0.0482
1 1 1
p-value 0.009 0.000 0.000
Mean -6.57±7.978 -14.29±6.510 -13.29±9.15 0.0292
difference
1
Table 4 shows that the mean of lower back capability. One way anova test obtained p-
functional capability in the yoga group before value 0.029, which indicated that yoga,
given intervention was 32.14 ± 13.091, and accupressure, and pregnancy exercise have a
after intervention was 25.57 ± 10.383, and the significant effect in increasing lower back
mean difference of lower back functional functional capability in pregnant women.
capability before and after intervention was - However, the mean difference in accupressure
6.57 ±7.978. The results of Paired t-test group showed a higher increase of back
obtained p-value 0.009, which indicated that functional capability compared with yoga and
there was a significant effect of yoga on lower control group.
back functional capability. While the mean of
lower back functional capability in the Table 6 shows that there was a significant
acupressure group before given intervention difference of pain level between yoga and
was 36.29 ± 12.048, and after intervention pregnancy exercise group with mean value
was 22.00 ± 7.104, and the mean difference 1.500 and p-value 0.000 (<0.05); and between
between lower back functional capability yoga and acupressure group with mean value -
before and after intervention was -14.29 1.071 and p-value 0.013 (<0.05). There was
±6.510. Paired t-test showed p-value 0.000, no significant difference between acupressure
which indicated that there was a significant and pregnancy exercise with p-value 0.697
effect of acupressure on lower back functional (>0.05).
capability.
For lower back functional capability, post hoc
The mean of lower back functional capability test showed a significant difference between
in the control group before given intervention yoga and acupressure with mean 7.714 and p-
was 31.14 ± 13.421, and after intervention value 0.042 (<0.05). There was no significant
was 17.86 ± 5.736. The mean difference of difference between yoga and pregnancy
lower back functional capability before and exercise with mean 6.714 and p-value 0.094
after intervention was -13.29 ±9.15. Paired t- (> 0.05), and between acupressure and
test showed p-value 0.000, which indicated pregnancy exercise with p-value 1.000
that there was a significant effect of (>0.05).
pregnancy exercise on lower back functional
Table 6 Mean difference of lower back pain and functional capability using post hoc test
Mean
Difference
Lower back pain Yoga vs pregnancy exercise 1.500 0.000
Acupressure vs pregnancy exercise 0.429 0.697
Yoga vs acupressure -1.071 0.013
Lower back functional Yoga vs acupressure 7.714 0.042
capability Yoga vs pregnancy exercise 6.714 0.094
Acupressure vs pregnancy exercise -1.000 1.000
!
DISCUSSION poor yoga movements. In addition, different

Effect of yoga on lower back pain and instructors in yoga group and pregnancy
functional capabilities compared with exercise group might be one of factors. In
pregnancy exercise pregnancy exercise, the instructor was the
The results showed that there was a midwife of the health center itself so that the
significant effect of yoga on the decrease of respondents were easily to communicate and
lower back pain. Back pain in pregnancy is more comfortable, while a yoga instructor was
the pain that occurs in the lumbosacral area. not a midwife who was not yet known by the
This is in line with previous study stated that respondents. Pregnancy exercise is one of the
alternative treatments to reduce low back pain activities in the prenatal care service during
in pregnancy were massage (61.4%), pregnancy to provide better pregnancy or
acupuncture (44.6%), yoga (40.6%) and delivery compared with pregnant women who
chiropractic (36.6%) (Wang et al., 2005). do not do pregnancy exercises (Thompson,
Yoga is one form of exercises that can be 2004). This is in accordance with previous
done by pregnant women. Yoga can make the research revealed the effectiveness of
body more flexible and comfortable in pregnancy exercise on decrease of back pain
addition to supporting blood circulation, in pregnant mother at the Community Health
overcoming back pain, waist, aches and Center of inpati Karya Wanita Pekanbaru with
swelling (Kozier, 2008). Doing yoga routinely p-value 0.001 (<0.05) (Lebang, 2014).
can increase ability to stand better, walk
longer, run faster and all done without leaving Effect of acupressure on lower back pain
the pain after doing so. The function and and functional capabilities compared with
efficacy of yoga can overcome problems pregnancy exercise
related to the anatomical functions of the body Findings showed that there was a significant
(Brayshaw, 2007). This study also revealed effect of acupressure on lower back pain and
that there was a significant effect of Yoga in functional capabilities. It proves that
the improvement of lower back functional acupressure is a healing technique by
capability. pressing, massaging, massage the body to
activate the circulation of energy.
However, in this study, pregnancy exercise
was more effective in reducing lower back Acupressure is one of the traditional
pain and improving functional capability in treatments by doing massage on acupuncture
pregnant women compared with yoga. points. Acupressure enhances body relaxation
However, it does not mean that yoga has no and creates positive thoughts (Mander, 2003).
effect to decrease the lower back pain level Acupressure is powerful to alleviate
and increase functional capability, but there discomfort and working greatly in improving
are several factors that can affect the decrease mother’s mental and emotional well being
of pain level in the yoga group, one of which because of the key to learning disorders and
is the environment. The physical environment emotional trauma. Emphasizing in the
has an influence on human thoughts, feelings, acupressure points could improve blood
and behavior. Environment is stimuli from the circulation and stimulate the release of
outside that can be responded by the system endorphin hormones (Khomsah et al., 2017).
of the five senses of human (sight, hearing, This is line with previous study revealed that
tasting, smell and touch), where acupressure could reduce lower back pain by
psychologically potentially form a perception 86%, and more effectively when combined
that indirectly affects the emotional and with psychotherapy (Wang et al., 2005).
human behavior. Supported by another study stated that
acupressure can effectively build a weak body
Physical environment referred to in this study and increase muscle strength and range of
is that during the implementation of yoga upper extremity motion in stroke patients. The
where 14 respondents with a narrow room results of this study revealed that acupressure
will cause uncomfortable feelings, and there was more effective in improving lower back
was a sense of stuffy and hot and lack of functional capability compared with yoga and
ventilation for air circulation that will cause pregnancy exercise (Pravikasari, 2014).

!
CONCLUSION HEALTH CENTER OF KAWUNGANTEN,

It is concluded that there was a significant CILACAP, INDONESIA. Belitung Nursing
Journal, 3(5), 508-514.
effect of yoga and acupressure in reducing Kozier, B. (2008). Fundamentals of nursing: concepts,
lower back pain and improving functional process and practice: Pearson Education.
capability of lower back. Therefore, it is Lebang, E. (2014). Yoga atasi backpain: Puspa Swara.
recommended for midwife to use these Mander, R. (2003). Nyeri persalinan (Labor Pain).
Jakarta: Penerbit Buku Kedokteran EGC.
interventions as an alternative to deal with Pravikasari, N. A. (2014). Perbedaan Senam Hamil dan
back pain and functional capability. Teknik Akupresur Terhadap Penurunan Nyeri
Punggung Bawah pada Ibu Hamil Trimester
III. Program Pascasarjana Undip.
REFERENCES Rosyida, D. A. C., Suwandono, A., Ariyanti, I.,
Mashoedi, I. D., & Fatmasari, D. (2017).
Ansari, N. N., Hasson, S., Naghdi, S., Keyhani, S., &
COMPARISON OF EFFECTS OF
Jalaie, S. (2010). Low back pain during
ABDOMINAL STRETCHING EXERCISE
pregnancy in Iranian women: Prevalence and
AND COLD COMPRESS THERAPY ON
risk factors. Physiotherapy Theory and
MENSTRUAL PAIN INTENSITY IN
Practice, 26(1), 40-48.
TEENAGE GIRLS. Belitung Nursing Journal,
Brayshaw, E. (2007). Senam hamil dan nifas: Jakarta:
3(3), 221-228.
EGC.
Thompson, J. (2004). Kehamilan dari Pembuahan
Hingga Kelahiran: Jakarta: Dian Rakyat.
McGraw-Hill.
Dase, R. N. T., RphD, C. H., BmedsSc, M., & PgChep,
Wang, S.-M., Zinno, P. D., Fermo, L., William, K.,
M. (2014). How do women manage
Caldwell-Andrews, A. A., Bravemen, F., &
pregnancy-related low back and/or pelvic
Kain, Z. N. (2005). Complementary and
pain? Descriptive findings from an online
alternative medicine for low-back pain in
survey. Evidence Based Midwifery, 12(3), 76.
pregnancy: a cross-sectional survey. Journal
Fairbank, J. C. T., & Pynsent, P. B. (2000). The
of Alternative & Complementary Medicine,
Oswestry disability index. Spine, 25(22),
11(3), 459-464.
2940-2953.
Cite this article as: Resmi, D. C., Hadisaputro, S., Runjati. (2017). Effect of yoga and acupressure on
pain and functional capability of lower back in pregnant mothers during the third trimester of
pregnancy. Belitung Nursing Journal, 3(6), 722-728.
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Nurjannah I, et al. Belitung Nursing Journal. 2017 December;3(6):729-734

CLINICAL INDICATORS OF FEEDING SELF-CARE DEFICIT BASED ON

BARTHEL INDEX MEASUREMENT IN PATIENTS SUFFERING FROM
STROKE
Intansari Nurjannah1*, Vini Febriyani Zulfa2, Dwi Harjanto3, Erna Fitriana4, Ngatini4
1
Associate Professor, Mental Health and Community Department, Faculty of Medicine,Universitas Gadjah Mada, Indonesia
2
Nursing Student, School of Nursing, Faculty of Medicine, Universitas Gadjah Mada, Indonesia
3
Mental Health and Community Department, Faculty of Medicine, Universitas Gadjah Mada, Indonesia
4
Clinical Nurse, Sardjito Central Hospital, Yogyakarta, Indonesia
*Correspondence:
Intansari Nurjannah, S.Kp., MN.Sc., Ph.D
Psychiatric and Community Nursing Department,
Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
E-mail: intansarin@ugm.ac.id
Abstract
Objective: This aim of this research is to describe clinical indicators of feeding self-care deficit based on Barthel Index
measurement in patients with stroke.
Methods: The research used a quantitative description study with cross-sectional design. This research was conducted in one
hospital in Yogyakarta, Indonesia on March – April 2017 with total sampling technique. Instrument was developed based on
clinical indicators of NANDA-I nursing diagnosis of feeding self-care deficit.
Results: There were 28 respondents involved in this study, with males (60.7%) and females (39.3%) with an average age of
57 years. Respondents who suffered from non-hemorrhagic stroke were 60.7% and hemorrhagic stroke were 39.3%. Clinical
indicator items for impaired ability to swallow sufficient amount of food (9.1%) was found in respondents with
independency criteria on Barthel Index. Impaired ability to swallow sufficient amount of food item (25%) and impaired
ability to prepare food (25%) were found in respondents with partial dependency criteria. The most items identified on
respondents with severe dependency criteria were impaired ability to self-feed a complete meal item (53.8%) and impaired
ability to prepare food item (53.8%).
Conclusion: There were different pattern of clinical indicators items found in different level of Barthel index level criteria.
Keywords: Clinical indicators, Nursing Diagnosis, Barthel Index, Stroke
INTRODUCTION
Stroke is rising up in numbers every year Kesehatan Kesehatan RI, 2013). This proved
proportionally with older age and certain risk that stroke cases in Yogyakarta is rising and
factors. Based on Indonesia’s data of basic needs significant attention from healthcare
health research, the prevalence of Indonesian professionals. Between 1990 to 2013, there is
that had been diagnosed as stroke by doctors a rising number of disabilities caused by
were 57.9%. Stroke prevalence in Yogyakarta ischemic stroke and death by ischemic and
is striking in second place (10.3%) after North hemorrhagic stroke (Feigin et al., 2015;
Celebes (10.8%) (Kementerian Kesehatan World Stroke Organization, 2016).
Kesehatan RI, 2013). The Indonesia’s data of
basic health research shows that prevalence of Stroke is caused by interruption of blood
stroke was 7.1% in Yogyakarta (Kementerian supply to the brain, mostly because of the

!
!
blood artery either broken or obstructed by Participants

mass on arterial wall causing nutrition and There were 28 samples recruited using total
oxygen supply are disturbed (World Health sampling technique in one hospital in
Organization, 2014). Stroke shows symptoms Yogyakarta. The inclusion criteria of the
such as face muscles paralysis, speaking sample were patients with stroke with
articulation problem, change in consciousness Barthel’s index score 1 in feeding function
status, and visual problem on eyes item. Exclusion criteria of the sample were
(Kementerian Kesehatan Kesehatan RI, unconscious, dysphagia, and patients who left
2013). hospital before they had permission to be
discharged.
Based on prominent symptoms, it is well-
noted that stroke patients definitely will have Measures
many difficulties in doing their daily This study used instruments of Barthel’s
activities, moving from one-point-to-another index and clinical indicator of nursing
and even a simple self-caring for example in diagnosis of feeding self-care. These
feeding themselves (Mark, 2016). Feeding instruments were developed and arranged
difficulty by definition is a difficulty in based on clinical indicators of nursing
fulfilling feeding function independently, diagnosis NANDA-I taxonomy by researchers
including in preparing the food and/or in checklist form and structured interview for
beverages (Klinke, Wilson, Hafsteinsdóttir, & data collecting technique. Total score of
Jónsdóttir, 2013). Self-care is actions that Barthel’s index ranged from 0 to 20,
brings patient to healthier lifestyle, able to consisting of independent, partial dependent,
maintain long-term condition, and to prevent severe dependent, and total dependent level of
from further incoming diseases criteria, with Guttman scale with score 1 for
(Woldemariam, 2013). Self-care deficit on “yes” answer and 0 for “no” of stroke clinical
stroke patients (walking, getting dressed, and indicators on patients. Clinical indicators
eating) happens in daily basis with or without instrument were checked by 3 experts for
help from others. One parameter used for content of validity before data sampling was
calculating the quality of independency of taken, and the result was valid (I-CVI = 1& S-
patients is Barthel’s index. CVI =1). Clinical indicators instrument using
reliability test with formula KR20 and the
Feeding function in stroke patients is based on result was 0.8751, which means this
nursing diagnosis of NANDA-1 as feeding instrument was reliable with value >0.70
self- care deficit. However, in NANDA-I (Sabri, 2013).
taxonomy, nursing diagnosis has clinical
indicator that is different from Barthel’s index Data Collection
in feeding function item. It takes further Data were collected in two months by nurses
research of nursing diagnosis to identify who were working in this stroke unit hospital.
clinical indicator to achieve a more accurate Nurses firstly screen patients using inclusion
nursing diagnosis based on patient’s and exclusion criteria and interview patients
responses. Furthermore, it is still a few using research instrument.
research about clinical indicator of nursing
diagnosis of feeding function (Pascoal et al., Data Analysis
2014). Data analysis in this research using univariate
analysis to recognize respondents
characteristic, the category of stroke,
METHODS respondents grouping into criteria in Barthel’s
Design indexing score, and the frequency distribution
This was a descriptive-quantitative research of clinical indicators of nursing diagnosis
with cross-sectional design. NANDA-I taxonomy feeding self-care deficit.
Data processing was done by computer.
Setting
This study was conducted in one hospital in
Yogyakarta from March to April 2017.

RESULTS hemorrhagic stroke than hemorrhagic stroke

The majority of respondents were males with (see Table 2). The most dominant criteria of
average age of 57.46 years old (SD±12,66). Barthel index was severe dependent followed
Most respondents were government employee by independent and partial dependent (see
with university background (see Table 1). Table 3 and Table 4).
More patients were suffering from non-
Table 1 Frequency distribution of respondents’ characteristic in patients with stroke (n=28)

Characteristic Mean ± SD Frequency (f) Percentage (%)
Age
17 – 25 years old 57.46 ± 12.66 1 3.6
26 – 35 years old 0 0
36 – 45 years old 3 10.7
46 – 55 years old 6 21.4
56 – 65 years old 12 42.9
>65 years old 6 21.4
Sex
Female 11 39.3
Male 17 60.7
Education
College 8 28.6
High school 6 21.5
Junior High 4 14.3
Elementary School 6 21.4
No school 4 14.3
Occupational Status
Employed 15 53.6
Unemployed 13 46.4
Civil status
Single 1 3.6
Married 23 82.1
widowed 1 3.6
widow 3 10.7
Stroke Classification
Hemorrhagic 11 39.3
Non-Hemorrhagic 17 60.7
Total 28 100
Table 2 The percentage of respondents with hemorrhagic and non-hemorrhagic stroke in every criteria of
Bathel’s index in the Stroke unit (n=28)
Criteria of Barthel’s index in Stroke Unit (%)
Severe
Stroke Classification Independent Partial dependent Total
Dependent
(n=11) (n=4) (%)
(n=13)
Stroke Hemorrhagic 27.3 18.2 54.5 100
Stroke Non Hemorrhagic 47.1 11.8 41.2 100
Table 3 Frequency distribution of patients with stroke in each category of Barthel’s index (n=28)
Gender
Indexing criteria of
Score Range of Percentage Number of
Barthel’s index in Mean ± SD
Barthel’s Index (%) respondents
Stroke Unit
M F
Independent 15 – 20 81.8 18.2 11 18.36 ± 1.57
Partial dependent 11 – 14 50 50 4 13± 1.16
Severe dependent 1 – 10 46.2 53.8 13 7.15 ± 2.04
Total dependent 0 0 0 0 0
Total 100 100 28 38.51 ± 4.77

!
Table 4 Average of total score in each criteria of Barthel’s index in stroke classification of patients with
stroke in stroke unit in 2017 (n=28)
Barthel’s index criteria (Mean ± SD)
Stroke
Independen Partial Dependent Severe dependent
Classification
t (n=11) (n=4) (n=13)
Hemorrhagic 18.67 ± 1.15 13 ± 1.41 7.33 ± 2.65
Non-hemorrhagic 18.63 ± 1.51 13 ± 1.41 7 ± 0.58
Table 5 Frequency Distribution of clinical indicators of nursing diagnosis of feeding self-care deficit in
Barthel’s index criteria in patients with stroke
Barthel Index Criteria
No. Items of Clinical indicators Partial Severe
Independent
(%) Dependent (%) dependent (%)
(n=11)
(n=4) (n=13)
1 Inability of eating in acceptable 0 0 0 0 1 7.7
way
2 Inability of eating in enough 1 9.1 1 25 2 15.4
amount of food
3 Inability to manipulate food in 0 0 0 0 3 23.1
the mouth
4 Inability to open food case 0 0 0 0 4 30.8
5 Inability to handle eating tools 0 0 0 0 4 30.8
6 Inability to swallow food 0 0 0 0 0 0
7 Inability to place food in/on 0 0 0 0 5 38.5
food tools
8 Inability to hold the cup 0 0 0 0 5 38.5
9 Inability to take the food and 0 0 0 0 4 30.8
put into mouth
10 Inability in using assist tools 0 0 0 0 4 30.8
11 Inability to finish meal portion 0 0 0 0 7 53.8
12 Inability to chew the food 0 0 0 0 0 0
13 Inability to prepare food to eat 0 0 1 25 7 53.8
DISCUSSION
The number of respondents in this research Stroke classification data shows that
was 28 patients. Most respondents aged respondents suffering from non-hemorrhagic
between 56 to 65 years, male, and married. stroke events were 17 patients (60.7%), and
Data from basic health research (Kementerian from hemorrhagic stroke were 11 patients
Kesehatan Kesehatan RI, 2013) stated that (39.3%). The research of Rachmawati, et al
citizen diagnosed with stroke are increasing shows that most respondents suffered from
accordingly with age (Kementerian Kesehatan non-hemorrhagic stroke, 28 patients (56%),
Kesehatan RI, 2013). Data from Riskesdas and hemorrhagic stroke was 22 patients (44%)
also stated that male and female have the (Rachmawati et al., 2013). Patients who
same prevalence. Married males have bigger suffered from non-hemorrhagic stroke are 171
case incidence of stroke compare with patients and followed by hemorrhagic stroke
females due to gender social experiences such of 70 patients. Non-hemorrhagic stroke is
as marriage history and social economy more common due to lifestyle that harmful to
(Rachmawati, Utomo, & Nauli, 2013). Based health in the community such as high-
on previous research, the highest number of cholesterol consumption, smoking and
stroke patients has college degree and alcohol-drinking habit in long term that will
working employee. Research also shows that cause plaque obstruction in blood vessels that
stroke are more common in society with lower obstruct blood supply (Rachmawati et al.,
education and unemployed (Rachmawati et 2013). One survey shows that high
al., 2013). temperature can be a risk factor for ischemic
or non-hemorrhagic stroke (Wang et al.,

2016). Lower temperature will cause criteria in Barthel’s index, except 2 items of
vasoconstriction, blood pressure and clinical indicators, namely inability to chew
thrombocyte aggregation increasing, and the food and inability to swallow the food.
activation of sympathy neural system that Condition of a few patients with these criteria
cause the increasing risk of stroke (Chen et are still weak including the extremities that
al., 2017). supposed to be helped these patients to eat
their food.
The result of this study shows that criteria of
severe dependent dominantly were on patients One of the causes of this feeding inability is
with hemorrhagic stroke, and independent on hemiparesis (Xiong et al., 2012). Hemiparesis
patients with non-hemorrhagic stroke. No is common in patients with stroke.
respondent was in total dependent since Hemiparesis is a neurological deficit that
researchers put it in the exclusion criteria. causes weakness on one side of the body and
Previous research has respondents of 50 this condition makes the patient unable to
patients and divided Barthel’s index into 5 maintain balance in activities (Dhiman et al.,
criteria and using a modified Barthel’s index 2014). This imbalance will affect patients in
with score between 0 to 100 (Chen et al., sitting, moving from one place to another,
2017). The identified criteria include total joints articulation, and standing straightly
dependent of 39 patients (78%), medium (Dhiman et al., 2014). Sitting position is not a
dependent of 8 patients (16%), and mild functional but it is an essential component that
dependent of 3 patients. No patient was is believed to be able to support another
categorized as independent (Rakhman, 2014). functional activities, such as getting dressed,
Dhiman et al (2014) research on 130 moving, and eating on sitting position
respondents also divided total score of (Morone et al., 2015). Dhiman et al (2014)
Barthel’s index criteria into 4, namely total research shows that there are no differences
dependent (0-4) with 49 respondents, severe between lesion of right hemiparesis or left
dependent (5-9) with 30 respondents, medium one. Each lesion affects patient’s dependency
dependent (10-14) with 34 respondents, and and fulfilling daily activities including eating
mild dependent (15-19) with 17 respondents (Dhiman et al., 2014).
(Dhiman et al., 2014). This research also
shows higher number on respondents with Stroke will lead patients into disability, and
criteria partial dependent. Nevertheless, the disability can be changed if patients change
higher of Barthel score, the lesser are the their lifestyle. Disabilities in stroke patients
respondents (Maselko, Bates, Avendano, & are marked with paralysis on extremities
Glymour, 2009). Observation on Morone et al including hemiparesis, blood pressure
(2015) research shows that patients with increasing, and aging. Disabilities will make
hemorrhagic stroke have better outcome of patients dependent in fulfilling daily activities
functional status based on total score of including feeding activity (Xiong et al., 2012).
Barthel’s index compared with non- Furthermore, stroke patients will increasingly
hemorrhagic stroke patients. This is different show progress on functional status in feeding,
with the result of this research which non- get dressed, go to toilet, and do make-up if
hemorrhagic stroke patients have higher given continuous rehabilitation therapy earlier
percentage in independent criteria than since treated in hospital (Oyewole, Ogunlana,
hemorrhagic stroke patients (Dhiman et al., Oritogun, & Gbiri, 2016).
2014). The research of Xiong et al (2012)
shows that patients with acute ischemic stroke CONCLUSION
or non-hemorrhagic were due to bad There are different patterns of clinical
functional status. indicators based on Barthel index
measurement.
Stroke respondents with independent criteria
show clinical indicators that the same as REFERENCES
respondents with partial dependent criteria in Chen, J., Jiang, H., Wu, L., Liao, X., Lu, Y., Tao, X., . .
Barthel’s index. All clinical indicators item . Huang, H. (2017). Association of ischemic
and hemorrhagic strokes hospital admission
appeared on stroke patients with dependent

!
with extreme temperature in Nanchang, respiratory infection. International journal of

China—A case-crossover study. Journal of nursing knowledge, 25(1), 54-61.
Clinical Neuroscience. Rachmawati, F., Utomo, W., & Nauli, F. (2013).
Dhiman, N., Shah, G., Joshi, D., & Gyanpuri, V. (2014). Gambaran Status Fungsional Pasien Stroke
Relationship between side of hemiparesis and Saat Masuk Ruang Rawat Inap RSUD Arifin
functional independence using activities of Achmad. Jurnal Publikasi. Pekanbaru:
daily living index. Journal of the Anatomical Program Studi Ilmu Keperawatan Universitas
Society of India, 63, S30-S35. Riau.
Feigin, V., Krishnamurthi, R., Barker-Collo, S., Rakhman, A. (2014). Buku Panduan Praktek
Norrving, B., Bennet, D., & Truelsen, T. Laboratorium Ketrampilan Dasar Dalam
(2015). Update on The Global Burden of Keperawatan II (KDDK II: Deepublish.
Ischemic and Hemorrhagic Stroke in 1990- Sabri, S. (2013). Item analysis of student comprehensive
2013 : The GBD 2013 study. test for research in teaching beginner string
Neuroepidemiology, 45(3), 161-176. ensemble using model based teaching among
Kementerian Kesehatan Kesehatan RI. (2013). music students in public universities.
Riskesdas. Riset Kesehatan Dasar. Jakarta: International Journal of Education and
Kesehatan Kementerian Kesehatan. Research, 1(12), 1-14.
Klinke, M., Wilson, M., Hafsteinsdóttir, T., & Wang, X., Cao, Y., Hong, D., Zheng, D., Richtering, S.,
Jónsdóttir, H. (2013). Recognizing new Sandset, E., . . . Salam, A. (2016). Ambient
perspectives in eating difficulties following temperature and stroke occurrence: a
stroke: a concept analysis. Disability and systematic review and meta-analysis.
rehabilitation, 35(17), 1491-1500. International journal of environmental
Mark, V. (2016). Stroke and behavior. Neurologic research and public health, 13(7), 698.
clinics, 34(1), 205-234. Woldemariam, Y. (2013). Exploring of stroke survivors’
Maselko, J., Bates, L., Avendano, M., & Glymour, M. information needs for an Information and
(2009). The intersection of sex, marital status, Communication Technology based home
and cardiovascular risk factors in shaping stroke rehabilitation plan to facilitate self-
stroke incidence: results from the health and care. Master thesis.
retirement study. Journal of the American World Health Organization. (2014). Stroke,
Geriatrics Society, 57(12), 2293-2299. Cerebrovascular accident. 2017, from
Morone, G., Paolucci, S., & Iosa, M. (2015). In What http://www.who.int/topics/cerebrovascular_ac
Daily Activities Do Patients Achieve cident/en/
Independence after Stroke? Journal of Stroke World Stroke Organization. (2016). Face the Facts:
and Cerebrovascular Diseases, 24(8), 1931- Stroke is Treatable. 2017, from
1937. http://www.worldstrokecampaign.org/learn/fa
Oyewole, O., Ogunlana, M., Oritogun, K., & Gbiri, C. ce-the-facts-stroke-is-treatable.html
(2016). Post-stroke disability and its predictors Xiong, L., Leung, H., Chen, X., Han, J., Leung, T., Soo,
among Nigerian stroke survivors. Disability Y., . . . Wong, K. (2012). Preliminary findings
and health journal, 9(4), 616-623. of the effects of autonomic dysfunction on
Pascoal, L., Lopes, M., da Silva, V., Beltrão, B., Chaves, functional outcome after acute ischemic
D., de Santiago, J., & Herdman, T. (2014). stroke. Clinical neurology and neurosurgery,
Ineffective breathing pattern: defining 114(4), 316-320.
characteristics in children with acute
Cite this article as: Nurjannah, I., Zulfa, V.F., Harjanto, D., Fitriana, E., Ngatini. (2017). Clinical
indicators of feeding self-care deficit based on Barthel index measurement in patients suffering from
stroke. Belitung Nursing Journal, 3(6), 729-734.

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Dayyana S, et al. Belitung Nursing Journal. 2017 December;3(6):735-742

EFFECTIVENESS OF MUSIC THERAPY ON ANXIETY AND

Β-ENDORPHIN LEVELS IN PRIMIGRAVIDA DURING THE THIRD STAGE
OF PREGNANCY
Surya Dayyana1*, Suryono2, Melyana Nurul Widyawati1, Syarief Thaufik Hidayat3,
Suryati Kumorowulan1
1
2
Instrumentation and Electronic Laboratory, Physic Department, Faculty of Science and Mathematic, Diponegoro University
of Semarang, Indonesia
3
*Correspondence:
Surya Dayyana
Email: suryadayyana44@gmail.com
Abstract
Objective: To examine the effectiveness of music therapy on anxiety levels and β-endorphin levels in primigravida during
the third stage of pregnancy.
Methods: This was a quasy experimental study with pretest-posttest control group design. The research was conducted in
December 2016 - Januari 2017. There were 39 respondents selected using purposive sampling technique, which 13 assigned
in the experiment group 1 (music therapy with a sound pressure of 40 dB), experiment group 2 (music therapy with a sound
pressure of 62 dB) and control group (health counseling). Anxiety levels were measured using the HARS (Hamilton Anxiety
Rating Scale), and β-endorphin hormone levels were measured using ELISA (Enzyme-Linked Immunosorbent Assay)
method. Data analysis used paired t-test, One-Way Anova test with post-hoc bonferroni, and Kruskall Wallis test with post-
hoc Mann Whitney.
Results: Findings revealed that there was a decrease of the mean of anxiety levels in the experiment group 1 from 31.92
(pretest) to 24.69 (posttest), and the experiment group 2 from 34.54 (pretest) to 25 (posttest) with p-value <0.05; and there
was an increase of the mean of β-Endorphin levels in the experiment group 1 from 53.63 (pretest) to 63.24 (posttest), and the
experiment group 2 from 48.55 (pretest) to 64.9 (posttest) with p-value <0.05; however there was no effect of counseling in
the control group on anxiety levels (p=0.413) and β-Endorphin levels (p= 0.394)
Conclusion: Music therapy is effective in reducing anxiety levels and increasing β-endorphin levels. Thus, music therapy
can be used as an alternative treatment for pregnant mothers at home who experienced anxiety.
Keywords: Music Therapy, Anxiety, Β-Endorphin, Pregnant Women
INTRODUCTION
During pregnancy, pregnant women complications during childbirth or after
experience some changes in both physical and delivery. Primigravida Pregnant women have
psychological changes. The changes that more experienced anxiety when compared
occur during pregnancy can cause discomfort with multigravida pregnant women. The
and anxiety during pregnancy. The anxiety anxiety experienced during the first and third
experienced by pregnant women especially trimesters of pregnancy is more severe than
during the third trimester is associated with a anxiety during the second trimester of
sense of worry about maternal and fetal pregnancy (Giakoumaki, Vasilaki, Lili,
health, such as the fear of childbirth, fear if Skouroliakou, & Liosis, 2009; Lee et al.,
the fetus is born disabled and if there are

!
2007; Teixeira, Figueiredo, Conde, Pacheco, Wong, & Thayala, 2011; Cook & Silverman,
& Costa, 2009). 2013; Hatem, Lira, & Mattos, 2006; Richards,
Johnson, Sparks, & Emerson, 2007). The use
Anxiety accompanied by negative thoughts of music therapy can reduce the anxiety level
can lead to an increase in sympathetic nerve in pregnant women during transvaginal
work, activating the hypothalamus-pituitary to ultrasound examination (Shin & Kim, 2011).
release the hormones cortisol, epinephrine and Moreover, music therapy performed during
adrenaline in the body that trigger the heart to labor can lower the level of anxiety and
pump blood faster and heart rate grows postpartum pain, increased vaginal delivery
stronger and faster (Pawlby, Hay, Sharp, satisfaction and reduced postpartum
Waters, & O'Keane, 2009; Van den Bergh, depression (Simavli et al., 2014).
Van Calster, Smits, Van Huffel, & Lagae,
2008). Uncomfortable feeling, anxiety and The results of preliminary study at the
increased release of stress hormones will Community Health Center of Bandarharjo
adversely affect the health of pregnant women Semarang showed that there were 92
themselves and the health of the fetus, such as primigravida pregnant women in trimester III
increase the risk of delivering babies with low among 395 pregnant women. The results of
birth weight, premature birth, asthma, infant interviews with 10 primigravida pregnant
disease, autism, IUGR (Intrauterine Growth women indicated that there were 7 pregnant
Retardation) and postpartum stress (Ding et women who experienced anxiety with the
al., 2014; Grote et al., 2010; Littleton, Bye, existence of sleep disorders and worried if
Buck, & Amacker, 2010). delivery did not run smoothly. In addition, the
mothers also worried if the baby was not
Secretion of β-endorphin hormone in the body healthy. They also said that midwives had
can improve mood or change the mood, done counseling about labor preparations,
especially in pregnant women in the third however, most of them were still feeling
trimester who experience anxiety. Although anxiety. Therefore, this study aimed to
β-endorphin can be secreted naturally in the examine the effectiveness of music therapy on
body but β-endorphin can also be secreted anxiety levels and β-endorphin levels in
when the body and mind are in a state of primigravida during the third stage of
relaxation. One alternative that can be done to pregnancy.
stimulate the secretion of the hormone β-
endorphin is by doing music therapy
(Haruyama, 2015). METHODS
Study design
Music therapy is the use of music as This was a quasy experimental study with
complementary therapy with the aim to pretest-posttest control group design.
reduce or minimize diseases that affect the
physical, emotional and / or spiritual. Music is Settings
an effective coping mechanism for one's The research was conducted in the working
negative emotions (Hosseini, Bagheri, & area of the Community Health Center of
Honarparvaran, 2013). Musical stimulation is Bandarharjo and the Community Health
processed by and through the brain (the limbic Center of Telogosari Kulon Semarang City in
system), which has a positive effect on nerve December 2016 - Januari 2017.
function and hormonal activity (Boso, Politi,
Barale, & Emanuele, 2006; Todres, 2006). Research Subjects
The calculation of the number of samples
Previous studies revealed that listening to used a paired numerical comparative sample
music in one period could help reduce formula. There were 39 respondents selected
symptoms of depression in adults. In addition, using purposive sampling technique and
music therapy can also improve relaxation, divided into 3 groups (2 groups of
mood, quality of life, and reduce stress and intervention and 1 control group) in which
anxiety. Structure in music can make the each group amounted to 13 respondents. The
patient feel comfortable and peaceful (Chan, distribution of respondents in the working
!
area of the Community Health Center of autonomic symptoms), with Likert scale 0 =
Bandarharjo was assigned as intervention never, 1 = rare, 2 = often, 3 = always. The
groups and respondents in the working area of questionnaire was adopted from previous
the Community Health Center of Telogosari study in Indonesian version with validity of r
Kulon assigned as control group (counseling). value of 0.39-0.79 and cronbach’s alpha was
The inclusion criteria of the sample in this 0.94 (Hawari, 2001). β-endorphin hormone
study were: 1) primigravida pregnant women levels were measured using ELISA (Enzyme-
during the third stage of pregnancy, 2) there Linked Immunosorbent Assay) method, as a
was no physical limitations and hearing biochemical technique mainly used in the
impairments, 3) no consuming cardiovascular field immunologists that utilize specific bonds
drugs, sedatives and related drugs, 4) willing between antibodies and antigens. Normal
to be a respondent. The exclusion criterion of values of β-endorphin hormone levels are
the sample was pregnant women with mental 0.01-100 ng/ml. Measurement of anxiety level
disorders. and β-endorphin hormone levels were done
two times, before and after intervention.
Intervention
Music therapy was given to the experiment Ethical consideration
groups. The experiment group 1 received Ethical approval was obtained from the
music therapy with sound pressure of 40 dB Research Ethics Committee of POLTEKKES
and the experiment group 2 received music Semarang with Number: 272/KEPK/
therapy with sound pressure of 62 dB. The Poltekkes-SMG/EC / 2016. The researchers
implementation of music therapy was done have confirmed that each respondent in this
for 30 minutes per day for 2 weeks at each study has signed an appropriate informed
respondent’s home to minimize the noise consent.
during therapy. The music therapy used Mp3
and speaker containing natural sound. A Data analysis
control group was given a counseling about Data analysis used paired t-test, One way
the inconvenience of a third trimester of Anova test with post hoc bonferroni, and
pregnancy and labor preparation. Counseling Kruskall Wallis test with post hoc Mann
begun with a material explanation by the Whitney.
researchers and then continued question and
answer and discussion between researchers
and respondents. Counseling was done at RESULTS & DISCUSSION
home of each respondent. Figure 1 shows that the average age of
respondents in the experiment group 1 was
Instrument 27.62 years old, experiment group 2 was 23
Anxiety levels were measured using the years old, and the control group was 24.62
HARS (Hamilton Anxiety Rating Scale) years old. This range of age is considered as
questionnaire introduced by Max Hamilton productive age. Thus, it could be said that
(Hamilton, 1960). HARS scale has been pregnant women with productive age had
proven to have high enough validity and more anxiety than pregnant women with
reliability. The questionnaire consisted of 13 unproductive age. However, age is one of the
items (feelings of anxiety, tension, fear, sleep factors that affect anxiety. Young age is more
disturbances, intelligence disorders, depressed prone to stress than old age (Akiki, Avison,
feelings, somatic symptoms, sensory Speechley, & Campbell, 2016; Thiagayson et
symptoms, cardiovascular symptoms, al., 2013). Homogeneity test showed p-value
respiratory symptoms, gastrointestinal >0.05 indicated that there was no different
symptoms, urogenital symptoms, and characteristic of respondent based on age.

!
30% 27.62%
23% 24.62%
25%
20%
15%
Age%(Year)%
10%
5%
0%
Figure 1 Characteristic of respondents based on age
Educational+level+
Elementary/Junior% Senior%high%school/University%level%
7% 8% 7%
6% 5% 6%
Figure 2 Characteristic of respondents based on educational level
Figure 2 shows that the respondents in the respondents in the control group had
experiment group 1 had elementary/junior elementary/junior high school background (6
high school background (7 people) and senior people) and senior high school and university
high school and university level (6 people), level (7 people). Homogeneity test showed p-
while respondents in the experiment group 2 value >0.05 indicated that there was no
had elementary/junior high school different characteristic of respondent based on
background (8 people) and senior high school educational level.
and university level (5 people), and
Family+income+
<%Rp%1.909.000% ≥%Rp%1.909.000%
9% 8%
6% 7%
4% 5%
Figure 3 Characteristic of respondents based on family income
Figure 3 shows that the majority of Homogeneity test showed p-value >0.05
respondents (24 people) in the three groups indicated that there was no different
had family income ≥ Rp. 1.909.000. characteristic of respondent based on family
!
income. Literature stated that educational because the three groups were homogeneous,
levels and family income are mediators that so the characteristics of respondents did not
affect maternal anxiety levels (Brandon et al., affect the outcome of this study.
2008; Lancaster et al., 2010). However,
paired t-test
Pretest 13 31.92 ± 0.57 21-42
Experiment 1 0.001
Posttest 13 24.69 ± 0.67 14-39
Pretest 13 34.54 ± 0.64 22-48
Experiment 2 0.000
Posttest 13 25 ± 0.65 14-39
Pretest 13 35.15 ± 2.7 23-53
Control 0.413
Posttest 13 40.49 ± 0.83 16-54
The results of paired t-test of anxiety level as anxiety levels from 34.54 (pretest) to 25
shown in the Table 1 showed there was a (posttest), with p-value <0.05, which
decrease of the mean of anxiety levels in the indicated that there was a statistically
experiment groups. The experiment group 1 significant effect of music therapy on anxiety
showed a decrease of anxiety levels from levels. There was no effect of counseling in
31.92 (pretest) to 24.69 (posttest), and the the control group on anxiety levels with p-
experiment group 2 showed a decrease of value 0.413 (>0.05)
using paired t-test
Pretest 13 53.63 ± 1.39 29.61-80.25
Experiment 1 0.027
Posttest 13 63.24 ± 1.42 34.15-92.14
Pretest 13 48.55 ± 1.61 24.58-99.31
Experiment 2 0.003
Posttest 13 64.9 ± 2.7 30.72-162.3
Pretest 13 56.14 ± 1.39 30.85-90.41
Control 0.394
Posttest 13 50.59 ± 1.24 27.74-90.88
The results of paired t-test of β-Endorphin control group was -1.23. It seems that the
levels as shown in the Table 2 showed there experiment group had a greater mean than the
was an increase of the mean of β-Endorphin other groups. P-value was 0.001 (<0.05)
levels in the experiment groups. The indicated that there was a significant
experiment group 1 showed an increase of β- difference of mean difference in anxiety
Endorphin levels from 53.63 (pretest) to 63.24 levels among the three groups.
(posttest), and the experiment group 2 showed
an increase of β-Endorphin levels from 48.55 While Kruskal Wallis test as shown in the
(pretest) to 64.9 (posttest), with p-value Table 3 shows that the mean difference of β-
<0.05, which indicated that there was a Endorphin levels before and after intervention
statistically significant effect of music therapy in the experiment group 1 was -7.23, the
on β-Endorphin levels. There was no effect of experiment group 2 was -10.85, and the
counseling in the control group on β- control group was -1.23. It seems that the
Endorphin levels with p-value 0.394 (>0.05). experiment group had a greater mean than the
other groups. P-value was 0.019 (<0.05)
While One way Anova test as shown in the indicated that there was a significant
Table 3 shows that the mean difference of difference of mean difference in β-Endorphin
anxiety levels before and after intervention in levels among the three groups.
the experiment group 1 was -7.23, the
experiment group 2 was -10.85, and the

!
Table 3 Mean difference of Effect of music therapy on anxiety levels and β-Endorphin levels of primigravida
during the third stage of pregnancy
Variable Group n Mean ± !" (min-max) p-value
Experiment 1 13 -7.23 ± 0.45 -15 – 2
Mean difference of
Experiment 2 13 -10.85 ± 0.52 -21 – 4 0.001
anxiety levels
Control 13 -1.23 ± 0.4 -12 – 6
Experiment 1 13 9.66 ± 1.06 -10.60 – 38.76
Mean difference of Β- Experiment 2 13 16.34 ± 1.24 -3.27 – 62.98 0.019
Endorphin level
Control 13 -5.53 ± 1.73 -30.68 – 40.76
post hoc bonferroni
Variable Group n Mean Different p-value
Experiment 2 13 3.615 0.410
Experiment 1
Control 13 -6.000 0.048
Experiment 1 13 -3.615 0.410
Anxiety levels Experiment 2
Control 13 -9,615 0.001
Experiment 1 13 6.000 0.048
Control
Experiment 2 13 9.615 0.001
using post hoc Mann Whitney
Variable Group p value
Experiment 1 Experiment 2 0.287
β-Endorphin
levels
Table 4 shows that there was no significant anxiety and endocrine system work. The
difference of the effect of intervention in the stimulation of music captured by the five
experiment group 1 and 2 (p=<0.05), while senses will be transmitted to the brain, which
there was a significant difference between the will affect the autonomic nervous system to
effect of intervention between the control decrease the work of the sympathetic nervous
group and experiment group 1 and 2 system and enhance the work of the
(p=>0.05); while Table 5 shows that there was parasympathetic system. So music can make a
no significant difference of the effect of person feel more relaxed and comfortable. In
intervention in the experiment group 1 and 2 addition, stimulation of music in the brain
with p-value 0.287 (>0.05), while there was a also affects the anterior pituitary work to
significant difference between the effect of suppress the production of catecholamine or
intervention between the control group and stress hormones (Chanda & Levitin, 2013;
experiment group 1 (p=0.034) and experiment Krout, 2007).
group 2 (p=0.012) on β-Endorphin levels.
The results of this study were in line with
The results of this study revealed that there previous research in which music therapy
was a significant effect of music therapy with could reduce the level of anxiety in pregnant
sound pressure of 40 dB and 62 dB on anxiety women, and postpartum mothers. The results
levels and β-Endorphin levels. Music therapy of previous studies showed that maternal
proved to be effective compared with anxiety levels were lower after given music
counseling in the control group in reducing therapy and there was a significant difference
anxiety levels and increasing the levels of β- in anxiety levels between the intervention and
Endorphin levels. control group (Chang, Chen, & Huang, 2008;
Lai et al., 2006; Shin & Kim, 2011; Simavli et
As literature stated that music therapy is one al., 2014; Yusuf et al., 2017).
of the non-pharmacological therapies that can
be used as one of the relaxation techniques This study provides the insight of evidence
that have a positive influence on the level of that music therapy with natural sound with
!
sound pressure 40 dB and 62 dB for 30 Giakoumaki, O., Vasilaki, K., Lili, L., Skouroliakou,
minutes in 2 weeks could reduce anxiety M., & Liosis, G. (2009). The role of maternal
anxiety in the early postpartum period:
levels and β-Endorphin levels in primigravida screening for anxiety and depressive
during the third stage of pregnancy. However, symptomatology in Greece. Journal of
further research is needed to examine the Psychosomatic Obstetrics & Gynecology,
variation of music pressure levels, duration 30(1), 21-28.
Grote, N. K., Bridge, J. A., Gavin, A. R., Melville, J. L.,
and frequency of the treatment. Iyengar, S., & Katon, W. J. (2010). A meta-
analysis of depression during pregnancy and
the risk of preterm birth, low birth weight, and
CONCLUSION intrauterine growth restriction. Archives of
It can be concluded that there was a general psychiatry, 67(10), 1012-1024.
Hamilton, M. (1960). A rating scale for depression.
significant effect of music therapy in reducing Journal of Neurology, Neurosurgery &
anxiety levels and increasing β-Endorphin Psychiatry, 23(1), 56-62.
levels in in primigravida during the third stage Haruyama, S. (2015). The miracle of endorphin: Mizan
of pregnancy. Thus, music therapy is Qanita.
Hatem, T. P., Lira, P. I. C., & Mattos, S. S. (2006). The
recommended to be an alternative treatment therapeutic effects of music in children
for pregnant mothers at home who following cardiac surgery. Jornal de pediatria,
experienced anxiety. 82(3), 186-192.
Hawari, D. (2001). Manajemen stress, cemas dan
depresi: Fakultas Kedokteran Universitas
Indonesia.
REFERENCES Hosseini, S. E., Bagheri, M., & Honarparvaran, N.
Akiki, S., Avison, W. R., Speechley, K. N., & (2013). Investigating the effect of music on
Campbell, M. K. (2016). Determinants of labor pain and progress in the active stage of
maternal antenatal state-anxiety in mid- first labor. Eur Rev Med Pharmacol Sci,
pregnancy: Role of maternal feelings about the 17(11), 1479-1487.
pregnancy. Journal of affective disorders, 196, Krout, R. E. (2007). Music listening to facilitate
260-267. relaxation and promote wellness: Integrated
Boso, M., Politi, P., Barale, F., & Emanuele, E. (2006). aspects of our neurophysiological responses to
Neurophysiology and neurobiology of the music. The Arts in Psychotherapy, 34(2), 134-
musical experience. Functional neurology, 141.
21(4), 187. Lai, H.-L., Chen, C.-J., Peng, T.-C., Chang, F.-M.,
Brandon, A. R., Trivedi, M. H., Hynan, L. S., Hsieh, M.-L., Huang, H.-Y., & Chang, S.-C.
Miltenberger, P. D., Labat, D. B., Rifkin, J. B., (2006). Randomized controlled trial of music
& Stringer, C. A. (2008). Prenatal depression during kangaroo care on maternal state anxiety
in women hospitalized for obstetric risk. The and preterm infants’ responses. Int J Nurs
Journal of clinical psychiatry, 69(4), 635. Stud, 43(2), 139-146.
Chan, M. F., Wong, Z. Y., & Thayala, N. V. (2011). The Lancaster, C. A., Gold, K. J., Flynn, H. A., Yoo, H.,
effectiveness of music listening in reducing Marcus, S. M., & Davis, M. M. (2010). Risk
depressive symptoms in adults: a systematic factors for depressive symptoms during
review. Complementary therapies in medicine, pregnancy: a systematic review. American
19(6), 332-348. journal of obstetrics and gynecology, 202(1),
Chanda, M. L., & Levitin, D. J. (2013). The 5-14.
neurochemistry of music. Trends in cognitive Lee, A. M., Lam, S. K., Lau, S. M. S. M., Chong, C. S.
sciences, 17(4), 179-193. Y., Chui, H. W., & Fong, D. Y. T. (2007).
Chang, M. Y., Chen, C. H., & Huang, K. F. (2008). Prevalence, course, and risk factors for
Effects of music therapy on psychological antenatal anxiety and depression. Obstetrics &
health of women during pregnancy. J Clin Gynecology, 110(5), 1102-1112.
Nurs, 17(19), 2580-2587. Littleton, H. L., Bye, K., Buck, K., & Amacker, A.
Cook, E. L., & Silverman, M. J. (2013). Effects of music (2010). Psychosocial stress during pregnancy
therapy on spirituality with patients on a and perinatal outcomes: a meta-analytic
medical oncology/hematology unit: a mixed- review. Journal of Psychosomatic Obstetrics
methods approach. The Arts in Psychotherapy, & Gynecology, 31(4), 219-228.
40(2), 239-244. Pawlby, S., Hay, D. F., Sharp, D., Waters, C. S., &
Ding, X.-X., Wu, Y.-L., Xu, S.-J., Zhu, R.-P., Jia, X.- O'Keane, V. (2009). Antenatal depression
M., Zhang, S.-F., . . . Tao, F.-B. (2014). predicts depression in adolescent offspring:
Maternal anxiety during pregnancy and prospective longitudinal community-based
adverse birth outcomes: a systematic review study. Journal of affective disorders, 113(3),
and meta-analysis of prospective cohort 236-243.
studies. Journal of affective disorders, 159, Richards, T., Johnson, J., Sparks, A., & Emerson, H.
103-110. (2007). The effect of music therapy on
patients' perception and manifestation of pain,

!
anxiety, and patient satisfaction. Medsurg prevalence and screening. General hospital
Nursing, 16(1), 7. psychiatry, 35(2), 112-116.
Shin, H. S., & Kim, J. H. (2011). Music therapy on Todres, I. D. (2006). Music is medicine for the heart.
anxiety, stress and maternal-fetal attachment Jornal de pediatria, 82(3), 166-168.
in pregnant women during transvaginal Van den Bergh, B. R. H., Van Calster, B., Smits, T.,
ultrasound. Asian nursing research, 5(1), 19- Van Huffel, S., & Lagae, L. (2008). Antenatal
27. maternal anxiety is related to HPA-axis
Simavli, S., Kaygusuz, I., Gumus, I., Usluogulları, B., dysregulation and self-reported depressive
Yildirim, M., & Kafali, H. (2014). Effect of symptoms in adolescence: a prospective study
music therapy during vaginal delivery on on the fetal origins of depressed mood.
postpartum pain relief and mental health. Neuropsychopharmacology, 33(3), 536-545.
Journal of affective disorders, 156, 194-199. Yusuf, N., Hadisaputro, S., Runjati, R., Suwondo, A.,
Teixeira, C., Figueiredo, B., Conde, A., Pacheco, A., & Mashoedi, I. D., & Supriyana, S. (2017). THE
Costa, R. (2009). Anxiety and depression EFFECTIVENESS OF COMBINATION OF
during pregnancy in women and men. Journal KANGAROO MOTHER CARE METHOD
of affective disorders, 119(1), 142-148. AND LULLABY MUSIC THERAPY ON
Thiagayson, P., Krishnaswamy, G., Lim, M. L., Sung, S. VITAL SIGN CHANGE IN INFANTS WITH
C., Haley, C. L., Fung, D. S. S., . . . Chen, H. LOW BIRTH WEIGHT. Belitung Nursing
(2013). Depression and anxiety in Journal, 3(4), 352-359.
Singaporean high-risk pregnancies—
Cite this article as: Dayyana, S., Suryono., Widyawati, N. M., Hidayat, S. T., Kumorowulan, S.
(2017). Effectiveness of music therapy on anxiety and β-endorphin levels in primigravida during the
third stage of pregnancy. Belitung Nursing Journal, 3(6), 735-742.
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Sulistiyo Y, et al. Belitung Nursing Journal. 2017 December;3(6):743-749

EFFECT OF PSYCHOEDUCATION ON ANXIETY IN PATIENTS WITH

CORONARY HEART DISEASE
Yuli Sulistiyo1*, Bedjo Santoso1, Shobirun1, Soeharyo Hadisaputro2, Leni Latifah3,
Rr Sri Endang Pujiastuti1
1
2
Postgraduate Program, Master of Applied Science, Semarang Health Polytechnic, Semarang, Indonesia
3
BPP GAKI Litbangkes Kemenkes Magelang, Indonesia
*Correspondence:
Yuli Sulistiyo, S.ST., M.Tr. Kep
Jl. Tirto Agung, Pedalangan, Banyumanik, Semarang, Central Java, Indonesia (50268).
E-mail: yulisulistiyo1984@gmail.com
Abstract
Background: Cardiovascular heart disease still remains high in Indonesia. Various interventions have been implemented as
an effort to deal with cardiovascular disease. However, little is known about intervention to reduce anxiety in patients with
cardiovascular disease although anxiety is related to angina attack in this patient. Psychoeducation is considered effective in
decreasing anxiety.
Objective: To examine the effect of psychoeducation in decreasing anxiety in patients with coronary heart disease (CHD) at
the General Hospital of Semarang.
Methods: This was a quasy experimental design with pretest posttest control group design. The study was conducted in the
inpatient wards of the General Hospital of Semarang on January 17 until March 8, 2017. Fifty-six respondents were recruited
using consecutive sampling, with 28 assigned in the experiment and control group. Hamilton Anxiety Rating Scale (HARS)
was used to measure anxiety levels. Paired t-test and Independent t-test were used for data analysis.
Results: Paired test showed that there was a statistically significant effect of psychoeducation on anxiety level in the
experiment group with p-value 0.001 (<0.05), and significant effect of given a brochure of CHD on the anxiety level in the
control group with p-value 0.001 (<0.05). Independent t-test showed a statistically significant difference of anxiety level
after intervention in the experiment and control group with p-value 0.001 (<0.05). The mean anxiety level in the experiment
group (22.46) was lower than the mean anxiety level in the control group (41.54).
Conclusion: Psychoeducation is effective in reducing anxiety levels in patients with CHD. It is suggested that
psychoeducation can be used as one of nursing intervention in an effort to reduce anxiety in patients with CHD.
Keywords: Psychoeducation, Anxiety, Coronary Heart Disease
INTRODUCTION
Cardiovascular disease, such as coronary heart disease causes 70% of global deaths,
heart disease (CHD) is one of the leading and considered as the first rank cause
causes of death, not only in developed (Mahdavi, Abbasi, & Mohammadi, 2015).
countries but also in developing countries, According to the American Heart Association
including Indonesia (Berndt et al., 2012). This (AHA) in Heart Stroke Statistic 2010,
disease is responsible for more than 25% of indicated that every 25 seconds there is one
all deaths worldwide (Cole, Smith, Hart, & person has coronary heart disease and every
Cupples, 2011). In the United Kingdom, for minute there is one death caused by CHD
example, over 90,000 people die from CHD (Dalusung‐Angosta, 2013). In the countries of
every year (Kones, 2011). According to the West Asia, especially in Iran, cardiovascular
World Health Organization (WHO), coronary disease exists 7-10 years earlier than in other

!
countries (Khayyam-Nekouei, Neshatdoost, daily life (Stuart, 2014). Patients tend to

Yousefy, Sadeghi, & Manshaee, 2013). experience anxiety conditions either as
independent or interrelated (e.g. anxiety leads
By 2015, the estimated death rate caused by to chronic illness, and/or chronic disease
heart disease and blood vessels increases to 20 causes anxiety) (DeJean, Giacomini,
million (MOH, 2013). In Indonesia, Vanstone, & Brundisini, 2013). In recent
prevalence of CHD based on a doctor's years, cases of cardiovascular disease,
diagnosis is 0.5%, or an estimated 883,447 especially CHD, are handled holistically by
people; and based on symptoms is 1.5% or an the Bio-Psycho-Cultural-Spiritual-Cognitive-
estimated 2,650,340 people; whereas, the Social approach (Dossey, 2008; Dossey,
prevalence of heart failure based on a doctor's Certificate, Keegan, & Co-Director
diagnosis in Indonesia is 0.13% (MOH, International Nurse Coach, 2012; Greco,
2015), and based on a physician or symptom 2013) in psycho-education to reduce anxiety
diagnosis is 0.3%. In Central Java, the (Aghayusefi, Mirzahoseini, Khazaeli, &
proportion of new cases of non-communicable Assarnia, 2016).
diseases of heart disease ranks fourth by
4.77% after hypertension 57.89%, diabetes In addition, studies show less anxiety after
mellitus 16.53%, and asthma bronchial given a psychological treatment approach,
11.61% (Dinkes, 2014). CHD complication such as cognitive-behavioral therapy, PPe
and risk factors not only increase mortality, (Guo et al., 2013; Tarr et al., 2014). The
but also reduce productivity and increase majority of studies on PPe have been
disability and healthcare costs (Sadeghi et al., performed on patients with psychiatric
2009; von Känel, 2008). disorders. However, little is known about the
impact of this program on patients with
Treatment with drugs is routinely used as the physical disorders such as cardiovascular
preferred method for CHD (Indonesia, 2006). disease. Thus, a nurse as an educator plays an
In addition, patients with CHD are confronted important role in assisting the patient in
with some psychological problems (Reid, Ski, increasing knowledge, decreasing anxiety,
& Thompson, 2013; von Känel, 2008). and understanding the symptoms of the illness
Studies have shown that 40%-65% of those and the action given through psycho-
patients have anxiety symptoms education program, which will impact to the
(Hashemzadeh, Garooci Farshi, Halabianloo, behavioral changes of the patients. It is also
& Maleki Rad, 2011). This problem occurs found that the treatment of patients with CHD
due to lack of social support, which among is not only from the physical aspects, but also
other things have the most adverse effects and psychosocial aspect needs to achieve a normal
the most common psychological responses in life (McGillion, Arthur, Victor, Watt-Watson,
patients with cardiovascular disease, but also & Cosman, 2008). This study aimed to
the recurrence of the disease. Studies show examine the influence of psychoeducation on
that anxiety and psychological problems are anxiety in patients with coronary heart disease
reduced through the use of psychological (CHD) in the General Hospital of Semarang
treatments, such as behavioral cognitive- City.
therapy and psycho-education programs (PPe)
(Dehdari, Heidarnia, Ramezankhani, METHODS
Sadeghian, & Ghofranipour, 2009; Tarr, Study design
Launay, & Dunbar, 2014). More recently, This was a quasy experimental design with
researchers have focused on using PPe pretest posttest control group design. The
methods as a basic treatment for the patient's study was conducted in the inpatient wards of
with psychological problems (Ågren, the General Hospital of Semarang on January
Evangelista, Hjelm, & Strömberg, 2012). 17 until March 8, 2017.
Patients with CHD will be accompanied by
anxiety, which will add pain such as angina Research subjects
attacks. Angina is a stressor or a threat to Consecutive sampling was used for this study
one's integrity including physiological to recruit 56 respondents. Twenty-eight
inability and decreased capacity to perform respondents were assigned in the experiment
!
and control group. The inclusion criteria of The intervention was given by the researcher
the sample were: patients with CHD, in first about psychoeducation. While the control
or recurrent CHD events, able to group was given a brochure of CHD only.
communicate verbally, not in the emergency
condition or mental disorder, have been Ethical consideration
treated for at least 1x24 hours, and have Ethical clearance of the research was obtained
family support assistance. from the ethics commission of Poltekkes
Kemenkes Semarang with No.054 / KEPK /
Instruments Poltekkes-Smg / ec / 2017. Each respondent
Anxiety was measured using Hamilton signed the informed consent prior to the data
Anxiety rating Scale (HARS) (Yazici, Demir, collection. The researcher explained about the
Tanriverdi, Karaagaoglu, & Yolac, 1998), objective and procedures of the research
which was developed by Max Hamilton in
1959 with good validity and reliability. The Data analysis
scale consisted of 14 items with 5 levels of Paired t-test and independent t-test were
score (between 0-4). The anxiety level was performed for data analysis.
classified based the number of score summed.
It refers to no anxiety if score <14, mild RESULTS
anxiety if score 14-20, moderate anxiety if Based on Table 1, the average age of
score 21-27, and severe anxiety if score > 28. respondents in the experiment group was
Anxiety was measured before and after given 54.68 and control group was 50.75. The
intervention. majority of respondents were males (57.1%),
with senior high school background (42.9%),
Intervention and working as entrepreneur (experiment
Psychoeducation was implemented for 3 days group=42.9%, control group=46.4%).
in five sessions, with 30 minutes in each Homogeneity test showed p-value >0.05,
session. It was performed in the inpatient which indicated that both groups were
ward of the General Hospital of Semarang. homogeneous.
Table 1 Characteristics of respondents based on age, gender, educational level and type of jobs
Group
Variable
Experiment Control
n (28) % n (28) %
Age (year)
26-35 2 7.1 2 7.1
36-45 5 17.9 6 21.4
46-55 9 32.1 13 46.4
56-65 7 25 4 14.3
>65 5 17.9 3 10.8
Mean= 54.68 Mean= 50.75
Mean age
(min 30 – max 80) (min 30 – max 76)
Gender
Male 16 57.1 16 57.1
Female 12 42.9 12 42.9
Education level
Elementary 10 35.7 5 17.9
Junior high 6 21.4 11 39.3
Senior high 12 42.9 12 42.9
Type of jobs
Labor 8 28.6 9 32.1
Housewife 4 14.3 3 10.7
Trader 2 42.9 3 10.7
Retired 1 3.6 0 0
Civil servant 1 3.6 0 0
Entrepreneur 12 42.9 13 46.4

!
Table 2 Anxiety levels before and after given intervention in the experiment and control group
Group
Total
Anxiety level Experiment Control
f % f % n %
Pretest
Severe 28 50 28 50 56 100
Moderate 0 0 0 0 0 0
Mild 0 0 0 0 0 0
Posttest
Severe 0 0.00 25 44.6 25 44.6
Moderate 23 41.1 3 5.40 26 46.5
Mild 5 8.90 0 0.00 5 8.9
Table 2 shows that all respondents before Kolmogorov smirnov test as shown in the
given intervention in the experiment and Table 3 shows p-value >0.05, which indicated
control group experienced severe anxiety that the experiment and control group were in
(100%), while after given intervention there normal distribution; while Levene’s test as
was a decrease of anxiety level to moderate shown in the Table 4 obtained p-value >0.05,
(41.1%) and mild level (8.90%) in the which indicated that the experiment and
experiment group; but there was only slight control group were homogeneous.
difference in the control group that 44.6% of
respondents still had severe anxiety and
5.40% had moderate anxiety.
Table 3 Normality test of respondents based on anxiety level in the experiment and control group using
Kolmogorov Smirnov (n=56)
Group
Anxiety level
Experiment Control
Pretest .502 .450
Posttest .713 .362
Table 4 Homogeneity test of respondents based on anxiety level in the experiment and control group using
Levene’s test (n=56)
Anxiety level P-value
Pretest .461
Posttest .090
Table 5 Effect of psychoeducation on anxiety level before and after given intervention in the experiment and
control group using paired t-test
Anxiety level n Mean ± SD t p
Experiment group
Pretest 28 41.54 ±4.426 22.083 0.001
Posttest 28 22.46 ±2.236
Control group
Pretest 28 41.54 ± 4.426 20.937 0.001
Posttest 28 22.46 ± 2.236
Table 5 shows there was a statistically given a brochure of CHD on the anxiety level
significant effect of psychoeducation on in the control group with p-value 0.001
anxiety level in the experiment group with p- (<0.05).
value 0.001 (<0.05), and significant effect of
!
Table 6 mean differences of anxiety levels before and after given intervention in the experiment and control
group using Independent t-test
Mean difference Group n Mean SD t p-value
Experiment 28 19.07 4.570
Pretest - posttest 9.017 0.001
Control 28 10.14 2.563
Independent t-test as shown in the table 6 Table 7 shows that there was a statistically
shows p-value 0.001, which indicated that significant difference of anxiety level after
there was a statistically significant difference intervention in the experiment and control
of anxiety level before and after intervention group with p-value 0.001 (<0.05). The mean
in the experiment and control group. anxiety level in the experiment group (22.46)
However, the experiment group shows the was lower than the mean anxiety level in the
greater mean difference (19.07) compared control group (41.54).
with the mean in the control group (10.14).
Table 7 Anxiety levels after given intervention in the experiment and control group using Independent t-test
Anxiety level Group n Mean ± SD t p-value
Experiment 28 22.46 ± 2.236
Posttest 20.937 0.001
Control 28 41.54 ± 4.426
DISCUSSION
Findings of this study showed that there was a posttest in control group indicated a positive
significant effect of psychoeducation on the effect of providing brochures to improve the
anxiety level in patients with CHD. ability of patients to overcome anxiety. Study
Differences in anxiety levels after given stated that every human has the ability to
intervention indicated a positive effect of learn from birth until the end of life
psychoeducation. Psychoeducation can (Dalimunthe, Se, & Heldy, 2007). Health
improve the patient's ability to overcome education in this study will increase the
anxiety. This is in accordance with previous knowledge of the respondents and may
study stated that psychoeducation is one way influence the behavior. However, the
that nurses can be carried out in community, increased knowledge is influenced by various
especially in hospitals in solving factors.
psychological problems related to family
physical problems (Stuart, 2014). By doing In this study, providing a brochure of CHD is
psychoeducation, a nurse will be able to less effective compared with psychoeducation
directly provide effective service and efficient for patients with CHD. This is consistent with
to solve problems. Another study also shows previous studies revealed that psycho-
that psychoeducation therapy could reduce education therapy is much better in reducing
psychosocial problems due to physical illness. anxiety in patients with cancer compared with
It is also effective for the prevention of health education. It could be said that health
emotional expression and the burden of education using brochure may be less
treating patients with the first episode of effective in lowering anxiety.
psychosis (Nurbani, 2009). Furthermore, it is
supported by previous study proved the
effectiveness of psychoeducation in the CONCLUSION
development of psychosocial health and It can be concluded that there was a
family performance in patients with significant effect of psychoeducation on
schizophrenia in China (Chien & Wong, anxiety level in patients with CHD, and
2007). psychoeducation is effective compared with
providing brochure of CHD only. Therefore,
This study also revealed that there was a it is suggested that psychoeducation can be
significant effect of given a brochure of CHD used as one of nursing intervention in an
in reducing anxiety levels of patients with effort to reduce anxiety.
CHD. Differences in anxiety levels in the

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REFERENCES patients undergoing radiotherapy. Health and

Aghayusefi, A., Mirzahoseini, H., Khazaeli, M., & quality of life outcomes, 11(1), 121.
Assarnia, A. (2016). The Effect of Hashemzadeh, A., Garooci Farshi, M., Halabianloo, G.,
Psychoeducational Interventions on Illness & Maleki Rad, A. (2011). The study of
Management in Families of Schizophrenic effectiveness of relaxation and distraction
Patients. Practice in Clinical Psychology, techniques training in anxiety reduction in
4(2), 129-135. cardiac patients. Arak Med Univ J, 14(56), 97-
Ågren, S., Evangelista, L. S., Hjelm, C., & Strömberg, 105.
A. (2012). Dyads affected by chronic heart Indonesia, D. (2006). Pharmaceutical Care Untuk
failure: a randomized study evaluating effects Penyakit Hipertensi: Direktorat Bina Farmasi
of education and psychosocial support to Komunitas dan Klinik Ditjen Bina
patients with heart failure and their partners. Kefarmasian dan Alat Kesehatan, Jakarta
Journal of cardiac failure, 18(5), 359-366. Indonesia.
Berndt, N., Bolman, C., Lechner, L., Mudde, A., Khayyam-Nekouei, Z., Neshatdoost, H., Yousefy, A.,
Verheugt, F. W. A., & de Vries, H. (2012). Sadeghi, M., & Manshaee, G. (2013).
Effectiveness of two intensive treatment Psychological factors and coronary heart
methods for smoking cessation and relapse disease. ARYA atherosclerosis, 9(1), 102.
prevention in patients with coronary heart Kones, R. (2011). Primary prevention of coronary heart
disease: study protocol and baseline disease: integration of new data, evolving
description. BMC cardiovascular disorders, views, revised goals, and role of rosuvastatin
12(1), 33. in management. A comprehensive survey.
Chien, W. T., & Wong, K.-F. (2007). A family Drug design, development and therapy, 5,
psychoeducation group program for Chinese 325.
people with schizophrenia in Hong Kong. Mahdavi, M., Abbasi, I., & Mohammadi, N. (2015).
Psychiatric services, 58(7), 1003-1006. Effect of Cardiac Rehabilitation Program on
Cole, J. A., Smith, S. M., Hart, N., & Cupples, M. E. Quality of Life in Patients Undergoing
(2011). Systematic review of the effect of diet Coronary Artery Bypass Graft Surgery. The
and exercise lifestyle interventions in the Horizon of Medical Sciences, 21(2), 67-74.
secondary prevention of coronary heart McGillion, M., Arthur, H., Victor, J. C., Watt-Watson,
disease. Cardiology Research and Practice, J., & Cosman, T. (2008). Effectiveness of
2011. psychoeducational interventions for improving
Dalimunthe, R. F., Se, M., & Heldy, B. Z. (2007). symptoms, health-related quality of life, and
Pengaruh Motivasi Intrinsik Terhadap Kinerja psychological well being in patients with
Perawat Pelaksana di Instalasi Rawat Inap stable angina. Current Cardiology Reviews,
RSU Dr. Pirngadi Medan Tahun 2007. 4(1), 1-11.
Dalusung‐Angosta, A. (2013). CHD knowledge and risk MOH. (2013). Riset Kesehatan Dasar; RISKESDAS
factors among Filipino‐Americans connected (Basic Health Research). Ministry of Health
to primary care services. Journal of the
MOH. (2015). Pusat data dan Informasi: Ministry of
American Association of Nurse Practitioners,
Health of Indonesia.
25(9), 503-512.
Nurbani. (2009). Pengaruh Psikoedukasi keluarga
Dehdari, T., Heidarnia, A., Ramezankhani, A.,
terhadap masalah psikososial: ansietas dan
Sadeghian, S., & Ghofranipour, F. (2009).
beban keluarga (caregiver) dalm merawat
Effects of progressive muscular relaxation
pasien stroke di RS Jakarta Pusat Dr. Cipto
training on quality of life in anxious patients
Mangunkusumo. Faculty of Nursing,
after coronary artery bypass graft surgery.
Universitas Indonesia. Retrieved from
DeJean, D., Giacomini, M., Vanstone, M., & Brundisini,
http://lib.ui.ac.id/file?file=digital/2016-
F. (2013). Patient experiences of depression
11/125192-Nurbani.pdf
and anxiety with chronic disease: a systematic
Reid, J., Ski, C. F., & Thompson, D. R. (2013).
review and qualitative meta-synthesis. Ontario
Psychological interventions for patients with
health technology assessment series, 13(16),
coronary heart disease and their partners: a
1.
systematic review. PLoS ONE, 8(9), e73459.
Dinkes. (2014). Health Profile of Central Java Province:
Sadeghi, S. M., Razmjouei, N., Ebadi, A., Najafi, M. S.,
Asadi, L. M., & Bozorgzad, P. (2009). Effect
Dossey, B. M. (2008). Theory of integral nursing.
of applying continuous care model on quality
Advances in nursing science, 31(1), E52-E73.
of life of patients after coronary artery bypass
Dossey, B. M., Certificate, C.-D. I. N. C., Keegan, L., &
graft.
Co-Director International Nurse Coach, A.
Stuart, G. W. (2014). Principles and Practice of
(2012). Holistic nursing: Jones & Bartlett
Publishers.
Sciences.
Greco, A. (2013). Effects of Music on Anxiety and Pain
Tarr, B., Launay, J., & Dunbar, R. I. M. (2014). Music
in the Diagnosis and Treatment of Patients
and social bonding:“self-other” merging and
With Breast Cancer.
neurohormonal mechanisms. Frontiers in
Guo, Z., Tang, H.-y., Li, H., Tan, S.-k., Feng, K.-h.,
psychology, 5.
Huang, Y.-c., Jiang, W. (2013). The benefits
of psychosocial interventions for cancer
!
von Känel, R. (2008). Psychological Distress and Yazici, M. K., Demir, B., Tanriverdi, N., Karaagaoglu,
Cardiovascular Risk: Journal of the American E., & Yolac, P. (1998). Hamilton anxiety
College of Cardiology. rating scale: interrater reliability and validity
study. Turk Psikiyatri Derg, 9(2), 114-117.
Cite this article as: Sulistiyo, Y., Santoso, B., Shobirun., Hadisaputro, S., Latifah. L., Pujiastuti, RR.
S. E. (2017). Effect of psychoeducation on anxiety in patients with coronary heart disease. Belitung

Maisi S, et al. Belitung Nursing Journal. 2017 December;3(6):750-756

EFFECTIVENESS OF LAVENDER AROMATHERAPY AND CLASSICAL

MUSIC THERAPY IN LOWERING BLOOD PRESSURE IN PREGNANT
WOMEN WITH HYPERTENSION
Sri Maisi1, Suryono2, Melyana Nurul Widyawati1, Ari Suwondo3, Suryati Kusworowulan4
1
Postgraduate Midwifery Program, Semarang Health Polytechnic, Central Java, Indonesia
2
Loboratoriun Instrumentasi dan Elektronika, Jurusan Fisika Fakultas Sains dan Matematika, Universitas Diponegoro,
Semarang, Central Java, Indonesia
3
Faculty of Medicine, Universitas Diponegoro, Semarang, Central Java, Indonesia
4
Program Pascasarjana Magister Terapan Kesehatan, Politeknik Kesehatan Kementrian Kesehatan Semarang, Central Java,
Indonesia
*Correspondence:
Sri Maisi
E-mail: srimaisi29@gmail.com
Abstract
Background: Hypertension during pregnancy remains high in Indonesia. It is a major cause of maternal death.
Aromatherapy lavender and classical music therapy are considered effective in lowering blood pressure in hypertension.
Objective: To examine the effect of lavender aromatherapy and classical music therapy in lowering blood pressure in
pregnant women with hypertension.
Methods: A quasy experimental study with pretest-posttest control group design. There were 52 pregnant women with the
inclusion criteria selected as samples using simple random sampling, divided into lavender aromatherapy group, classical
music group, combination of aromatherapy and music group, and control group. Sphygmomanometer was used to measure
blood pressure. Mann Whitney and Post Hoc test were used for data analysis.
Results: Results showed that four groups have a significant decrease in systolic blood pressure after given intervention with
p-value <0.05. The mean decrease of systolic blood pressure among four groups was: lavender group (5.77 mmHg), music
group (7.23 mmHg), combination group (9.54 mmHg), and control group (3.67 mmHg); and the mean decrease of diastolic
blood pressure was: the lavender group (2.77 mmHg), music group (0.61 mmHg), combination group (8.23 mmHg), and
control group (3.42 mmHg).
Conclusion: there was a significant effect of lavender aromatherapy and classical music therapy in lowering blood pressure
in pregnant women with hypertension. However, the combination of both interventions was more effective than lavender
aromatherapy or music therapy alone.
Keywords: Lavender Aromatherapy, Mozart Classic Music, Blood Pressure, Pregnant Women
INTRODUCTION
Pregnancy is the most critical stage of a The most common complication is
woman as this is the time when she needs the hypertension in pregnancy (Chen, Wen,
maximum protection, love, and care; and it Smith, Yang, & Walker, 2006). According to
becomes a major concern of health WHO (World Health Organization),
professionals, especially midwives. A mother hypertension during pregnancy is the leading
with health condition physically and cause of perinatal death and morbidity (WHO
emotionally is expected. However, this & partners, 2015). Some complications that
expectation is not always achievable, as there can be caused by hypertension in pregnancy
may be health problems during pregnancy. include plasma fluid deficiency due to blood
750 BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017 !

Maisi, S., Suryono., Widyawati, M. N., Suwondo, A., Kusworowulan, S. (2017)!
vessel disorders, renal impairment, style. Music is not just a sound but also a
hematological disorders, cardiovascular composition of sounds and is able to help the
disorders, liver disorders, respiratory body and mind cooperating with each other
disorders, HELLP syndrome (hemolysis, (Gouk, 2017). The music used for relaxation
elevated liver enzymes, low platelet count), is the alkaline music, which is a soft,
and fetus problems such as late growth, instrumental music, meditative music, and
prematurity to uterine death. Hypertension in relaxing and happy music (Yusuf et al., 2017).
pregnancy can also continue in preeclampsia In the brain there is a center of visual and
and eclampsia that can cause death in the auditory association that serves to interpret
mother as well as in the fetus (Prawirohardjo, the object seen and heard. Information from
2010). the center located on the surface of the brain
will be delivered to the emotional center of
In Indonesia, mothers are still dominated by the limbic system, thus it will lead to
bleeding, hypertension in pregnancy, and calmness and relaxation (Astuti, Suryono,
infection. However, since 2010 the Widyawati, Suwondo, & Mardiyono, 2017).
proportions have changed, where bleeding Calm can have an impact on the body's
and infection tend to decrease while physiology such as slowing heartbeat, deep
hypertension in pregnancy increases in 2013. and long breathing, and decreased blood
More than 25% of maternal deaths in pressure.
Indonesia are caused by hypertension in
pregnancy (MOH, 2014). The highest Previous study showed that music has been
maternal deaths in Semarang were due to shown to increase interleukin-I (IL-1) in
eclampsia (34%), bleeding (28%), disease blood so that it can improve immunity. It also
(26%), and others (12%) (Dinkes, 2014). affects the cardiovascular system (lowering
Thus, an effort to deal with hypertension is blood pressure in adolescents) after given
needed. classical music for 30 minutes (Sarayar,
Mulyadi, & Palandeng, 2013). Other studies
Based on data obtained at the Community also revealed that music is able to improve the
Health Center of Gayamsari, the number of psychological health of pregnant women by
pregnant women with hypertension in 2015 lowering the number of anxiety, stress, and
amounted to 8 women, Health Center of depression, which usually experienced by
Tlogosari was 13 women, Health Center of pregnant mother (Chang, Chen, & Huang,
Kedungmundu as many as 7 women, Health 2008).
Center of Ngesrep was 5 women, Health
Center of Pudakpayung was 6 women, Health
Center of Gunung Pati was 11 women, and METHODS
Health Center of Ngaliyan 11 women. Study Design
This study employed a quasy experimental
This study aimed to use non-pharmacological design with pretest posttest control group.
treatment, namely aromatherapy using
lavender and music therapy. Literature Settings
indicated that aroma lavender therapy not This research was conducted on 11 November
only affects the physical but also the 2016 until 8 January 2017 in the working area
emotional level (Sharma, 2009). of the Community Health Center of
Aromatherapy using lavender can decrease Gayamsari, Tlogosari, Kedungmundu,
anxiety, joint pain, high blood pressure, heart Ngesrep, Pudakpayung, Gunungpati, and
frequency, metabolic rate, and overcome sleep Ngaliyan.
disorders (insomnia), stress and increase
production of the hormone melatonin and Research Subject
serotonin (Apryanti, Suhartono, & Using simple random sampling, there were 52
Ngadiyono, 2017; Karo, Pramono, Wahyuni, pregnant women recruited, which 13 assigned
Mashoedi, & Latifah, 2017). While music is in the four groups: (i) Lavender aromatherapy
an organized audio stimulus consisting of group, (ii) Classical music group, (iii)
melody, rhythm, harmony, timbre, shape and Combination group (aromatherapy and

!
classical music therapy), and (iv) Control blood pressure if systolic blood pressure is
group. The inclusion criteria in this study equal to 120 mmHg and diastole 80 mmHg.
were pregnant women with hypertension,
gestational age 20 weeks and above, mothers Ethical Consideration
and babies were in health condition, and Prior to data collection, the researcher first
willing to be respondent. While the exclusion requested study permission from the National
criteria included pregnant women with Unity and Politics of Semarang and
eclampsia, and those who followed alternative Department of Health of Semarang. The
treatments such as massage or acupuncture. ethical clearance was obtained from the Ethics
Commission of POLTEKKES Semarang with
Intervention number: 279 / KEPK / Poltekkes-SMG / EC /
Lavender aromatherapy is a fragrance 2016.
extracted from lavender flowers (Lavandula
Angustifolia) in the form of essential oil. Data Analysis
Lavender aromatherapy is given by mixing Data were in non-normal distribution based
five drops of lavender essential oil with 20 ml on the results of Kruskall Wallis test. Thus,
of water inserted into the diffuser, which Mann Whitney and Post Hoc test were used
emits steam. Aromatherapy was administered for data analysis.
at the respondent's home for 20 minutes. As
for music therapy, the music used was the
classic cassation of the composer of W.A RESULTS
Mozart and given for 20 minutes. For Table 1 shows that the mean age of the
combination group, aromatherapy and respondents ranged from 28 to 30 years old,
classical music were given simultaneously, with parity 1-2, and gestational age ranging
and the control group received standard from 25- 27 weeks. Further analysis obtained
services for pregnant women. p=>0.05 in all characteristics, which indicated
that there was no significant difference of the
Instrument characteristics of pregnant women in the four
A digital sphygmomanometer was used to groups.
measure blood pressure, which was measured
before and after given intervention. Normal
Table 1 Characteristics of the respondents based on age, parity, and gestational age
Variable Group Mean ±SD Min Max
X1 28.46 ±6.59 17 40
X2 30.54±7.63 20 42
Age (year)
X3 29.23±8.05 19 41
C 29.17±7.56 19 46
X1 1.69±0.75 1 3
X2 2.08±1.11 1 4
Parity
X3 2.15±0.98 1 4
C 1.92±1.08 1 4
X1 25.38±3.68 21 31
Gestational age X2 25.69±3.52 20 31
(week) X3 26.38±3.12 21 30
C 27.58±4.66 20 36
X1 : Lavender aromatherapy group | X2 : Classical music group | X3 : Combination group
C : Control group
752 ! BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017

Table 2 Systolic and diastolic blood pressure before and after given intervention in the lavender aromatherapy
group, classical music group, combination group, and control group
Group
Variable
X1 X2 X3 C
Systolic pretest
Mean (SD) 137.69±5.02 137.6±24.40 142.00±5.33 137.25±5.08
Median 140 137 140 136,5
Minimum 130 129 134 150
Maximum 146 146 150 146
Systolic Posttest
Mean (SD) 131.92±7.29 130.38±6.07 132.46±3.75 133.58±4.83
Median 132 132 132 133.5
Minimum 121 121 126 126
Maximum 148 138 138 143
Diastolic Pretest
Mean (SD) 86.77±4.45 86.31±5.45 90.23±5.24 88.17±3.88
Median 86 87 90 89,5
Minimum 81 80 82 81
Maximum 94 95 100 93
Diastolic Post test
Mean (SD) 84.00±3.10 85.69±3.54 82.00±4,12 84.75±4.13
Median 83 86 81 85
Minimum 80 80 75 80
Maximum 90 90 88 91
X1 : Lavender aromatherapy group | X2 : Classical music group | X3 : Combination group | C : Control group
Table 2 shows that the mean systolic – While Table 3 shows that all group have a
diastolic blood pressure before given significant decrease of systolic blood pressure
intervention was 137.69/86.77 mmHg after given intervention with p-value <0.05.
(Lavender aromatherapy group), 137.62/86.31 The mean decrease of systolic in the lavender
mmHg (Classical music group), 142.00/90.23 group was 5.77 mmHg, music group 7.23
mmHg (Combination group), and mmHg, combination group 9.54 mmHg, and
137.25/88.17 mmHg (Control group); and that control group 3.67 mmHg; and the mean
the mean systolic – diastolic blood pressure decrease of diastolic blood pressure in the
after given intervention was 131.92/84.00 lavender group was 2.77 mmHg, music group
mmHg (Lavender aromatherapy group), 0.61 mmHg, combination group 8.23 mmHg,
130.38/85.69 mmHg (Classical music group), and control group 3.42 mmHg. Among the
132.46/82 mmHg (Combination group), and four groups, the combination group showed
133.58/84.75 mmHg (Control group). the highest decrease in systolic – diastolic
blood pressure in pregnant women.
Table 3 Effect of lavender aromatherapy, classical music and its combination in lowering blood
pressure in pregnant women with hypertension
Variable Group Mean±SD Median Min Max P-value
X1 5.77±7.87 8 8 18 0.026
Systolic
X2 7.23±4.07 6 2 15
difference
X3 9.54±4.19 9 1 17
(mmHg)
C 3.67±4.23 3 2 14
X1 2.77±3.85 3 3 11 0.002
Diastolic
X2 0.61±5.12 1 9 13
difference
X3 8.23±4.58 9 2 17
(mmHg)
C 3.42±4.21 1.5 1 11
X1 : Lavender aromatherapy group | X2 : Classical music group | X3 : Combination group | C : Control group

!
Table 4 Post hoc test in systolic-diastolic blood pressure among the four groups
Variable Group Group p-value
X1 X2 0.650
X3 0.204
Systolic C 0.574
(mmHg) X2 X3 0.113
C 0.010*
X3 C 0.003*
X1 X2 0.139
X3 0.007*
Diastolic C 0.979
(mmHg) X2 X3 0.001*
C 0.186
X3 C 0.007*
X1 : Lavender aromatherapy group | X2 : Classical music group | X3 : Combination group
C : Control group
Post hoc test as shown in the Table 4 shows brain that control and relate to the mood,
that there was a significant difference in emotion, memory that provides information to
systolic blood pressure between classical the hypothalamus which is the regulator of the
music group and control group (p=0.010), and internal system of the body, including the
between combination group and control group system of regulating body temperature and
(p=0.003); while in diastolic group there was heart rate. Inhaling lavender aromatherapy
a significant difference between lavender will increase alpha waves in the brain and it is
aromatherapy group and combination group these waves that create a relaxed feeling that
(p=0.007), between classical music group and can cause decreased blood pressure (Hwang,
combination group (p=0.001), and between 2006).
combination group and control group
(p=0.007). The significant effect of classical music
therapy in this study also supports the results
of previous study that revealed that there was
DISCUSSION a decrease of systolic of 8.6 mmHg and
This study aimed to examine the effect of diastolic of 5.8 mmHg after given
lavender aromatherapy and classical music aromatherapy (Suviani, Artana, & Putra,
therapy in lowering blood pressure in 2014). Other studies have shown that
pregnant women with hypertension. Findings intervention by listening to classical music
of this study showed that there was a can effectively alter brain waves, which in a
significant effect of lavender aromatherapy stressful state become more relaxed resulting
and classical music therapy and combination in decreased blood pressure and pulse
of both interventions in systolic-diastolic (Campbell, 2001).
blood pressure in pregnant women with
hypertension. Music is heard through the ear and then
stimulated to the brain, the music will be
A lavender aromatherapy showed a significant continued to the hypothalamus. Music
effect on the decrease of blood pressure in this interacts on an organic level with a variety of
study is in line with previous study revealed neural structures. It produces rhythmic
that there was a decrease of blood pressure stimuli, which are then captured through the
after given aromatherapy. In addition, auditory organs and processed through the
aromatherapy can also improve sleep quality nervous system and glands that further
(Sarayar et al., 2013). organize sound interpretations into the
internal rhythm of hearing (Chang et al.,
The smell from aromatherapy has a direct 2008).
effect on the human brain. The aroma is
captured by the receptor in the nose which Sound waves of music delivered to the brain
then sends further information to areas of the in the form of electrical energy through a

neural network that will generate brain waves REFERENCES

that will be distinguished over the frequency Apryanti, Y. P., Suhartono, S., & Ngadiyono, N. (2017).
of alpha waves that will generate relaxation; THE IMPACT OF LAVENDER
AROMATHERAPY ON PAIN INTENSITY
where beta waves are associated with mental AND BETA-ENDORPHIN LEVELS IN
activity, theta waves are associated with POST-CAESAREAN MOTHERS. Belitung
stressful situations and creative efforts; and Nursing Journal, 3(5), 487-495.
the delta waves are connected with a sleepy Astuti, A., Suryono, S., Widyawati, M. N., Suwondo,
A., & Mardiyono, M. (2017). EFFECT OF
situation. The sound of music can affect the AUDIO THERAPY USING AL-QUR'AN
frequency of the brain according to the music. MURROTAL ON BEHAVIOR
When the body relaxes, it will emit alpha, DEVELOPMENT IN CHILDREN WITH
beta, theta and delta waves, which give the AUTISM. Belitung Nursing Journal, 3(5),
effect of relaxation and blood pressure 470-477.
Campbell, D. G. (2001). Efek mozart: Gramedia Pustaka
decreased (Merritt, 2003). Utama.
Chang, M. Y., Chen, C. H., & Huang, K. F. (2008).
However, this study revealed that the Effects of music therapy on psychological
combination of lavender aromatherapy and health of women during pregnancy. J Clin
Nurs, 17(19), 2580-2587.
classical music therapy have a highest effect Chen, X. K., Wen, S. W., Smith, G., Yang, Q., &
in lowering blood pressure in pregnant Walker, M. (2006). General obstetrics:
women with hypertension compared with Pregnancy‐induced hypertension is associated
lavender aromatherapy or music therapy with lower infant mortality in preterm
alone. This combination at the same time can singletons. BJOG: An International Journal of
Obstetrics & Gynaecology, 113(5), 544-551.
simultaneously lower blood pressure in Dinkes. (2014). Health Profile in Semarang. Retrieved
pregnant women with hypertension. It can 25 October, 2016, from
increase the alpha and beta waves in the brain http://dinkes.semarangkota.go.id/
and these waves will form to create a relaxed Gouk, P. (2017). Musical healing in cultural contexts:
state. The effect of lavender aromatherapy is Routledge.
Hwang, J. H. (2006). The effects of the inhalation
similar to the effects of classical music that method using essential oils on blood pressure
have similar calming effect, balance, comfort, and stress responses of clients with essential
sense of openness and confidence, while also hypertension. Journal of Korean Academy of
reducing stress, pain, anxiety, unbalanced Nursing, 36(7), 1123-1134.
Karo, H. Y. K., Pramono, N., Wahyuni, S., Mashoedi, I.
emotion, the hysteria, the frustration, and D., & Latifah, L. (2017). LAVENDER
provide a sense of relaxation that can affect (LAVANDULA ANGUSTIFOLIA)
blood pressure, heart rate and breathing. AROMATHERAPY AS AN ALTERNATIVE
TREATMENT IN REDUCING PAIN IN
Limitation of the study included that the PRIMIPAROUS MOTHERS IN THE
ACTIVE FIRST STAGE OF LABOR.
measurement of blood pressure before and Belitung Nursing Journal, 3(4), 420-425.
after given intervention was at the same day Merritt, S. (2003). Simfoni otak: 39 aktivitas musik yang
which might limit the observation to see the merangsang IQ, EQ, SQ, untuk
effect of intervention. Therefore, further study membangkitkan kreativitas & imajinasi:
Kaifa.
with longer time is needed. MOH. (2014). Health profile of Indonesia 2014: Menteri
Kesehatan Republik Indonesia, Jakarta.
Prawirohardjo, S. (2010). Ilmu Kebidanan Edisi IV
CONCLUSION Cetakan ke-2: Tridasa Printer. Jakarta.
In summary, there was a significant effect of Sarayar, C., Mulyadi, N., & Palandeng, H. (2013).
PENGARUH MUSIK KLASIK TERHADAP
lavender aromatherapy and classical music PENURUNAN TEKANAN DARAH PADA
therapy in lowering blood pressure in PASIEN PRA-HEMODIALISIS DI RUANG
pregnant women with hypertension. However, DAHLIA BLU RSUP. PROF. DR. RD
the combination of both interventions was KANDOU MANADO. Jurnal keperawatan,
1(1).
more effective than lavender aromatherapy or Sharma, S. (2009). Aroma Terapi. Tanggerang:
music therapy alone. Thus, the combination of Karisma Publishing Group.
the two interventions is recommended to Suviani, N. W., Artana, I. W., & Putra, P. W. K. (2014).
lower blood pressure in pregnant women with PENGARUH PEMBERIAN AROMA
hypertension. TERAPI LAVENDER (LAVANDULA
ANGUSTIFOLIA) TERHADAP

!
PENURUNAN HIPERTENSI PADA Yusuf, N., Hadisaputro, S., Runjati, R., Suwondo, A.,
LANSIA DI DESA CEMAGI, Mashoedi, I. D., & Supriyana, S. (2017). THE
KECAMATAN MENGWI, KABUPATEN EFFECTIVENESS OF COMBINATION OF
BADUNG. Jurnal Dunia Kesehatan Volume 3 KANGAROO MOTHER CARE METHOD
No 1 Juni 2014, 3(1). AND LULLABY MUSIC THERAPY ON
WHO, & partners, U. (2015). Country statistics and VITAL SIGN CHANGE IN INFANTS WITH
global health estimates. from LOW BIRTH WEIGHT. Belitung Nursing
http://www.who.int/gho/countries/idn.pdf?ua= Journal, 3(4), 352-359.
1
Cite this article as: Maisi, S., Suryono., Widyawati, M. N., Suwondo, A., Kusworowulan, S. (2017).
Effectiveness of lavender aromatherapy and classical music therapy in lowering blood pressure in
pregnant women with hypertension. Belitung Nursing Journal, 3(6), 750-756.

Dzulfaijah NE, et al. Belitung Nursing Journal. 2017 December;3(6):757-764

COMBINATION OF COLD PACK, WATER SPRAY, AND FAN COOLING

ON BODY TEMPERATURE REDUCTION AND LEVEL OF SUCCESS TO
REACH NORMAL TEMPERATURE IN CRITICALLY ILL PATIENTS
WITH HYPERTHERMIA
Nur Eka Dzulfaijah*, Mardiyono, Sarkum, Djenta Saha
*Correspondence:
Nur Eka Dzulfaijah
Email: ekatamtam44@yahoo.com
Abstract
Objective: To examine the effect of the combination of cold pack, water spray, and fan cooling on body temperature
reduction and level of success to reach normal temperature in critically ill patients with hyperthermia.
Methods: This was a randomized control trial (RCT) with pretest postest control group design and repeated measurement,
conducted on December 2016 – January 2017. There were 32 respondents selected using total sampling, with 16 respondents
randomly assigned in the experiment and control group. A digital thermometer was used to measure hyperthermia. Paired t-
test, Repeated Anova with post hoc, and Mann Whitney were used for data analysis.
Results: Findings showed that the mean of body temperature in the experiment group in pretest was 38.762oC and decreased
to 37.3oC after given intervention for 60 minutes. The mean difference of body temperature was 1.4625, with p-value 0.000
(<0.05). In control group, the mean of body temperature in pretest was 38.669oC and decreased to 38.188oC given
intervention for 60 minutes. The mean difference of body temperature was 0.4812, with p-value 0.000 (<0.05).
Conclusion: There was a significant effect of the combination of cold pack, water spray, and fan cooling on body
temperature reduction and level of success to reach normal temperature in critically ill patients with hyperthermia. This
combination is more effective than water compress alone.
Keywords: Cold Pack, Water Spray, Fan Cooling, Hyperthermia
INTRODUCTION
Increased body temperature or fever is a Typhoid, sepsis, head injury, stroke are some
frequent problem in the intensive care unit, types of diseases that have an increase in body
with incidence ranging from 23% to 70% temperature. WHO stated that the prevalence
caused by infection or non-infection (Kothari of typhoid was 16 million cases per year with
& Karnad, 2005; Sari, Redjeki, & 600 death cases, while Indonesia is the third
Rakhmawati, 2013). Hyperthermia is from the ten most prevalent disease patterns
associated with local or systemic infection of inpatients supported by the data of the
caused by bacteria, viruses or parasites; and Indonesian Ministry of Health in 2011. The
with non-infection caused by environmental incidence of head injury in Indonesia reaches
factors, autoimmune disease, malignancy, 7.5% of the population (MOH, 2013). Head
drug use and central nervous system disorders injuries are the leading cause of death and
such as cerebral hemorrhage, epilepsy status, morbidity in the world under the age of 45
coma, and hypothalamic injury (Nield & years, requiring proper handling of health
Kamat, 2011). personnel (Werner & Engelhard, 2007).

Dzulfaijah, N. E., Mardiyono., Sarkum., D Saha, D. (2017)!
!
Increased body temperature in head injury that the nurse is responsible for identifying
generally occurs due to a set point disorder in patients who have increased body
the hypothalamus, which is caused by temperature, planning nursing care as well as
bacterial endotoxins stimulate PMN cells to implementing and evaluating it. In critical
produce endogenous pyrogens ie interleukin- nursing manner, provision of cooling method
1, interleukin 6 or TNF (tumor necrosis is very important due to the magnitude of the
factor). Pyogen is a substance that can cause effect of increased body temperature on the
fever. Pyogen is composed of endogenous and chances of cure and increased risk of death of
exogenous. Exogenous pyrogens are pyrogens the patient. Management of hyperthermia with
that come from outside the body, especially pharmacological method is by giving
microbes and products such as toxins. antipyretic such as paracetamol,
Endotoxin is a potential substance that is not acetaminophen, and others; and non-
only a pyrogen but also as an inducer of pharmacology is by external cooling.
varying pathological changes observed in Compress is one of external cooling or
gram-negative infections (Kothari & Karnad, physical methods of cooling. The types of
2005; Sari et al., 2013). However, temperature compresses include warm compresses, cold
increase in head injury can cause higher compresses, alcohol compresses, wet
intracranial pressure and a mortality rate of blankets, cold packs, water spray to the body
78% (Diringer, Reaven, Funk, & Uman, area and fan cooling (Purwanti & Nur
2004). Ambarwati, 2008).
Hyperthermia can be associated with a Previous study on the effects of wet blanket
number of damaging effects, especially compress and cold-packs on body temperature
increased cardiac output, oxygen in head injury patients, indicated that the
consumption, carbon dioxide production, and usual wet blanket compress method has the
an increase in basal metabolic rate (BMR). same effect on the decrease in body
Increased oxygen consumption of about 10% temperature of head injury patients with cold-
per 0C can cause death, so that some incidents pack compress, which the results obtained
of temperature increase must be handled effect size value -1 as a weak category
properly to avoid negative impact, including (Pratiwi, Ropi, & Sitorus, 2015). Thus, an
excessive body fluid evaporation resulting in instant cold-pack made from ammonium
lack of fluids and seizures (Kothari & Karnad, nitrate gel was developed and used to lower
2005; Setiawati, 2009). body temperature. In addition to cold pack,
water spray and fan cooling are used as a
Severe hyperthermia (temperatures greater medium of temperature (Sari et al., 2013).
than 41°C) can also cause hypotension, This study aimed to use the combination of
multiple organ failure, coagulopathy, and cold pack, water spray and fan cooling that
irreversible brain damage. Heart rate and has never been done in previous studies.
breathing will increase as well as the
nutritional needs of the body. This However, cold packs and wet blankets and
metabolism uses energy that generates ordinary compresses have an external cooling
additional heat. Patients suffering from heart method so that most conduction will affect the
or respiratory problems, the fever becomes periphery compared to core temperature
severe. Long-term fever will waste the (Scrase & Tranter, 2011). In addition,
patient's energy savings and become weak. physical cooling therapy implements the
Increased metabolism requires additional concept of radiant body heat transfer to the
oxygen, if the body cannot meet the need for environment by radiation, evaporation,
supplemental oxygen, then cell hypoxia may conduction and convection. The combination
occur. Myocardial hypoxia can cause angina of physical cooling and antipyretics is the
(chest pain) and cerebral hypoxia to cause most frequently studied and most widely
anxiety (Susanti, 2012). applied topic for reducing fever in critically ill
patients (Price & McGloin, 2003).
Increased temperature is one of the
disturbances that patients often experience so
!
The success of temperature to normal is what Intervention

every research wants to achieve, such as in The experiment group was given a cold pack
previous study that provided warm compress in the axillary, a water spray sprayed on the
intervention which the normal temperature stomach every 10 minutes and repeated 6
occurred within 15 minutes and 20 minutes times for 60 minutes, and fan cooling
while in the onion intervention group within exposure for 1 implemented by researchers.
10 minutes. While another study obtained the While control group was given a plain water
temperature decrease in 20 minutes but not compress with temperature ranging from 260C
yet reached the success of temperature -280C.
become normal, similar with another study
that the success of temperature decrease Instrument
occured significantly in 60 minutes but not yet A digital thermometer placed in the axilla area
achieved the success of temperature become every 10 minutes of intervention and
normal (Cahyaningrum & Julianti, 2015; performed for 60 minutes. Normal body
Pratiwi et al., 2015). temperature if ranging from 36.5oC -37.5oC,
hypertermia if >37.5oC, and hypothermia if
Result of effect size calculation in previous <36.o5.
research indicated that the effect size of water
spray was in medium category (0.625), fan Ethical consideration
cooling with warm water increased to 0.8 Ethical approval was obtained from the
(1.9%), and cold water increased to 0.5 General Hospital of West Nusa Tenggara with
(1.1%). Another research showed weak effect No. 070.1/07/KEP/2016. Study permission
size (0.42), with improvement on wet blanket was also obtained from each hospital in this
compress to 0.16 (0,3%), and cold pack to study piror to data collection. An appropriate
0.19 (0.4%) (Pratiwi et al., 2015; Sari et al., informed consent was done by the
2013). So, to increase the effect size of cold researchers.
pack, its combination with water spray and
fan cooling is needed. Data analysis
Shapiro-wilk test was used for testing
normality of data distribution, and the results
METHODS showed that data were in normal distribution.
Study design Paired t-test, Repeated Anova with post hoc,
This was a randomized control trial (RCT) and Mann Whitney were used for data
with pretest postest control group design and analysis.
repeated measurement.
Setting RESULTS
This study was conducted on December 2016 Table 1 shows that the mean age of
– January 2017 in the Hospital of West Nusa respondents in the experiment group was
Tenggara Province, the General Hospital of 41.50 years old and the control group was
Mataram, the Hospital of Patuh Patut Patju 40.94 with p-value 0.430 (>0.05), which
Gerung, and the General Hospital of Praya. indicated that there was no difference
characteristic of respondent based on age
Research subject between the two groups. The majority of
The number of population in this study was respondents in both groups was female with
32 people, and the sample of respondents was p-value 0.154 (>0.05), and had medical
32 using total sampling, with 16 respondents diagnoses of post craniotomy (18.75%), post
randomly assigned in the experiment and laparatomi (12.5%), sepsis (18.75%), DHF
control group. The inclusion criteria of the (25%), and SNH (25%), with p-value 1.000
sample were patients with hyperthermia in (>0.05). In conclusion, there was no
inpatient ward, having antipyretic, and body significant differences of the characteristics of
temperature ≥38.3oC. the respondents in the experiment and control
group.

!
Table 1 Frequency distribution of the characteristics of respondents based on age, gender, and medical
diagnosis (n = 32)
Variable P-value
N % N %
Age (year) Mean ± SD Mean ± SD
(41.50±17.478) (40.94±12.923)
< 25 3 18.75% 5 31.25% 0.430
25-50 6 37.50% 4 25.00%
>50 7 43.75% 7 43.75%
Total 16 100% 16 100%
Gender 0.154
Female 10 62.5% 12 75%
Male 6 37.5% 4 25%
Total 16 100% 16 100%
Medical diagnosis
Post craniotomy 3 18.75% 3 18.75% 1.000
Post laparatomi 2 12.5% 2 12.5%
Sepsis 3 18.75% 3 18.75%
DHF 4 25% 4 25%
SNH 4 25% 4 25%
Total 16 100 16 100
Body%temperature%
39&
38.5&
38&
37.5&
37&
36.5&
Pretest& 10&min& 20&min& 30&min& 40&min& 50&min& 60&min&
Experiment& 38.762& 38.369& 38.15& 38& 37.762& 37.494& 37.3&
Control& 38.669& 38.556& 38.544& 38.438& 38.338& 38.269& 38.188&
Figure 1 Description of the decrease of body temperature in the experiment and control group
Figure 1 shows that there was a decrease of showed the higher decrease of body
body temperature in the experiment and temperature (37.3oC) after 60 minutes
control group from pretest and 60 minutes intervention compared with body temperature
intervention. However, the experiment group (38.188oC) in control group.
Table 2 Description of the level of success to reach normal temperature

60 min Intervention
Level of success to reach normal
Succesfull Unsuccessful
temperature
N % N %
Experiment 15 93.75 1 6.25
Control 1 6.25 15 93.75
Table 2 shows that 15 respondents (93.75%) the control group only had 1 respondent
in the experiment group had a body (6.25) having normal body temperature while
temperature ranging from 36.5oC to 37.5 oC the other 15 respondents (93.75%) had body
after given intervention for 60 minutes, while temperature >370C.
!
Table 3 Mean difference of body temperature in the experiment and control group using Paired t-test (n=32)
Experiment Control
Mean Mean
Group Mean Mean
±SD SD P-value ±SD SD P-value
difference difference
Pretest – 60 min 38.762± 1.4625 0.3612 0.000 38.669± 0.4812 0.2562 0.000
0.4603 0.4045
37.300± 38.188±
0.6218 0.5807
Pretest – 10 min 38.762± 0.3937 0.1289 0.000 38.669± 0.1125 0.1500 0.009
0.4603 0.4045
38.369± 38.556±
0.4701 0.4366
10 min – 20 min 38.369± 0.2188 0.1559 0.000 38.556± 0.0125 0.1746 0.779
0.4701 0.4366
38.150± 38.544±
0.5586 0.4690
20 min – 30 min 38.150± 0.1062 0.1506 0.001 38.554± 0.1062 0.1237 0.004
0.4701 0.4690
38.000± 38.438±
0.5621 0.5188
30 min – 40 min 38.000± 0.2375 0.1258 0.000 38.438± 0.1000 0.0894 0.000
0.5621 0.5188
37.762± 38.338±
0.5864 0.5427
40 min - 50 min 37.762± 0.2687 0.0873 0.000 38.338± 0.0687 0.0687 0.011
0.5864 0.5427
37.494± 38.269±
0.6180 0.5486
50 min – 60 min 37.494± 0.1938 0.2351 0.005 38.269± 0.0813 0.1047 0.007
0.6180 0.5486
37.300± 38.188±
0.6218 0.5807
Table 3 shows that the mean of body intervention (p=<0.05). In control group, the
temperature in the experiment group in pretest mean of body temperature in pretest was
was 38.762oC and decreased to 37.3oC after 38.669oC and decreased to 38.188oC after 60
60 min intervention. The mean difference of min intervention. The mean difference of
body temperature was 1.4625, with p-value body temperature was 0.4812, with p-value
0.000 (<0.05), which indicated that there was 0.000 (<0.05), which indicated that there was
a statistically significant difference of body a statistically significant difference of body
temperature in the experiment and control temperature in the experiment and control
group. It also shows the significant difference group. However, this temperature was still far
of body temperature in every ten minutes of from normal body temperature.
Table 4 Mean difference of body temperature before and after given intervention using Pairwise comparison
Time Group P-value
Pretest Experiment Control .545
Control Experiment
10 min Experiment Control .252
Control Experiment
Control Experiment
Control Experiment
Control Experiment
Control Experiment
Control Experiment

!
Pairwise comparison test showed that the body temperature between experiment and
decrease of body temperature started from 10 control group started from 20 minutes of
minutes of intervention, and the difference of intervention.
Table 5 The level of success to reach normal body temperature before and after intervention in the
experiment and control group
Variable Group N Mean rank Z p
Level of success to reach Experiment 16 21.03 -3.295 0.001
normal body temperature Control 16 11.97
Table 5 shows that the mean of level of evaporation, but by convection, so that the
success to reach normal body temperature in water in the body evaporates not because of
the experiment group was 21.03 and in the body heat but because of the wind
control group was 11.97, with p-value 0.001 (McDermott et al., 2009).
(<0.05), which indicated that there was a
significant difference of the level of success to While cold pack can be used for hot and cold
reach normal body temperature between both compresses, which contains a safe ammonium
groups. nitrate gel that can be used repeatedly. This
gel can also keep the temperature cool for
long periods of time. The use of cold pack is
DISCUSSION expected to absorb body heat by using the
Findings of this study revealed that there was concept of conduction. Cold pack with
a significant effect of the combination of cold surrounding tissue including blood vessels can
pack, water spray, and fan cooling on body cause the blood temperature that flow around
temperature reduction and level of success to the compressing area decrease due to the
reach normal temperature in critically ill conduction process. This is in line with the
patients with hyperthermia with p-value study stated that handling the increase in body
<0.05; there was a significant difference of temperature with acethaminophen and cold
the effect of the combination of cold pack, compress method are more effective than the
water spray, and fan cooling in the experiment drug alone or just compress (Henker, 1999).
group compared with plain water compress in
the control group on body temperature Compress is one of the measures to reduce
reduction and level of success to reach normal heat production and increase heat expenditure.
temperature with p-value <0.05. This proved Compressive therapy performed on the
that the combination of the three interventions axillary and groin area is done due to the
was effective in reducing body temperature presence of large blood vessels that can
and reaching normal body temperature. provide stimulation to the hypothalamus to
lower body temperature (Potter & Perry,
This finding is supported by previous studies 2005). Heat moves from the blood, through
indicated that water spray is a method for the blood vessel wall to the skin surface and
temperature reduction using evaporation then disappears into the environment through
principle, while fan cooling is to produce a heat loss mechanism. By placing a cold pack
wind to prevent the air saturation by water in the axillary area and the water spray in the
vapor, thus the evaporation process stops so abdominal area, it is expected that the venous
that the air flow causes the turn of the blood vessels will change the size regulated
saturated layer with the dry air, which then the by the anterior hypothalamus to control the
evaporation process continues (Sari et al., heat release, resulting in vasodilation of the
2013). This is also supported by another blood vessels and heat production constraints
research explaining that the use of water spray (Potter & Perry, 2005).
and fan cooling with low speed supports the
evaporation process. Using high speeds can On the other hand, findings of this study
cause heat transfer process not by revealed that the combination of cold pack,
!
water spray, and fan cooling had a faster CONCLUSION

effect in reducing body temperature compared In conclusion, there was a significant effect of
with water compress alone. the combination of cold pack, water spray,
and fan cooling on body temperature
According to literature, the body temperature reduction and level of success to reach normal
is regulated by thermostat in hypothalamus. temperature in critically ill patients with
The mechanism of body temperature hyperthermia. This combination is more
reduction is a complex homeostatic system effective than plain water compress alone.
facilitated by feedback mechanisms, which Thus, this intervention is expected to be an
the nerve cells control thermoregulation and input material in nursing care, and can
many other aspects of homeostasis, especially contribute to the development of nursing
in the hypothalamus. The hypothalamus has a theory in the management of hyperthermia by
thermostat that responds to changes in body including cold pack, water spray and fan
temperature above and below the tide point by cooling interventions in the application of
activating mechanisms that increase heat loss Nursing Interventions Classification (NIC).
or heat gain. Nerve cells sensing body
temperature lie in the skin, hypothalamus and
some other nervous systems, including hot REFERENCES
receptors that signal the thermostat in the Cahyaningrum, E. D. C., & Julianti, H. P. J. (2015).
hypothalamus as skin temperature increases. Perbedaan kompres hangat dan kompres
bawang merah terhadap penurunan suhu tubuh
In addition, it is a cold receptor that signals anak dengan demam. Jurnal Ilmu dan
the thermostat when the body temperature Teknologi Kesehatan, 5(1).
falls. The thermostat will respond to body Diringer, M. N., Reaven, N. L., Funk, S. E., & Uman, G.
temperature below normal range and inhibit C. (2004). Elevated body temperature
independently contributes to increased length
heat loss mechanism, and activate heat saving of stay in neurologic intensive care unit
mechanism, such as heat-generating patients. Critical care medicine, 32(7), 1489-
supervisorial vasoconstriction (Wong, 2009). 1495.
Henker, R. (1999). Evidence-based practice: fever-
In addition, findings of this study obtained related interventions. American journal of
critical care, 8(1), 481.
effect size of 1.9, which indicated that there Kothari, V. M., & Karnad, D. R. (2005). New onset
was a significant influence on the fever in the intensive care unit. Japi, 53, 949-
combination of cold pack, water spray and fan 953.
cooling in patients with hyperthermia. This McDermott, B. P., Casa, D. J., Ganio, M. S., Lopez, R.
M., Yeargin, S. W., Armstrong, L. E., &
shows that the strength of this study is very Maresh, C. M. (2009). Acute whole-body
strong to be implied at the decrease in cooling for exercise-induced hyperthermia: a
temperature as well as level of success to systematic review. Journal of athletic
normal temperature. The position of this training, 44(1), 84-93.
research occupies the first sequence that is MOH. (2013). Riset Kesehatan Dasar; RISKESDAS
(Basic Health Research). Ministry of Health
equal to 1.9 when compared with previous of the Respublic of Indonesia, Jakarta.
research which was only 0.62 after given Nield, L. S., & Kamat, D. (2011). Fever without a focus.
water spray and fan cooling, and 0.08 after the Nelson Textbook of Pediatrics, 896-901.
cold pack. Thus, it can be concluded that the Potter, P. A., & Perry, A. G. (2005). Buku ajar
fundamental keperawatan: konsep, proses, dan
effect size value in this study is quite large praktik. Jakarta: EGC, 1.
compared to the effect size of previous Pratiwi, S. H., Ropi, H., & Sitorus, R. (2015). Perbedaan
researchs (Pratiwi et al., 2015; Sari et al., Efek Kompres Selimut Basah dan Cold-pack
2013). The combination of cold pack, water terhadap Suhu Tubuh Pasien Cedera Kepala di
spray and fan cooling given for 1 hour with 6 Neurosurgical Critical Care Unit. Jurnal
Keperawatan Padjadjaran, 3(3).
times repetition of intervention strongly Price, T., & McGloin, S. (2003). A review of cooling
influence the decrease in body temperature of patients with severe cerebral insult in ICU
patients with hyperthermia. (Part 1). Nursing in critical care, 8(1), 30-36.
Purwanti, S., & Nur Ambarwati, W. (2008). Pengaruh
Kompres Hangat terhadap Perubahan Suhu
Tubuh pada Pasien Anak Hipertermia di
Ruang Rawat Inap RSUD Dr. Moewardi
Surakarta. Jurnal Berita Ilmu Keperawatan.

!
Sari, E. K., Redjeki, I. S., & Rakhmawati, W. (2013). Susanti, N. (2012). Efektifitas kompres dingin dan
Perbandingan pengaruh water spray dan fan hangat pada penataleksanaan demam. Sainstis.
cooling menggunakan air hangat dengan air Werner, C., & Engelhard, K. (2007). Pathophysiology of
suhu ruangan terhadap penurunan suhu tubuh. traumatic brain injury. British Journal of
Jurnal Ilmu Keperawatan, 1(2), 150-156. Anaesthesia, 99(1), 4-9.
Scrase, W., & Tranter, S. (2011). Improving evidence- Wong, D. L. (2009). Buku Ajar Keperawatan Pediatrik
based care for patients with pyrexia. Nursing Vol 1 Wong.
Standard, 25(29), 37-41.
Setiawati, T. (2009). Pengaruh tepid sponge.
Universitas Indonesia, Jakarta.
Cite this article as: Dzulfaijah, N. E., Mardiyono., Sarkum., D Saha, D. (2017). Combination of cold
pack, water spray, and fan cooling on body temperature reduction and level of success to reach
normal temperature in critically ill patients with hyperthermia. Belitung Nursing Journal, 3(6), 757-
764.
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Wahyuni I, et al. Belitung Nursing Journal. 2017 December;3(6):765-770

EFFECT OF PREGNANCY EXERCISE ON DURATION OF THE FIRST AND

SECOND STAGE OF LABOR IN PRIMIGRAVIDA MOTHERS DURING
THE THIRD TRIMESTER OF PREGNANCY
Iin Wahyuni1*, Noor Pramono2, Titi Suherni1, Melyana Nurul Widyawati1
1
2
*Correspondence:
Iin Wahyuni
E-mail: iinwahyuni189@gmail.com
Abstract
Objective: This study aimed to examine the pregnancy exercise during the third trimester of pregnancy on duration of the
first and second stage of labor in primigravida at the Community Health Center of Sukamaju, Bandar lampung, Indonesia.
Methods: This study employed a quasy experimental design with posttest-only non-equivalent control group. This study
was conducted from 8 January 2017 to 12 February 2017 at the Community Health Center of Sukamaju. Forty-eight
primigravida mothers were selected using consecutive sampling, with 24 assigned in the experiment and control group. Data
were analyzed using Mann whitney and Chi square test.
Results: The average duration of the first stage of labor in the experiment group was 495 minutes and in the control group
was 685 minutes (p= 0.000); while the average duration of the second stage of labor in the experiment group was 42.5
minutes and in the control group was 68.75 minutes (p=0.000).
Conclusion: There was a statistically significant difference in the duration of the first and second stage of labor between
experiment and control group. It is expected for midwives in the community health centers to implement pregnancy exercise
program to help mothers in accelerating the delivery process.
Keywords: Pregnancy Exercise, First Stage Labor, Second Stage Labor
INTRODUCTION
Prolonged labor, also known as failure to as well as a serious infection for the mother
progress, occurs when the total duration of and fetus (Manuaba, 2012).
childbirth is greater than 24 hours
(Cunningham, Leveno, Bloom, Spong, & Efforts made by the the Government of
Dashe, 2014). There are two main types, one Lampung Indonesia in reducing maternal and
when the latent phase of labor is greater than infant mortality rate are by posyandu (a
8 hours and the other when the active phase of community based vehicle to improve child
labor is greater than 12 hours, which cervical survival and development), polindes (Health
dilation to the right of the alert line on the maternity Hub), health fund and TOGA
partograph (Cunningham et al., 2014). program. These activities are means of health
efforts that stand for the participation of the
One of complications from the prolonged community. In posyandu, the community held
labor is neonatal asphyxia, which the newborn a class of pregnant women organized by
is unable to breathe spontaneously and health facilities, ie the community health
regularly after birth accompanied by hypoxia center (Dinkes, 2014).
and hypothermia and often ends with acidosis

Wahyuni, I., Pramono, N., Suherni, T., Widyawati, M. N. (2017)!
!
Activities in the class of pregnant women aim inclusion criteria of the sample were
to prepare and train the muscles so that can be primigravida mother with 35 or 36 weeks of
utilized to function optimally in normal gestational age and stayed in the work area of
deliveries. It is because prolonged labor is the Community Health Center of Sukamaju
also caused by the power factor of mothers Lampung. The exclusion criteria of the
due to irregular contraction, no coordination sample were pregnant women who had a
and synchronization between the contraction, history of preeclampsia and other pregnancy
which leads to less no relaxation of the womb complications, such as history of bleeding, at
(Heardman, 1996). Doing pregnancy exercise risk of premature labor, slow intrauterine fetal
can be started at 28 weeks of gestation. The growth (IUGR) and mothers with fever.
recommendation of pregnancy exercise is
mainly aimed at pregnant women with normal Intervention
condition (Widyawati & Syahrul, 2014). Pregnancy exercise was given by a midwife
Pregnancy exercise is a form of exercise to who was certified to train the exercise. The
strengthen and also maintain the flexibility of exercise was performed 4 times in two weeks.
the abdominal wall, pelvic floor muscles that The movements arranged in pregnancy
will facilitate the process of normal labor. exercise were designed to eliminate the
Previous study revealed that the anxiety that arises before labor because it
implementation of pregnancy exercise in contains elements of relaxation that can
pregnant women can speed up the time of the stabilize the emotional condition of pregnant
second stage of labor as well as to relax the women.
pelvic floor muscle, and safe for the baby
(Gavard & Artal, 2008; Nagle, 2013; Some types of relaxation were applied in
Widyawati & Syahrul, 2014) . pregnancy exercise, namely breathing and
muscle relaxation. Breathing relaxation was
Preliminary study at the Community Health done by raising the abdomen when inhaling,
Center of Sukamaju Lampung showed that and deflating the stomach while exhaling
there were 21 cases of prolonged labor in slowly from the mouth; while muscle
primigravida during in the last 6 months relaxation was done through the stretching of
before this study. The average duration of first certain muscles for several seconds and then
stage of labor was more than 12.5 hours, and released. When pregnant women do the
in the second stage labor was more than 1.5 exercises correctly, it will feel a relaxation
hours. Thus, this study aimed to examine the effect on pregnant women who will be useful
exercise during the third trimester of to overcome the pressure or tension during
pregnancy on duration of the first and second pregnancy. Mastering diaphragm breathing
stage of labor in primigravida at the technique will make the diaphragm becomes
community health center of Sukamaju, strong to help the mother at the time of
Bandar lampung, Indonesia. straining, because at the time of straining, in
addition to contraction and abdominal
muscles, the diaphragm also actively pushes
METHODS the baby out.
Study design
This study employed a quasy experimental Instrument
design with posttest-only non-equivalent Partograph was used to monitor the process of
control group. labor. For primipara, the normal cervix
dilation in the first stage of labor is 12.5
Setting hours, and the second stage of labor was 1.5
This study was conducted from 8 January hour.
2017 to 12 February 2017 at the Community
Health Center of Sukamaju. Ethical consideration
Research subjects Ethical celarance was obtained from the
There were 48 primigravida mothers selected Ethics Comission of POLTEKKES Semarang
using consecutive sampling, with 24 assigned with No. 030/KEPK/Poltekkes-smg/EC/2017.
in the experiment and control group. The Inform consent was done in each respondent,
!
which the researchers gave the explanation Data analysis

about the benefits and procedures of the Data were analyzed using Mann Whitney and
study. Each respodents was signed a written Chi Square test.
informed consent prior to data collection.
RESULTS
30!
24.04! 24.38!
25!
20!
15!
10.38! 11! Interven6on! Control!
10!
5!
0!
Age!(year)! Educa6on!
Figure 1 Characteristics of respondents based on age and education in the experiment and control group
Figure 1 shows that the average age of The average of education in the experiment
respondents in the experiment group was group was 10.38 years with standard of
24.04 years old with standard of deviation of deviation of 1.527, and in the control group
2.789, with minimum of 20 years and was 11.00 years with standard of deviation of
maximum of 29 years; while the control group 3.036. Thus, the minimum duration of
was 24.38, with standard of deviation of education was 9 years (junior high school)
3.104, with minimum of 20 years and and the maximum was 12 years (senior high
maximum of 30 years. Homogeneity test school). Homogeneity test obtained p-value
obtained p-value 0.634 (>0.05), which 0.295 (>0.05), which indicated that there was
indicated that there was no significant no significant difference of age between the
difference of age between the experiment and experiment and control group.
control group.
16!
14!
14! 13!
12! 11!
10!
10!
8! Working! Not!working!
6!
4!
2!
0!
Interven6on! Control!
Figure 2 Characteristics of respondents based on working status in the experiment and control group

!
Figure 2 shows that the majority of indicated that there was no difference
respondents in the experiment and control characteristic of working status between both
group were working. Homogeneity test groups.
obtained p-value 0.590 (>0.05), which
800!
685!
700!
600!
500! 490!
Experiment!
400!
300! Control!
200!
68.75!
100!
42.5!
0!
Stage!I!labor! Stage!II!labor!
Figure 3 Duration of the first and second stage of labor in the experiment and control group
Figure 3 shows that the average duration of is influenced by age, eduation, and
the first stage of labor in the experiment group occupation.
was 495 minutes with SD of 56.645, and in
the control group was 685 minutes with SD of In this study, the age of respondents in the
39.232, with p-value 0.000 (<0.05), which experiment and control group ranged between
indicated that there was a significant 20 to 30 years old. The reproductive age is
difference in the duration of the first stage of divided into three groups, ie too young (<20
labor between both groups. While the average years), reproductive age (20-35 years) and too
duration of the second stage of labor in the old (> 35 years). As pregnancy requires extra
experiment group was 42.5 minutes with SD energy and greater power, labor at too young
of 13.105 minutes, and in the control group age can lead to complications of pregnancy
was 68.75 with SD of 13.929 minutes, with p- and childbirth, as reproductive organs for
value 0.000 (<0.05), which indicated that pregnancy are immature which may adversely
there was a statistically significant difference affect maternal health and fetal development
in the duration of the second stage of labor and growth. While at age > 35 years may also
between both groups. The mean difference in cause complications of labor due to maternal
the first stage of labor between the experiment age at risk, which there is a decline function
and control group was 85 minutes, and the of the organs due to the aging process
second stage of labor was 17.50 minutes. It (Hidayah, Andarini, & Anjaswarni, 2014).
could said that the duration of the first and
second stage of labor in the experiment group Whereas, educational factors determine
was faster that the duration in the control whether or not a person easily absorbs and
group. understands the knowledge they gain in
general, the higher a mother's education the
better her knowledge. Moreover, the
DISCUSSION knowledge gained by mothers during
The result of this study shows that the pregnancy affects the readiness of labor
characteristics of respondents are equal or associated with the mother's emotional level
homogeneous, which indicated that the (Berentson‐Shaw, Scott, & Jose, 2009). The
respondent's characteristic did not affect the work of the respondents was divided into two
outcome of intervention in both groups. It groups, ie 14 respondents were working
should be the same because the labor process during pregnancy and 10 did not work in the
!
treatment group. Work is an activity done to exercise enhances flexibility, strength and
meet the needs of life. In this case, the work maintains the cardiovascular system. The
might be a barrier for the mother for doing movement in pregnancy exercise is intended
pregnancy exercise. In accordance with the to prepare pregnant mothers physically and
research that factors affecting pregnancy mentally for a rapid labor (Susilowati, Rini, &
exercise is fatigue due to mother activity and Setyoningsih, 2013).
mother's work (Duncombe, Wertheim,
Skouteris, Paxton, & Kelly, 2009). CONCLUSION
In summary, pregnancy exercise four times in
Changes that occur in pregnant mothers can two weeks had a significant effect in reducing
take place physiologically, and it might be duration of the first and second stage of labor
complicated during pregnancy and labor. in pregnant women. Thus, it is expected that
Difficulties during pregnancy such as back health workers, especially midwives in the
pain or low back pain, pelvic pain, and community health centers to implement
shortness of breath can increase maternal and pregnancy exercise program to help mothers
infant mortality (Hidayah et al., 2014). in accelerating the delivery process.
Therefore, it is important for pregnant women
to check regularly during pregnancy.
REFERENCES
Pregnancy exercise as proposed in this study Berentson‐Shaw, J., Scott, K. M., & Jose, P. E. (2009).
is one of the activities in pregnancy that can Do self‐efficacy beliefs predict the
increase the mother's labor during childbirth. primiparous labour and birth experience? A
longitudinal study. Journal of Reproductive
Findings of this study revealed that there was and Infant Psychology, 27(4), 357-373.
a significant difference of the duration of the Cunningham, F., Leveno, K., Bloom, S., Spong, C. Y.,
first and second stage of labors between the & Dashe, J. (2014). Williams Obstetrics, 24e:
experiment and control group with p-value McGraw-Hill.
Dinkes. (2014). Health Profile of Lampung Province:
<0.05 after given pregnancy exercise. Department of Health of Lampung, Bandar
Lampung, Indonesia.
As we know that the duration of labor is Duncombe, D., Wertheim, E. H., Skouteris, H., Paxton,
influenced by 5 factors, namely labor, birth, S. J., & Kelly, L. (2009). Factors related to
fetal, psychological response and the exercise over the course of pregnancy
including women's beliefs about the safety of
assistant/helper (Manuaba, 2012); however, exercise during pregnancy. Midwifery, 25(4),
this study focused on the maternal strength 430-438.
factor/power which affects the length and Gavard, J. A., & Artal, R. (2008). Effect of exercise on
frequency of labor duration. pregnancy outcome. Clinical obstetrics and
gynecology, 51(2), 467-480.
Hasibuan, S. (2016). Hubungan Senam Hamil terhadap
Lama Persalinan Kala II pada Wanita
Findings of this study were in line with theory Primigravida di RSKIA Sadewa Yogyakarta.
stated that pregnancy exercise provides JKKI: Jurnal Kedokteran dan Kesehatan
benefits for pregnancy to childbirth. Indonesia, 11-15.
Heardman, H. (1996). Senam Hamil (Relaxation and
Implementation of pregnancy exercise can Exercise for Childbirth). Jakarta: Arcan.
increase the readiness of the mother to face Hidayah, R., Andarini, S., & Anjaswarni, T. (2014).
labor and increase contraction (Mintarsih, HUBUNGAN FAKTOR INTERNAL
2012). In addition, the benefits of pregnancy DENGAN PERAN SERTA IBU HAMIL
DALAM MENGIKUTI SENAM HAMIL.
exercise are mastering breathing techniques, Jurnal keperawatan, 5(1).
strengthening muscle elasticity, reducing Manuaba, I. B. G. (2012). Pengantar Kuliah Obstetri dan
complaints, training relaxation and avoiding Ginekologi Sosial: Jakarta: CV. Trans Info
labor difficulty (Hasibuan, 2016). Media.
Mintarsih, S. (2012). EFFEKTIFITAS SENAM HAMIL
TERHADAP LAMA PERSALINAN KALA I
This finding was also consistent with previous PRIMIPARA. Profesi, 8.
study with 4,069 respondents revealed that Nagle, J. A. (2013). Measuring exercise self-efficacy in
pregnancy exercise 3-5 times a week has a pregnant women: psychometric properties of
14% lower risk of pelvic pain during the pregnancy-exercise self-efficacy scale (P-
pregnancy. This is because pregnancy

!
ESES). Journal of nursing measurement, Widyawati, W., & Syahrul, F. (2014). Pregnancy
21(3), 349. Exercise Influence In Labor And Neonatal
Susilowati, D., Rini, T. H., & Setyoningsih, T. (2013). Health Status. Jurnal Berkala Epidemiologi,
Keteraturan Senam Hamil Terhadap Lama 1(2).
Persalinan Kala II Pada Ibu Bersalin. Journal
of Midwifery Science, 1(3), 147-151.
Cite this article as: Wahyuni, I., Pramono, N., Suherni, T., Widyawati, M. N. (2017). Effect of
pregnancy exercise on duration of the first and second stage of labor in primigravida mothers during
the third trimester of pregnancy. Belitung Nursing Journal, 3(6), 765-770.
!
Nisa R, et al. Belitung Nursing Journal. 2017 December;3(6):771-777

EFFECT OF ROSELLE (HIBISCUS SABDARIFFA) ON CHANGES IN

HEMOGLOBIN LEVELS IN PREGNANT WOMEN WITH ANEMIA
TAKING IRON SUPPLEMENT
Rif’atun Nisa*, Ariawan Soejoenoes, Sri Wahyuni
Postgraduate Midwifery Program, Semarang Health Polytechnic, Central Java, Indonesia
*Correspondence:
Rif’atun Nisa
E-mail: rivanisa24@gmail.com
Abstract
Background: Anemia during pregnancy is one of the most common disorders in pregnant women in Indonesia. The
Government has made efforts to overcome this problem, however, the rate of anemic mothers remains high. Rosella
(Hibiscus Sabdariffa) is considered able to increase the hemoglobin levels in pregnant mothers.
Objective: To analyze the effect of Rosella flower extract (Hibiscus Sabdariffa) on the increase of Hemoglobin level in
pregnant women with anemia receiving Fe tablet.
Methods: This study was a quasy experiment with pretest-posttest control group design conducted in November - December
2016 in the working area of Tlogosari Wetan Community Health Center. Forty-two participants were selected using
accidental sampling, which 21 assigned in the experiment and control group. All samples were pregnant women in the
second trimester suffering from anemia and receiving iron tablets. Hemoglobin levels were measured using hematology
analyzer in laboratory. Independent t-test and paired t-test were used for data analysis.
Results: Paired t-test obtained p-value 0.00 (<0.05), indicated that there was an increase of hemoglobin levels in both
experiment and control group. The mean increase of hemoglobin levels in the control group was 0.61 gr and in the
experiment group was 1.08. The hemoglobin levels in the experiment group were higher than the levels in the control group.
Independent t-test obtained p-value 0.000 (<0.05) indicating that there was a significant difference of mean of hemoglobin
levels between the control group and the treatment group.
Conclusion: The consumption of rosella extract combined with Fe tablet showed a significant increase of hemoglobin levels
compared with the consumption of Fe tablet alone. Therefore, it is suggested for midwife to use the result of this research as
a evidence practice through counseling for pregnant mother about utilization of rosella extract that can increase hemoglobin
level in pregnant woman with anemia.
Keywords: Rosella Extract, Hemoglobin Level, Pregnant Mother, Anemia, Fe Tablet
INTRODUCTION
Anemia is one of the most common disorders (hemodilution) beginning at 16 weeks of
during pregnancy. Anemia in pregnancy is a gestation and peak at 32-36 weeks of
condition of blood hemoglobin levels < gestation (Cunningham et al., 2014).
11g/dL in the first and third trimester, and
<10.5 g/dL in the second trimester The most common anemia in pregnancy is
(Cunningham, Leveno, Bloom, Spong, & due to iron deficiency and acute hemorrhage,
Dashe, 2014). Physiologically, maternal blood which is often related each other. The
circulation during pregnancy will have an consequences of anemia in pregnancy vary,
increase of blood volume, which the amount from very mild complaints to the occurrence
of blood serum is greater than blood cell of impaired pregnancy severity (abortion,
growth, resulting in blood thinning immature part/premature), labor impairment

Nisa, R., Soejoenoes, A., Wahyuni, S. (2017)!
(uterine inertia, uterine atony, old partus), 96.36% in 2013, 97.23% in 2014, and 97.05%
puerperal disorders (uterine subclinical, in 2015 (Dinkes, 2014).
resistance to infection and low milk
production), and impairment of the fetus In addition, the efforts made by the
(abortion, dysmaturity, microsomy, low birth Government of Semarang city to decrease the
weight, perinatal death, etc.) (Cunningham et incidence of anemia are through the formation
al., 2014; Manuaba, 2010). of team work in Maternal-Child Health, local
regulation of safety of mother and child,
According to the World Health Organization cooperation with universities in high risk
(WHO), the prevalence of anemia in pregnant pregnant women, recruitment of Health
women was 41.8% in the world, and Asia Surveillance (GASURKES) for data
ranks second in the world with percentage of collection and mentoring pregnant women, as
prevalence of anemia of 48.2% of pregnancies well as activities of assisting pregnant women
(WHO, 2012). Based on data of Riskesdas, until childbirth by health cadres (Dinkes,
the prevalence of anemia in pregnant women 2014). However, these efforts did not give a
in Indonesia amounted to 37.1%, and in significant decrease of anemia incidence in
Central Java Province was 57.7%; while in Indonesia, particularly in Central Java
the City of Semarang the prevalence of Province.
anemia in 2013 was 20.01%, in 2014 was
18.86% and in 2015 was 18.34%. It tells that Inhibition factors of iron absorption are
the prevalence of anemia has decreased influenced by substances that are mostly
slightly in the last three years (Kementerian found in plant foods. The strongest inhibitors
Kesehatan, 2013). Data from January to are polyphenol compounds such as tannins
March 2016, the incidence of anemia in present in tea. Tea can reduce absorption to
pregnant women in Semarang city was 80% as a result of the formation of iron-
highest in the Public Health Center of tannate complex. This is one of the factors
Tlogosari Wetan with 174 cases, followed by causing the coverage of Fe tablets has met the
the Public Health Center of Bandarharjo target but the incidence rate of anemia in
with144 cases and Public Health Center of pregnant women is still quite high (Arief,
Mijen with 115 cases of anemia (Dinkes, 2008; Varney, Kriebs, & Gegor, 2007).
2014). Rosella (Hibiscus Sabdariffa) is one of the
easiest growing herbs in many regions.
The government has made efforts to Generally this plant is known to have benefits
overcome the problem of anemia in Indonesia as antihypertensive drugs, diabetes, and
by launching the distribution of Fe tablet to antimitosis. This plant also has the highest
health service to be distributed to all pregnant mineral (Fe) and vitamin C content among
women for free. The distribution includes one other plants, such as Spinach (Amarthus
of the achievement targets in the Antenatal Janjeticus), Cassava leaf (Manihot esculenta),
Care (ANC). Four time of ANC visits is and Katuk leaf (Sauropus androgynous). The
considered sufficient, with one-time per content in 100gr of Rosella petals has iron as
trimester and twice in the last trimester much as 8.98 mg and vitamin C as much as
(Manuaba, 2010). Provision of at least 90 iron 244.4 mg (Kustyawati & Ramli, 2008).
tablets during pregnancy is also one of the
operational applications of minimum standard The role of vitamin C in the process of iron
of "7T" for antenatal care (Depkes, 2007). absorption is to help in reduction of iron ferri
(Fe3 +) to ferro (Fe2 +) in the small intestine.
The government program in regarding to the The reduction process will be greater when
distribution of Fe tablets for pregnant women the pH in the stomach is increasingly acid.
is almost reaching to the national target, and Vitamin C can also increase the acidity so it
the compliance of pregnant women in can increase the absorption of iron up to 30%.
consuming Fe tablets is good enough. The Vitamin C inhibits the formation of
coverage of 90 iron tablets in pregnant women hemosiderin, which is difficult to mobilize to
in Semarang city from 2013 until 2015 has free iron when necessary. The absorption of
reached the expected target (96%), which was iron in nonheme increases fourfold when
!
there is vitamin C. Vitamin C also plays a role type and amount of food that had been
in transferring iron from transferrin in plasma consumed within 24 hours.
to liver ferritin (Almatsier, 2002). Previous
study showed that Rosella calyx extract gave Ethical consideration
an effect to the increase of erythrocytes and Ethical clearance was obtained from the
hemoglobin (Hb) level in the blood of white Ethics Commission of POLTEKKES
rat. The most optimal dosage of Rosella's Semarang. The researchers have confirmed
extract to increase the amount of erythrocytes that all participants have signed informed
and hemoglobin (Hb) levels in the blood of consent prior to data collection.
white rats was 0.72 g/head/ day, followed by
doses of 0.36 and 0.18 g/head/day Data analysis
(Munawaroh, 2009). The purpose of this Univariate analysis was used to explain or
study was to prove the effect of Rosella describe the distribution and percentage of
flower extract (Hibiscus Sabdariffa) on each variable; and bivariat analysis used
changes in hemoglobin level in pregnant Independent t-test and paired t-test. Paired t-
women with anemia who got Fe tablet. test was used to compare the average of two
sets of data (data before and after
intervention) pairwise. In this study two sets
METHODS of data were hemoglobin levels before and
Research design after treatment in each sample group, at 95%
This study was a quasy experiment with of confidence level (α 0,05); while
pretest-posttest control group design to know Independent t-test was to identify differences
the effect of Rosella flower extract on changes in control and experiment group. Prior to
in hemoglobin level in pregnant women with bivariate analysis, the data normality test was
anemia who got iron tablet supplementation. performed by Shapiro-Wilk test, resulting on
This study aimed to reveal the possibility of a normal data distribution.
causal relationship between variables without
the manipulation of a variable. This research
was conducted in November - December 2016 RESULTS
in the working area of Tlogosari Wetan Characteristics of respondents showed that all
Community Health Center. respondents were not in high-risk category in
both control or treatment group, which was 21
Research subject people (100%). The majority of respondents
Forty-two participants were selected using had a middle education (47.6%), working a
accidental sampling, which 21 assigned in the private employee in control group (47.6%)
experiment and control group. All samples and a housewife (28.6%) in experiment group;
were pregnant women in the second trimester and the characteristics of respondents based
who had anemia and received iron tablets. on parity showed that most of the respondents
in the control group were multigravida (60%)
Intervention and in the experiment group were
The experiment group was given the extract primigravida (64.7%).
of Rosella petals with doses of 115.2 mg / kg
BW / day for 10 days together with iron
tablets, which was consumed at night; while Table 2 shows that the mean of hemoglobin
for the control group was only given iron levels in the experiment group before given
tablets. the intervention of Rosella extract and Fe
tablet were 9.31 g / dl with the lowest
Instrument hemoglobin level of 7.8 g / dl and the highest
Hemoglobin levels were measured using was 10.3 g / dl; while the mean of hemoglobin
hematology analyzer in laboratory. An levels after given intervention were 10.395 gr
observation sheet was used for checking the / dl with the lowest hemoglobin level of 9 g /
time for consuming the extract, and food dl and the highest of 11.8 gr / dl.
recall sheet was used as a tool to record the

The mean of hemoglobin level in the control hemoglobin levels after the intervention of
group before given the intervention of giving giving Fe tablet were 9.705 gr/dl with the
Fe tablets as much as 9.09 gr / dl with the lowest hemoglobin level was 8 gr / dl and the
lowest hemoglobin level of 7.3 gr / dl and the highest was 11 gr / dl.
highest was 10.4 gr / dl; while the average
Table 1 Characteristics of respondents
Experiment
Control group
Characteristic group p-value
f % f %
Age (year)
<20 0 0 0 0
20-35 21 100 21 100 -
>35 0 0 0 0
Education
Elementary 3 28.6 6 14.3 1.692
Middle 10 47.6 10 47.6
High 8 23.8 5 38.1
Occupation
Housewife 6 47.6 10 28.6
Entrepreneur 3 9.5 2 14.3 1.674
Private employee 11 38.1 8 52.4
Government employee 1 4.8 1 4.8
Parity
Primigravida 6 52.4 11 28.6 2.471
Multigravida 15 47.6 10 71.4
Table 2 Hemoglobin level before and after intervention in the experiment and control group
Hemoglobin Control group Experiment group

levels Before After Before After
Mean 9.090 9.705 9.310 10.395
Minimum 7.3 8.0 7.8 9.0
Maximum 10.4 11.0 10.3 11.8
Table 3 Mean Difference of hemoglobin levels before and after intervention in the experiment and control
group using Paired t-test
Paired t-test
Std. 95% CI Sig.
Group t df
Mean SD Error (2-tailed)
Mean Lower Upper
Control
-.6143 .4385 .0957 -.8139 -.4147 -6.420 20 .000
Pretest-posttest
Experiment
-1.0857 .3554 .0775 -1.2475 -.9240 -14.001 20 .000
Pretest-posttest
Paired t-test as shown in the table 3 obtained group was 0.61 gr and in the experiment
p-value 0.00 (<0.05), which indicated that group was 1.08. The hemoglobin levels in the
there was an increase of hemoglobin levels in experiment group were higher than the levels
both experiment and control group. The mean in the control group.
increase of hemoglobin levels in the control
!
Table 4 Mean Difference of hemoglobin levels in the experiment and control group
Levene's Test t-test for Equality of Means

95% CI of the
Sig. Mean Std. Error Difference
F Sig. t df (2-tailed) Diff Diff Lower Upper
Difference Equal
variances 1.164 .287 3.828 40 .000 .47143 .12317 .22250 .72036
assumed
Equal
variances 3.828 38.354 .000 .47143 .12317 .22217 .72069
not assumed
.
Table 4 shows that the value of significance supported by previous research revealed that
on Equal Variance Assumed was 0.287 there was an increase in Hb, serum ferritin,
(>0.05), which indicated that both sets of data body weight and BMI levels for those who
in the experiment and control group were were given vitamin C compared with the
homogeneous. While the result of control group (Asiyah, Rahayu, & Isnaeni,
independent t-test obtained p-value 0.000 2017); while Guntur Argana, Kusharisupeni,
(<0.05), with mean difference of 0.47 gr / dl and Diah M. Utari revealed that vitamin C is a
average, which indicated that there was a dominant factor on hemoglobin levels. The
significant difference of mean of hemoblobin role of vitamin C in the process of iron
levels between the control group and the absorption is to help reduce iron ferri (Fe3 +)
treatment group. to ferro (Fe2 +) in the small intestine so easily
absorbed. Vitamin C can increase the acidity
so it can increase iron absorption by up to
DISCUSSION 30% (Guntur & Kusharisupeni, 2004).
Findings of this study showed that there was a
significant effect of rosella extract combined Vitamin C is also known by other names
with Fe tablets on the increase of hemoglobin namely "cevitamic acid", "antiscorbutic
levels in pregnant women with anemia. This factor" and “scurvy preventive dietary
proves that rosella extract was effective for essential". There are two forms of active
human, especially in pregnant women in this vitamin C molecules, namely reduced form
study, as previous study revealed that rosella (ascorbic acid) and oxidized forms (dehydro
extract had a significant effect in increasing ascorbic acid). When dehydroscobic acid is
the number of erythrocytes and hemoglobin oxidized then it is converted into
level (Hb) in white rat (Rattus norvegius) diethylaconic acid that is biologically
(Munawaroh, 2009). inactive. Vitamin C is instrumental in the
formation of hemoglobin. In addition, vitamin
In this study the dose of Rosella flower C can help the absorption of potassium by
extract given to the respondent was 115.2 mg/ keeping potassium in the form of solution.
kg/day/day for 10 days. Each 100 grams of The need for pregnant women increases 10
dried Rosella petals contain 260-280 mg of mg / day, so the need per day becomes 70-85
vitamin C, including vitamin D and B2. mg / day. Consumption of vitamin C is said to
Vitamin C content is 3 times higher that black be good if consumption ≥ 100% based on
wine, 9 times higher than citrus, 10 times Nutritional Adequacy Rate, moderate if 80-
higher than the star fruit, and 2.5 times higher 90%, less if consumption 70-80%, and deficit
from guava. In addition, dried rosella contains when <70% (Susiloningtyas, 2017).
high calcium (486 mg / 100g), magnesium Additionally, roselle also contains protein,
and omega-3, vitamin A, iron, potassium, β- calcium, and other elements that are useful for
carotene and essential fatty acids (Winarti, the body. Amino acids contained in this plant
2010). include arginine, cystine, histidine, isoleucine,
leucine, lysine, methionine, phenylalanine,
The high vitamin C content in rosella is threonine, trytophan, tyrosine, valine, aspartic
helping the absorption of iron. This is

acid, glutamic acid, alanine, glycine, proline the result of this research as a evidence
and serine (Okasha, 2008). practice through counseling for pregnant
mother about utilization of rosella extract that
This study also revealed that there was an can increase hemoglobin level in pregnant
increase of hemoglobin levels after given iron woman with anemia.
tablets alone. However, the mean increase of
Hb levels was lower than Hb levels in the
experiment group. The need for iron in a REFERENCES
normal pregnancy is about 1000 mg. Almatsier, S. (2002). Prinsip dasar ilmu gizi: Gramedia
Approximately 300mg is actively in the Pustaka Utama.
Arief, N. (2008). Panduan lengkap kehamilan dan
transfer of fetus and placenta, and about 200 kelahiran sehat. Yogyakarta: Dianloka.
mg is lost along the various normal excretion Asiyah, S., Rahayu, D. E., & Isnaeni, W. D. N. (2017).
pathways. The need for iron becomes PERBANDINGAN EFEK SUPLEMENTASI
considerable high during second half of TABLET TAMBAH DARAH DENGAN
DAN TANPA VITAMIN C TERHADAP
pregnancy, with an average of 6 to 7 mg / day KADAR HEMOGLOBIN PADA IBU
(Cunningham et al., 2014). In addition, HAMIL DENGAN USIAKEHAMILAN 16-
pregnancy food with every 100 calories will 32 MINGGU DI DESA KENITEN
produce about 8-10 mg of iron. The KECAMATAN MOJO KABUPATEN
calculation of eating three times with 2,500 KEDIRI. Jurnal Ilmu Kesehatan, 3(1), 76-81.
calories will produce about 20-25 mg of iron & Dashe, J. (2014). Williams Obstetrics, 24e:
per day. During pregnancy with a calculation McGraw-Hill.
of 288 days, pregnant women will produce as Depkes. (2007). Pedoman Pelayanan Antenatal Jakarta:
much as 1,000 mg of iron, which still lacks. Dirjen Pelayanan Bina Medik: Dirjen
Pelayanan Bina Medik. Departemen
Therefore, iron intake is needed and able to Kesehatan Republik Indonesia. Jakarta.
increase Hb levels (Manuaba, 2010). Dinkes. (2014). Health profile of Semarang City:
Department of Health of Semarang, Indonesia.
Each tablet of iron contains 200 mg of Guntur, A., & Kusharisupeni, D. M. U. (2004). Vitamin
ferrosulfat and 0.25 mg of folic acid, given to C Sebagai Faktor Dominan Untuk Kadar
Hemoglobin Pada Wanita Usia 20-35 Tahun.
pregnant women to overcome the problem of Jurnal Kedokteran Trisakti. Januari-Maret,
iron nutritional anemia. Pregnant women get 23(1).
90 iron tablets during pregnancy Kementerian Kesehatan, R. I. (2013). Laporan Hasil
(Kementerian Kesehatan, 2013). However, Riset Kesehatan Dasar (Riskesdas) 2013.
Jakarta: Kementerian Kesehatan RIDinKes
many factors influence the absorption of iron Jateng.
in the body, such as tea, coffee, and milk Kustyawati, M. E., & Ramli, S. (2008). Pemanfaatan
(Varney et al., 2007). This study provides the hasil tanaman hias Rosela sebagai bahan
evidence that rosella extract can help the minuman. Paper presented at the Seminar
absorption of iron in increasing Hb levels in Nasional Sains dan Teknologi II. Universitas
Lampung, Lampung, Indonesia.
pregnant mothers. Manuaba, I. A. C. (2010). Ilmu Kebidanan, Penyakit
Kandungan, Dan KB Edisi 2: Jakarta:
Yayasan Bina Pustaka.
CONCLUSION Munawaroh, S. (2009). Pengaruh Ekstrak Kelopak
Rosela (Hibiscus Sabdariffa) Terhadap
It is concluded that the consumption of rosella Peningkatan Jumlah Eritrosit Dan Kadar
extract combined with Fe tablet showed a Hemoglobin (Hb) Dalam Darah Tikus Putih
higher increase of hemoglobin levels (Rattus Nurvegicus) Anemia. Malang:
compared with the consumption of Fe tablet Fakultas Sains dan Teknologi Universitas
alone. Therefore, pregnant women who have Islam Negeri Maulana Malik Ibrahhim.
Okasha, M. A. M., Abubakar, M.S., Bako, I.G. (2008).
anemia are recommended to consume Fe Study of the Effect of Aqueous Hibiscus
tablets accompanied by the consumption of Sabdariffa LinnSeed Extract on Serum
Rosella extracts containing vitamin C to help Prolactin Level of Lactating Female Albino
the absorption and increased levels of Rats. European Journal of Scientific
Research, 22(4), 575-583.
hemoglobin. It is expected the incidence rate Susiloningtyas, I. (2017). Pemberian Zat Besi (Fe)
of anemia in Indonesia that causes Dalam Kehamilan. Majalah Ilmiah Sultan
complications in pregnancy can be Agung, 50(128), 73-99.
suppressed. It is suggested for midwife to use
!
Varney, H., Kriebs, J. M., & Gegor, C. L. (2007). Buku Winarti, S. (2010). Makanan fungsional. Yogyakarta:
ajar asuhan kebidanan. Jakarta: EGC. Graha Ilmu, 137-165.
WHO. (2012). Worldwide prevalence of anaemia World
Health, Organization.
Cite this article as: Nisa, R., Soejoenoes, A., Wahyuni, S. (2017). Effect of roselle (hibiscus
sabdariffa) on changes in hemoglobin levels in pregnant women with anemia taking iron supplement.

Aditia DS, et al. Belitung Nursing Journal. 2017 December;3(6):778-783

BINAHONG LEAVES (ANREDERA CORDIFOLIA TENORE STEEN)

EXTRACT AS AN ALTERNATIVE TREATMENT FOR PERINEAL WOUND
HEALING OF POSTPARTUM MOTHERS
1* 2 1 3
Dita Selvia Aditia , Syarief Thaufik Hidayat , Nur Khafidhoh , Suhartono , Ari Suwondo4
1
Magister Apllied Midwifery Program, Health Polytechnic of Semarang, Semarang, Indonesia
2
3
Postgraduate Epidemiology Program, Diponegoro University of Semarang Indonesia
4
Health and Work Safety Department, Faculty of Public Health, Diponegoro University, Semarang, Indonesia
*Correspondence:
Dita Selvia Aditia
Magister Apllied Midwifery Program, Health Polytechnic of Semarang, Semarang, Indonesia
E-mail: aditiaselvia@gmail.com
Abstract
Background: Perineal wounds are at risk for infection, without a good treatment, perineal wound can harbor sepsis and
become a chronic, long-term problem. Binahong leaves is considered as an alternative to accelerate perineal wound healing
process.
Objective: To determine the effect of binahong leaf extract (anredera cordifolia (tenore) steen) on perineal wound healing
process in postpartum mothers.
Methods: This study employed a quasy experimental study with control group posttest-only design. The study was
conducted in the working area of Telogosari Wetan Health Center and Health Center of Kulon Kota Semarang in January-
February 2017. There were 36 respondents selected using purposive sampling assigned in the intervention group (Binahong
leaves extract) and the control group (Povidon Iodine 10%). REEDA scale was used for assessing perineal healing. Data
were analyzed using Mann Whitney, Chi Square and Kruskall Wallis test.
Results: Findings showed that the average day of perineal wound healing process in the binahong leaves group was 6.11
days and in the povidon iodine group was 7.66 days. There was a statistically significant difference in the duration of wound
healing between the experiment and control group with p-value 0,001 (p value <0.05).
Conclusion: Binahong leaves extract is effective in healing perineal wound in postpartum mothers. Therefore, binahong
leaves are recommended to use as an alternative treatment for the mothers.
Keywords: Binahong leaves, Perineal Wound, Postpartum Mother
INTRODUCTION
The period of the birth of the placenta and the experienced by mothers after childbirth
fetal membrane is a mark of the final period indicated that there are some mothers
of intrapartum to the return of the female continue to have problems (Marshall &
reproductive tract in nonpregnant conditions. Raynor, 2014). The birth canal wound may
This period is also called the puerperium occur due to the head of the fetus being born
period, and the woman with puerperium is too soon, labor not being led properly, and the
called puerperal. Postpartum recovery lasts need for episiotomy in order to avoid a wide
about six weeks (Mohamed & El-Nagger, perineal rupture (Prawirohardjo, 2006).
2012). Recent studies of morbidity

Aditia, D. S., Hidayat, S. T. , Khafidhoh, N., Suhartono., Suwondo, A. (2017)!
Perineal injury from episiotomy, rupture, or treated properly, then wound healing process
laceration is an area that is not easily becomes longer and can cause infection
maintained. In postpartum period, a mother (Potter & Perry, 2005). Perineal wound
will be susceptible to infection. Infections of infections due to episiotomy, rupture, or
this perineal injury can occur because the laceration are areas that are not easy to keep
mother has lack of understanding about how clean and dry, the act of cleaning the vulva
to care for the correct perineal wound, what may provide an opportunity for careful
the benefits and goals of perineal wound care, inspection of the perineal area.
no pay attention to good personal hygiene
which is one of the internal factors that inhibit On the other hand, perineal wound infections
wound healing (Prawirohardjo, 2006). are also common from birth attendant by a
Besides, the existence of 50% of an anaerobic shaman who is less concerned with hygiene
Streptococcus bacteria is the cause of during labor. If this is not treated promptly, it
infection (Mochtar, 2011). will lead to cervicitis, endocervical,
endometritis, parametritis and
This condition if not treated promptly will palveoperitonitis and abscesses. In response,
impact to the maternal mortaility rate. Based mother care can be done with local
on the report of the Community Health Center antibiotics, bethadine and hygiene to prevent
in Semarang City, maternal mortality in 2014 infection, clean the genital area every time
occurred as many as 33 cases from 26,992 after urination and defecation (Bahiyatun,
live births or about 122.25 per 100,000 live 2009).
births. Maternal mortality due to infection was
3.03%, with the condition during the Currently, herbal medicines become a trend in
puerperium was 54.55%. Based on data from Indonesia, one of which is Binahong leaves.
the Health Department in 2015, the maternal The chemical content contained in the
mortality rate as many as 35 cases increased Binahong Plant (Anredera Cordifolia (Tenore)
from 2014, and the incidence due to infection Steen) consists of oleanolic acid,
in 2015 in the working area of the Community antimicrobial, ascorbic acid, saponin
of Health Center of Telogosari Wetan was 1 triterpenoid flavonoid, and protein (Adriani et
mother and in the working area of the al., 2012). The content in binahong is also
Community of Health Center of Telogosari shown to have anti-inflammatory, anti-fever
Kulon was 1 mother (Dinkes, 2014). and anti parasitic effects. This can be an
alternative treatment, as providon iodine 10%
The wound can heal through the primary only has antiseptic but does not have anti
process (primary intention) that occurs when inflammatory content (Adriani et al., 2012).
the edge of the wound is approximated by
sewing it. The second healing through Clinical test on the content of binahong leaf
secondary processes (secondary intention) as extract has been done in several previous
the formation of granulation tissue and wound studies, with the content of binahong leaf
contraction (Mochtar, 2011). However, the extract, namely flavonoid, saponin, phenol,
perineal wound itself will have an impact for terpenoid, oleanolic acid, protein, asrobat
the mother that is discomfort disorders acid, antimikroba (Adriani et al., 2012;
(Prawirohardjo, 2006). Darsana, Besung, & Mahatmi, 2012; Widya,
Max, & Gayatri, 2013).
Wound healing process consists of three
stages, namely inflammatory stage, In addition, Adnyana, et al study has done a
poliferative stage, maturation stage. One of clinical trial on binahong leaves in patients
the factors that can accelerate the healing of with diabetic injuries regarding the extent of
the perineal wound includes vascularization, minimum inhibitory concentrations (KHM)
while factors that can slow wound healing and minimum killing (KBM) levels against
include anemia, age, other diseases, nutrition staphylococcus aureus and pseudomonas
and stress. Normally the wound can heal for aureginosa bacteria (Adnyana & Sukandar,
6-7 days when a mother can do well 2014).
treatment, on the contrary, if the wound is not

!
Therefore, this study aimed to examine the binahong leaf extract was given 2 times per
effect of binahong leaf extract on perineal day given during the healing period of the
wound healing process. perineal wound. Because the perineal wound
in this study was perineal wound level I with
no hecting, then it was considered that the
METHODS wound healing process will last for 6-7 days.
Study Design
A quasy experimental study with control While the control group received perineal
group posttest-only design wound care using providon iodine 10% in
liquid form. The providon iodine content of
Setting 10%, given 2 times per day. The 10% of
The research was conducted in the working iodine administration was performed during
area of Telogosari Wetan Health Center and perineal wound healing for 7-8 days. At the
Health Center of Kulon Kota Semarang in initial treatment of binahong leaf extract and
January-February 2017. providon iodine 10% provision was assisted
by the researcher so that the respondents can
Population and Sample perform as recommended by the researcher
There were 36 respondents selected using for the next days.
purposive sampling assigned in the
intervention group (Binahong extract) and the Instruments
control group (Povidon Iodine 10%). To assess postpartum perineal trauma in this
study, the REEDA scale was used. The
The inclusion criteria of the sample were a REEDA scale is a tool for assessing perineal
mother with a normal delivery, parity > 1, healing that was primarily developed by
postpartum 6-10 hours, postpartum with Davidson (Davidson, 1974) and later
perineal wound of degree I with no hecting, reviewed by Carey (Alvarenga et al., 2015) It
willing to use binahong leaf extract for includes five items related to the healing
perineal wound treatment (intervention process: hyperaemia, oedema, ecchymosis,
group), and willing to use providon iodine discharge and coaptation of the wound edges
10% for the treatment of perineal wound (Redness, Oedema, Ecchymosis, Discharge,
(control group). The exclusion criteria Approximation - REEDA) (see Figure 1). The
included a mother who had a history of length of time and level of wound density
diabetes, BMI <18.4, and had a food obstacle. were measured and observed one day after
treatment.
Intervention
Binahong leaf extract was administered by Ethical Consideration
dropping 5-10 drops directly on the mother's This study has been approved by the Health
perineal wound or by dropping 10 drops in Research Ethics Committees (K.E.P.K) of the
sterile gauze and then gently rubbing on the Health Polytechnic of Semarang with number:
perineal wound of the mother. The dosage 033 / KEPK / Poltekkes-SMG / EC / 2017.
given to each mother was 0.5 g (500 mg) of Prior to data collection, informed consent in
thick extract of binahong leaf dissolved into each respondent was performed.
using aquadest of 60 ml, then shaved with a
special tool until the extract blended with the Data Analysis
solvent to obtain 0.8 % of concentration of Data were analyzed using Mann Whitney, Chi
dose extract leaf binahong liquid. The use of Square and Kruskall Wallis test.
!
Figure 1 REEDA Scale (Alvarenga et al., 2015)
RESULTS 28.83 years old. The majority of the

Characteristics of the respondents based on respondents had senior high school
age, education, changing pad, and Hb level background. The hemoglobin level in the
of postpartum mothers experiment group was 10.95 gr/dL and in the
control group was 10.68 gr/dL. The majority
Figure 2 and 3 show that the average of the of them between the two groups changed the
respondents’ age in the experiment group was pads 3-4 times per day.
25.56 years old and in the control group was
40!
28.83!
30! 26.56!
20!
10.95! 10.68!
10! Experiment!group!
3.94! 3.78!
0! Control!group!
Age! Changing!pad! Hb!level!
Figure 2 Characteristics of the respondents based on age, changing pad, and Hb level of postpartum mothers
77.80%!
66.70%!
33.30%!
22.20%! Experiment!group!
0! 0! Control!group!
Elementary!school! Senior!high!school! University!level!

Figure 3 Characteristics of the respondents based on education level of postpartum mothers
The average day of perineal wound control group was 7.66 days. Binahong
healing process leaves extract group shows a faster wound
As shown in the figure 4, the average day of healing process compared with healing
perineal wound healing process in the process in the control group.
experiment group was 6.11 days and in the

!
7.66!
6.11!
Binahong!leaf!
Providon!Iodine!10%!
Day!
Figure 4 The average day of perineal wound healing process
Table 1 Change analysis of REEDA (Redness, Edema, Ecchymosis, Discharge dan Approximation) in the
experiment and control group in the fifth day using Kruskal Wallis
REEDA Dimension Experiment group Control group P-value
Redness 0.61±0.502 1.11±0.232 0.000
Edema 0.06±0.236 0.89±0.323 0.000
Ecchymosis 0.11±0.323 0.50±0.514 0.013
Discharge 0.11±0.323 0.44±0.511 0.028
Approximation 1.00±0.000 1.39±0.502 0.004
REEDA 1.00±0.000 1.11±0.323 0.000
Mean difference of REEDA (Redness, Edema, experiment group with binahong leaves
Ecchymosis, Discharge dan Approximation) extract shows a better perineal wound healing.
between the two groups as shown in the Table Kruskal wallis test shows that there was a
1 indicated that REEDA in the experiment significant difference of REEDA score
group has the lower scores compared with the between the experiment and control group
score in the control group. It could be said the with p-value in each dimension <0.05.
Table 2 Analysis of difference of perineal wound healing process using Mann Whitney test
Duration of wound healing Experiment group Control group 0.000
Mann Whitney test as shown in the table 2 perineal wound healing would last for 6-7
showed p-value 0.000 (<0.05), which days if no infection occurs (Prawirohardjo,
indicated that there was a statistically 2006). Wound is a process in which the
significant difference in the duration of damaged tissue is restored to normal and there
wound healing process between the will be an inflammatory reaction divided into
experiment and control group. several phases of wound healing, namely the
inflammatory phase that occurs in the 1st–4th
day characterized by erythema, warmth to the
DISCUSSION skin, edema and pain. The proliferative phase
Perineal wound is the missing or damaged in the 5th – 20th day is the formation of
part of the body tissue located between the granulation tissue to cover defects or injured
vulva and the anus with an average length of 4 tissue. The maturation phase occurs on the
cm (Prawirohardjo, 2006). Wound care in this 21st day until one month even reaching the
study is done 3 times by dripping or rubbing year (Adriani et al., 2012).
the liquid extract of binahong leaves to the
perineal injury. This was done referring to a Findings of this study revealed that there was
good time for perineal wound care, namely a significant effect of Binahong leaf on the
when bathing, urination, and defecation (at perineal wound healing process, and there was
least 3 times per day) by washing the wound a significant difference of REEDA score
area cleanly from the front of the vagina between the use of binahong leaves and
towards the back of the vagina, wipe dry and povidon iodine 10% (one day difference).
give antibiotics (Lumbessy, Abidjulu, & Thus, it could be said that binahong leaf has a
Paendong, 2013). better result in wound healing process.
The results of this study were in accordance Binahong leaves are considered having a
with previous study indicated that basically flavonoid content that serves as anti-
!
inflammatory, anti-septic, antioxidants and Alvarenga, M. B., Francisco, A. A., Oliveira, S. M. J. V.

analgesic. This is in line with previous study d., Silva, F. M. B. d., Shimoda, G. T., &
Damiani, L. P. (2015). Episiotomy healing
proved that binahong leaf extract accelerates assessment: Redness, Oedema, Ecchymosis,
wound healing in infection in mice (Firdausi, Discharge, Approximation (REEDA) scale
2015). Supported by Darsana, et al indicated reliability. Rev Lat Am Enfermagem, 23(1),
that the higher the binahong content used, the 162-168.
Bahiyatun, S. P. (2009). Buku Ajar Asuhan Kebidanan
greater the inhibition of bacterial growth. The Nifas Normal.
mechanism of inhibition of the growth of Darsana, I. G. O., Besung, I. N. K., & Mahatmi, H.
microorganisms is by destroying the (2012). Potensi daun binahong (Anredera
peptiglodikan components in bacterial cells by cordifolia (Tenore) Steenis) dalam
alkaloids, polyphenols, saponi, flavonoids menghambat pertumbuhan bakteri Escherichia
Coli secara In vitro. Indonesia Medicus
(Darsana et al., 2012). Veterinus, 1(3).
Davidson, N. (1974). REEDA: evaluating postpartum
This study provides the evidence that healing. Journal of nurse-midwifery, 19(2), 6-
binahong leaves are effective to use in the 8.
Dinkes. (2014). Health profile of Semarang City:
healing process of perineal wound. In Department of Health of Semarang, Indonesia.
addition, binahong plants are very easy to Firdausi, R. N. (2015). Pengaruh ekstrak etanol
obtain and planted in home gardening without binahong (Anredera cordifolia (Ten). Steenis)
any special cares. terhadap profil histopatologi penyembuhan
luka tikus Wistar jantan yang diinduksi
aloksan.
CONCLUSION Lumbessy, M., Abidjulu, J., & Paendong, J. J. E. (2013).
It can be concluded that binahong leaves has a Uji Total Flavonoid Pada Beberapa Tanaman
significant effect on perineal wound healing Obat Tradisonal Di Desa Waitina Kecamatan
process in postpartum mothers. Therefore, Mangoli Timur Kabupaten Kepulauan Sula
Provinsi Maluku Utara. Jurnal Mipa Unsrat
binahong leaves are recommended to use as Online, 2(1), 50-55.
an alternative treatment for the mothers. Marshall, J. E., & Raynor, M. D. (2014). Myles'
However, further research is needed to Textbook for Midwives: Elsevier Health
explore the effect of binahong leaves for Sciences.
mothers who have hecting perineal wound. Mochtar, R. (2011). Sinopsis Obstetri: obstetri fisiologi,
obstetri patologi. Jakarta: EGC.
Mohamed, H. A. E., & El-Nagger, N. S. (2012). Effect
REFERENCES of self perineal care instructions on episiotomy
Adnyana, I. K., & Sukandar, E. Y. (2014). KAJIAN pain and wound healing of postpartum
AKTIVITAS PENYEMBUHAN LUKA DAN women. J Am Sci, 8(6), 640-650.
ANTIBAKTERI BINAHONG (Anredera Potter, P. A., & Perry, A. G. (2005). Buku ajar
cordifolia (Ten.) STEENIS, PEGAGAN fundamental keperawatan: konsep, proses, dan
(Centella asiatica (L.) Urban) SERTA praktik. Jakarta: EGC, 1.
KOMBINASINYA TERHADAP BAKTERI Prawirohardjo, S. (2006). Buku acuan nasional
Staphylococcus aureus DAN Pseudomonas pelayanan kesehatan maternal dan neonatal
aeruginosa DARI PASIEN LUKA KAKI [National reference book of maternal and
DIABETES. new Bionatura, 16(2). neonatal health services]. Jakarta: Yayasan
Adriani, W. P., Ardianingtiyas, I., Wulansari, N. H., Bina Pustaka.
Safitri, D. N. a., Ap, I. P., & Mahanani, E. S. Widya, S., Max, R. J. R., & Gayatri, C. (2013).
(2012). Uji Pemanfaatan Daun Binahong Kandungan Flavonoid dan Kapasitas
(Anredera Cardifolia (Tenore) Steenis) Pada Antioksidan total ekstrak etanol daun
Proses Penyembuhan Luka Gingiva Tikus binahong(Anredera cordifolia). Steenis.
Wistar (Rattus norvegicus) Melalui Pharmacon, 2(1), 18-22.
Pengamatan Kepadatan Serabut Kolagen Dan
Ketebalan Epitel. Insisiva Dental Journal,
1(2).
Cite this article as: Aditia, D. S., Hidayat, S. T. , Khafidhoh, N., Suhartono., Suwondo, A. (2017).
Binahong leaves (anredera cordifolia tenore steen) extract as an alternative treatment for perineal
wound healing of postpartum mothers. Belitung Nursing Journal, 3(6), 778-783.

Hesti KY, et al. Belitung Nursing Journal. 2017 December;3(6):784-790

EFFECT OF COMBINATION OF BREAST CARE AND OXYTOCIN

MASSAGE ON BREAST MILK SECRETION IN POSTPARTUM MOTHERS
Kadek Yuli Hesti1*, Noor Pramono2, Sri Wahyuni1, Melyana Nurul Widyawati1, Bedjo Santoso3
1
Postgraduate Midwifery Program, Politeknik Kesehatan Kementrian Kesehatan Semarang, Central Java, Indonesia
2
SMF Obstetri Ginekologi, Faculty of Medicine, Universitas Diponegoro, Semarang, Central Java, Indonesia
3
Program Studi Terapis Gigi dan Mulut, Program Pascasarjana Magister Terapan Kesehatan, Politeknik Kesehatan
Kementrian Kesehatan Semarang, Central Java, Indonesia
*Correspondence:
Kadek Yuli Hesti
E-mail: : k_dekyuli@yahoo.co.id
Abstract
Background: Optimal nutrition from an early age can be achieved through exclusive breastfeeding (ASI). Lack of milk
production is one reason why mothers decide to give formula milk to their babies. Preliminary study at Public Health Center
of Batealit Jepara indicated that 60% of mothers unable to breastfeed optimally, thus, breast care and oxytocin massage are
proposed to increase milk secretion in postpartum mothers.
Objective: To examine the effect of combination of breast care and oxytocin massage on breast milk secretion in postpartum
mothers.
Methods: This was a quasy experimental study with non-randomized control trial with pretest-posttest control group,
conducted in the working area of the Community Health Center of Batealit of Jepara from December 5, 2016 to January 15,
2017. There were 44 postpartum mothers recruited in this study using purposive sampling, which 22 assigned in the
experiment and control group. Data were analyzed using dependent t-test and Mann Whitney test.
Results: There was a significant increase of breast milk secretion in the experiment and control group with p-value 0.000
(<0.05). In the experiment group, there was an increase of breast milk seceretion from 17.09 to 220.91 cc, and in the control
group there was also an increase from 17.09 to 72.00 cc. The mean difference of breast milk secretion between pretest and
posttest in the experiment group was 203.82 and in the control group was 54.90 with p-value 0.000 (<0.05)
Conclusion: There was a significant increase of breast milk secretion in postpartum mothers after given the combination of
oxytocin massage and breast care in the experiment group compared with the education and counseling about breast care in
the control group. Thus, this result can be used as an evidence to perform oxytocin massage and breast care to increase the
secretion of breast milk in postpartum mothers.
Keywords: Breast Care, Oxytocin Massage, Breast Milk Secretion
INTRODUCTION
Adequate nutrition during infancy will provision of breast milk exclusively for
promote rapid growth and development newborns (Dewey, 2013).
during the golden period (Dewey, 2013).
Good nutritional support should be supported Data from the United Nations Children's Fund
by opportunities for social, psychological, and (UNICEF) indicated that the coverage rate of
educational interaction between parents and early initiation of breastfeeding practices in
their babies. Provision of optimal nutrition the world was 42% (World Health & Unicef,
from an early age can be given through the 2014). The prevalence of early breastfeeding

Hesti, K. Y., Pramono, N., Wahyuni, S., Widyawati, M. N., Santoso, B. (2017). !
initiation in Indonesia is still lower at 39%. coverage of exclusive breastfeeding has

This figure is still very low when compared to increased from year to year, from 45.86% in
other countries in some Southeast Asian 2011 to 49.96% in 2012, and increased to
countries such as Myanmar (76%), Thailand 57.67% in 2013 and 2014. However,
(50%), and Philippines (54%). This indicates exclusive breastfeeding coverage in Central
that early initiation of breastfeeding programs Java is very far from the target of 80%. While
in Indonesia has not been fully implemented according to Department of Health of Jepara
(World Health & Unicef, 2014). showed that the coverage of exclusive
breastfeeding in 2013 amounted to 66.8%,
Early lactation or breastfeeding in the first increased to 71.3% in 2014 and decreased to
hour after birth will stimulate an increase in 69.39% in 2015. Initial breastfeeding data
prolactin in the blood and peak in the first 45 assessed from the implementation of early
minutes. If breast-milk is discharged or breastfeeding initiation in 2013 was 95%, and
emptied thoroughly, it will increase milk in 2014 was 99%, which has already been
production. Early breastfeeding may affect good because the coverage target of the
breastfeeding in infants up to 6 months of age initiation of breastfeeding in 2016 was 41%.
(exclusive breastfeeding) (Geneva, 2001). Of 21 community health centers in Jepara
regency, Batealit Community Health Center is
The results of a study in Kuwait conducted on the third lowest coverage of initial
373 breastfeeding mothers after returning breastfeeding with 45.80% (Dinkes, 2014).
from the hospital revealed that only 111
(29.8%) of breastfeeding mothers who Based on the preliminary study at Batealit
succeeded in breastfeeding at the beginning of Public Health Center in April 2016, of 10
labor, 205 mothers (55.0%) mixed breast milk postpartum mothers, six postpartum mothers
and breastfeeding, and the rest of 57 mothers said they were not able to breastfeed
or 15.3% were given only complementary maximally in the first three days after birth
feeding (Arora et al., 2017). Other studies because milk was not released so it was
conducted on breastfeeding mothers in Arab assisted with formula milk, while four others
showed that there was 57% of early initiation stated that only a little milk production. From
of breastfeeding, 18.9% of <6 months the results of further interviews, it was found
exclusive breastfeeding, and 49.9% of that six postpartum mothers can breastfeed
breastfeeding mothers up to one year age (Al- smoothly on the fourth and fifth day, while
Kohji, Said, & Selim, 2012); while in Uganda the other four postpartum mothers have been
breastfeeding in the first hours after delivery able to breastfeed from the first day
averaged 46% - 56% (Bbaale, 2014). postpartum.
Chairman of Lactation Center of Indonesia Lack of milk production is one reason why
(SLI), Dr. Utami Roesli said that the mothers decide to give formula milk to their
possibility of infant death due to various babies. UNICEF confirmed that infants who
infectious diseases would be higher if a new use infant formula have the possibility of
mother does not immediately give breast milk dying in the first month of their birth, and the
to her baby after labor. One of the causes of possibility of formula-fed infants is 25 times
infant and under-five mortality is the higher in mortality rates than breastfed infants
nutritional factor due to poor exclusive exclusively. Research conducted at
breastfeeding (Yasmin, 2016). Based on Basic Kilimanjaro Tanzania shows that exclusive
Health Research (Riskesdas), the coverage breastfeeding is effective to prevent toddler
rate of exclusive breastfeeding in Indonesia mortality up to 13% -15% (Mgongo, Mosha,
was only 42 percent. This is clearly below the Uriyo, Msuya, & Stray-Pedersen, 2013).
WHO target, which requires minimum
breastfeeding coverage of 50 percent (MOH, Failure in the breastfeeding process is often
2013). caused by several factors, such as maternal
factors, infant factors, psychological factors,
Based on the profile of Health Office of socio-culture, and health personnel factors.
Central Java Province showed that the One of the main maternal factors is lack of

!
breast milk production, which is strongly milk production (Meng, Deng, Feng, Pan, &
influenced by psychological factor. Mothers Chang, 2015).
who are depressed, sadness, lack of
confidence and various forms of emotional Therefore, with the phenomena explained
tension will decrease the volume or even stop above and the effect of breast care and
breast milk production. Lack of milk oxytocin massage, this study aimed to
production in the first days after delivery can examine the effectiveness of breast care and
be caused by a lack of stimulation of prolactin oxytocin massage in increasing breast milk
and oxytocin hormones, which play a role in production in postpartum mothers in the
the smooth production of breast milk working area of the community health center
(Widayanti, 2014). of Batealit Jepara.
Techniques to increase breast milk production

include breast care, breast gymnastics, breast METHODS
massage and oxytocin massage. Breast care is Study design
the maintenance of breast to facilitate breast This was a quasy experimental study with
milk and avoid difficulties when breastfeeding pretest-posttest control group design.
by doing massage. Breast care stimulates the
receptor in the ductal system, causing the duct Setting
to become wide and soft, thus releasing The study was conducted in the working area
oxytocin from the posterior pituitary gland of the Community Health Center of Batealit
(Sutrisminah & Alfiyati, 2015). In addition, of Jepara from December 5, 2016 to January
oxytocin massage is one solution to overcome 15, 2017. The area of the Community Health
the insufficiency of milk production. The Center spread in 11 villages, namely: Beringin
oxytocin massage is a massage along the side village, Bate village, Bawu village, Mindahan
of the spine to the fifth-sixth costae bone and village, Ngasem village, Geneng village,
is an attempt to stimulate the hormone Raguklampitan village, Samosari village,
prolactin and oxytocin after delivery. This Rajekwesi village, Bantrung village and
massage works to increase the hormone Pekalongan village.
oxytocin that can calm the mother, so that
milk is also automatically out (Suwondo & Population and Sample
Wahyuni, 2015). Previous studies showed that There were 44 postpartum mothers recruited
normal postpartum mothers who were given in this study using purposive sampling, which
oxytocin massage had a faster breast milk 22 assigned in the experiment and control
production (6.21 hours after delivery) group. The inclusion criteria of the samples
compared with mothers who did not receive included: 1) A postpartum mother at the first
an oxytocin massage (8.93 hours after day (1 x 24 hours), 2) Babies only got breast
delivery). Another study found a significant milk alone without any additional drinks or
influence of oxytocin massage therapy in food, 3) Good baby suction reflexes, 4)
increasing milk production that is equal to Baby’s weight > 2500 gr, and 5) Mothers did
72% (Ummah, 2014). The results of research not consume herbs or breast milk
in Central Java showed a combination of supplements. The inclusion criteria included:
marmet technique and oxytocin massage can 1) Mothers with unhealthy or emergency
increase milk production (Karuniawati, conditions, 2) Mothers who were smoking,
Fauziandari, & Wulandari, 2014). According and 3) Mothers with chronic energy
to research in South Korea, the postpartum deficiency (upper arm circumference <23.5
mother who performed breast care can reduce cm). From 11 villages in Batealit Jepara Sub-
breast pain and increase milk production so as district, there were 8 villages with the number
to increase the intensity of breastfeeding in of postpartum mothers: Bringin village (6
infants (Ahn, Kim, & Cho, 2011). While mothers), Batealit village (9 mothers), Bawu
research in China revealed that breast care village (5 mothers), Manti village (7 mothers),
through breast massage and aloe vera Ngasem village (5 mothers), Geneng village
compresses in postpartum mothers can reduce (3 mothers), Raguklampitan village (4
breast pain and is more effective in increasing mothers), and Samosari (5 mothers).
!
sheet developed by the researcher.

Intervention Demographic data of the mothers were also
Intervention was given to the experiment recorded including name (initials), age,
group was the combination of breast care and education, employment and parity.
oxytocin massage. Breast care was performed
with soft massage techniques, and Ethical consideration
compressing and sorting on the breast and in The ethical approval of the study was
the areola area, while oxytocin massage is a obtained from the Health Research Ethic
circular massage performed from the neck, Committee of Poltekkes Kemenkes Semarang
scapula, until the spine (costae 5-6), with number: 031 / KEPK / Poltekkes-SMG /
performed in the morning and evening, with EC / 2017. Prior to data collection, informed
duration 15-20 minutes for three days consent was signed by each respondent.
conducted by researchers and enumerators.
The control group was given an education and Data analysis
counseling about breast care. Shapiro Wilk test was used for testing
normality of data. Dependent t-test was
Instrument performed for normal data distribution and
To measure the volume of breast milk Mann Whitney for non-normal data
production, breast milk pump was used distribution. To identify difference of breast
manually. The volume of breast milk (cc milk secretion between the experiment control
format) was then recorded in the observation group, Independent t-test was performed.
RESULTS
Table 1 Characteristics of respondents

Variable Experiment group Control group P-value
Age (year)
Minimum 20 18 0.758
Maximum 36 36
Mean(SD) 27.18 (5.252) 26.68 (5.446)
Education (year)
Minimum 6 6 0.784
Maksimum 16 16
Mean(SD) 11.77 (2.776) 11.50 (3.036)
Occupational status
Employed 12 14 0.544
Unemployed 10 8
Parity (Total)
Minimum 1 1 0.831
Maximum 4 4
Mean(SD) 1.91 (0.868) 1.95 (0.844)
Table 1 shows that the average of age of the All variables showed p-value >0.05, which
respondents was 27.18 years on the indicated that there was no significant
experiment group and 26.68 in the control difference of the characteristics of the
group. The mean of education of respondents respondents between the experiment and
in the intervention group was 11.77 years and control group. It could be said that both group
in control group was 11.50 years, with were homogeneous.
minimum 6 years (Elementary school) and 16
years (university level). The majority of them Breast milk secretion in the experiment
were employed, and multiparity with and control group
minimum 1 and maximum 2. Table 2 shows that there was a significant
increase of breast milk secretion in the
experiment and control group with p-value

!
0.000 (<0.05). In the experiment group, there cc. It could said the secretion of breast milk in
was an increase of breast milk seceretion from the experiment group was better than the
17.09 to 220.91 cc, and in the control group secretion in the control group.
there was also an increase from 17.09 to 72.00
Table 2 Breast milk secretion in the experiment and control group using paired t-test
Variable Experiment group Control group
Pretest (cc)
Mean(SD) 17.09 (SD 5.032) 17.09 (SD 5.032)
Postest (cc)
Mean(SD) 220.91 (SD 54.328) 72.00(SD 28.947)
t count 18.603 8.633
P-value 0.000 0.000
Mean difference of breast milk secretion in and in the control group was 54.90 with p-
the experiment and control group value 0.000 (<0.05). It can be concluded that
Table 3 shows that the mean difference of the experiment group showed the higher
breast milk secretion between pretest and increase of breast milk secretion compared
posttest in the experiment group was 203.82 with the control group.
.
Table 3 Mean difference of breast milk secretion in the experiment and control group using Mann Whitney
Experiment Control
Variable P-value
group group
Mean difference of breast milk secretion (cc)
Mean 203.82 54.90 0.0001
(SD) (51.389) (29.83)
DISCUSSION
Findings of this study showed that there was a mothers 0-3 months, with average amount of
significant increase of breast milk secretion milk production of 40.83 ml, with minimum
after given breast care and oxytocin massage. of 18 ml and maximum of 65 ml (Muliani,
It proved that the combination of these 2013).
interventions showed a significant effect on
breast milk secretion. In fact, the breast milk This is also consistent with the previous study
secretion in the experiment control was higher showed that most of postpartum mother have
than its secretion in the control group. a very good breast milk secretion after given
breast care (Safitri, Wijayanti, & Werdani,
The combination of breast care and oxytocin 2016). This was supported by research that
massage is a combination of two methods of there was a significant relationship between
massage on the breast through the provision breast care in postpartum mother with the
of stimuli to the muscles of the breast and smooth breast milk secretion (Rosita, 2017).
back of the mother in order to provide In addition, the movement in breast care is
stimulation to the mother's milk glands in very effective to increase the volume of breast
order to produce milk and trigger the hormone milk, but it is useful to launch reflexes of
oxytocin or let down reflex and give comfort breast milk secretion, and prevent dam in the
and create a sense of relaxation in the mother. breast. It proves that breast care can increase
The combination of these two methods leads milk production (Latifah, Wahid, & Agianto,
to increased breastfeeding production through 2015). In addition to breast care, oxytocin
touch stimulation of the breast and the massage gives another positive effect on
mother's back, which will stimulate the breast milk secretion in this study. It is in line
production of oxytocin causing a contraction with the previous study showed that there was
of myophitel cells (Muliani, 2013). This is in an increase of breast milk secretion (283.73
line with research in Tegal revealed that front ml) in the mothers who were received
and back massage of the breast can affect the oxytocin massage compared with those who
increase of breastfeeding production in were not received oxytocin massage (221.35
!
ml) (Widiyanti, Setyowati, Sari, & Susanti, among Arab mothers in Qatar. Saudi Med J,
2014). Another study revealed that the 33(4), 436-443.
Arora, A., Manohar, N., Hayen, A., Bhole, S.,
oxytocin massage for at least 2 hours could Eastwood, J., Levy, S., & Scott, J. A. (2017).
accelerate breast milk secretion. It was also Determinants of breastfeeding initiation
found that the amount of colostrum released among mothers in Sydney, Australia: findings
by postpartum mothers after given oxytocin from a birth cohort study. International
breastfeeding journal, 12(1), 39.
massage was 5.333 cc in average while in the Bbaale, E. (2014). Determinants of early initiation,
control group was 0.0289 cc in average exclusiveness, and duration of breastfeeding in
(Wulandari, Aminin, & Dewi, 2016). Study in Uganda. Journal of health, population, and
Makassar revealed that there was a significant nutrition, 32(2), 249.
correlation between oxytocin massage and Dewey, K. G. (2013). The challenge of meeting nutrient
needs of infants and young children during the
breast milk secretion in c-section mothers period of complementary feeding: an
(Gustriani, 2015). evolutionary perspective. The Journal of
nutrition, 143(12), 2050-2054.
In this study, there was also an increase of Dinkes. (2014). Health Profile of Central Java Province:
breast milk production in the control group, Geneva, S. (2001). The optimal duration of exclusive
which is in line with the theory stated that breastfeeding. A systematic review. Geneva
from the first until the third day of WHO.
postpartum, the breast milk secretion is still Gustriani, N. (2015). Pengaruh Pijat Oksitosin Terhadap
lack because of high level of estrogen and Pengeluaran ASI Pada Pasien Post Seksio
Sesarea Di Ruangan Nifas Rumah Sakit
progesterone, and the next days these Wilayah Makassar. Universitas Hasanuddin
hormones will be lower thus the breast milk Makassar.
will be more produced. Biochemical markers Karuniawati, B., Fauziandari, E. N., & Wulandari, A.
indicate that the lactogenesis II process begins (2014). Studi Komparasi Teknik Marmet Dan
Pijat Oksitosin Terhadap Produksi Asi Pada
about 30-40 hours after delivery, but usually Ibu Post Partum Primipara Di Rumah Sakit
new mothers feel full breasts about 50-73 Wilayah Daerah Istimewa Yogyakarta. Jurnal
hours (2-3 days) after delivery (Soetijiningsih, Kesehatan Karya Husada.
2007). Thus, it is the true that breast milk is Latifah, J., Wahid, A., & Agianto, A. (2015).
not directly produced after childbirth. PERBANDINGAN BREAST CARE DAN
PIJAT OKSITOSIN TERHADAP
Limitations of the study PRODUKSI ASI PADA IBU POST
This study did not control the psychological PARTUM NORMAL. Dunia Keperawatan,
factor of the mothers, the frequency of 3(1), 34-43.
breastfeeding babies, nutrition patterns in Meng, S., Deng, Q., Feng, C., Pan, Y., & Chang, Q.
(2015). Effects of massage treatment
postpartum mothers, and the enumerator that combined with topical cactus and aloe on
might affect the outcome of the intervention. puerperal milk stasis. Breast disease, 35(3),
173-178.
CONCLUSION Mgongo, M., Mosha, M. V., Uriyo, J. G., Msuya, S. E.,
There was a significant effect of the & Stray-Pedersen, B. (2013). Prevalence and
predictors of exclusive breastfeeding among
combination of oxytocin massage and breast women in Kilimanjaro region, Northern
care in increasing breast milk secretion in Tanzania: a population based cross-sectional
postpartum mothers in the working area of the study. International breastfeeding journal,
Community Health Center of Batealit of 8(1), 12.
MOH. (2013). Riset Kesehatan Dasar; RISKESDAS
Jepara. Thus, this result can be used as an (Basic Health Research). Ministry of Health
evidence to perform oxytocin massage and of the Respublic of Indonesia, Jakarta.
breast care to increase the secretion of breast Muliani, R. H. (2013). Perbedaan Produksi ASI
milk. Sebelum dan Sesudah Dilakukan Kombinasi
Metode Massase Depan (Breast Care) dan
Masase Belakang (Pijat Ositosin) Pada Ibu
REFERENCES Menyusui 0-3 Bulan di Wilayah Kerja
Ahn, S., Kim, J., & Cho, J. (2011). [Effects of breast Puskesmas Kesamiran Kabupaten Tegal:
massage on breast pain, breast-milk sodium, Skripsi. Semarang: Program Studi DIV
and newborn suckling in early postpartum Kebidanan STIKES Ngudi Waluyo.
mothers]. J Korean Acad Nurs, 41(4), 451- Rosita, E. (2017). HUBUNGAN PERAWATAN
459. doi: 10.4040/jkan.2011.41.4.451 PAYUDARA PADA IBU NIFAS DENGAN
Al-Kohji, S., Said, H. A., & Selim, N. A. (2012). BENDUNGAN ASI (Studi Di Desa Jolotundo
Breastfeeding practice and determinants

!
dan Desa Kupang Kecamatan Jetis Kabupaten NIFAS:(Quasi Ekperimen, di BPM Wilayah
Mojokerto). Jurnal Kebidanan, 13(1). Kabupaten Cirebon Tahun 2013). Program
Safitri, I., Wijayanti, A. C., & Werdani, K. E. (2016). Pascasarjana Undip.
Faktor-faktor yang Mempengaruhi Widiyanti, F. A., Setyowati, H., Sari, K., & Susanti, R.
Kelancaran Produksi ASI pada Ibu Menyusui (2014). PERBEDAAN ANTARA DILAKUKAN
di Desa Bendan, Kecamatan Banyudono, PIIJATAN OKSITOSIN DAN TIDAK
Kabupaten Boyolali. Universitas DILAKUKAN PIJATAN OKSITOSIN
Muhammadiyah Surakarta. TERHADAP PRODUKSI ASI PADA IBU
Soetijiningsih. (2007). ASI Petunjuk untuk Tenaga NIFAS DI WILAYAH KERJA PUSKESMAS
Kesehatan: EGC: jakarta. AMBARAWA. Paper presented at the Prosiding
Sutrisminah, E., & Alfiyati, N. (2015). BENEFITS OF seminar nasional & internasional.
BREAST MASSAGE ON POSTPARTUM World Health, O., & Unicef. (2014). UNFPA and the
UTERINE INVOLUTION. INVOLUSI Jurnal World Bank. Trends in maternal mortality:
Ilmu Kebidanan (Journal of Midwifery 1990-2010. Geneva, Switzerland: WHO;
Science), 3(5). 2012.
Suwondo, A., & Wahyuni, S. (2015). EFEKTIFITAS Wulandari, F. T., Aminin, F., & Dewi, U. (2016).
KOMBINASI PIJAT OKSITOSIN TEHNIK PENGARUH PIJAT OKSITOSIN
EFFLEURAGEDAN AROMATERAPI TERHADAP PENGELUARAN
ROSE TERHADAP KADAR HORMON KOLOSTRUM PADA IBU POST PARTUM
PROLAKTIN IBU POST PARTUM DI RUMAH SAKIT UMUM DAERAH
NORMAL DI WILAYAH PUSKESMAS PROVINSI KEPULAUAN RIAU. Jurnal
DAWE KUDUS TAHUN 2013. Jurnal Ilmu Kesehatan, 5(2).
dan Teknologi Kesehatan, 5(1). Yasmin, P. A. (2016). Pejuang ASI yang pernah gagal
Ummah, F. (2014). Pijat oksitosin untuk mempercepat menyusui. Retrieved December 5, 2016,
pengeluaran ASI pada ibu pasca salin normal from
di Dusun Sono Desa Ketanen Kecamatan https://health.detik.com/read/2016/11/18/0708
Panceng Gresik. Jurnal Surya, 2. 47/3348195/763/cerita-dr-utami-roesli-
Widayanti, W. (2014). EFEKTIVITAS METODE pejuang-asi-yang-pernah-gagal-menyusui
“SPEOS”(STIMULASI PIJAT ENDORPHIN,
OKSITOSIN DAN SUGESTIF) TERHADAP
PENGELUARAN ASI PADA IBU
Cite this article as: Hesti, K. Y., Pramono, N., Wahyuni, S., Widyawati, M. N., Santoso, B. (2017).
Effect of combination of breast care and oxytocin massage on breast milk secretion in postpartum
mothers. Belitung Nursing Journal, 3(6), 784-790.
!
Safitri IR, et al. Belitung Nursing Journal. 2017 December;3(6):791-795

EFFECT OF EGGSHELL FLOUR ON BLOOD CALCIUM LEVELS IN

PREGNANT MICE
Ida Ratna Safitri*, Supriyana, Bahiyatun
*Correspondence:
Ida Ratna Safitri
E-mail: ida.ratnasaft92@gmail.com
Abstract
Objective: To examine the effect of eggshell flour on blood calcium levels in pregnant mice.
Methods: This was a true experimental study with pretest and posttest control group design. The research was conducted at
the Nutrition Laboratory of the Center for Food and Nutrition Studies, Gadjah Mada University on December 1, 2017 to
December 31, 2017. There were 30 pregnant rats included using simple random sampling, which assigned in five groups.
Spectrophotometer was used to measure blood calcium levels. Paired t-test and One-way ANOVA were used for data
analysis.
Results: There were significant differences in blood calcium levels before and after treatment with eggshell flour dose 5.4
mg/dl (p= 0.000), 10.8mg/dl (p = 0.000), and 21.6 mg/dl (p = 0.000). There was also significant difference in blood calcium
levels in control group with generic tablet of calcium powder of 21.6 mg/dl (p = 0.000).
Conclusion: There was a significant effect of given eggshell flour for 7 days with dose 5.4 mg/dl, 10.8 mg/dl, and 21.6 mg/l
as well as generic tablet of calcium powder of 21.6 mg/dl in increasing blood calcium levels. Thus, eggshell can be used as
alternative for calcium supplement.
Keywords: Eggshell Flour, Blood Calcium Level, and Pregnant Mice
INTRODUCTION
World Health Organization (WHO) indicated of maternal deaths occurred during childbirth,
that in 2010 maternal mortality during 27.00% at the time of pregnancy, and 15.05%
pregnancy and childbirth amounted to at the time of delivery (Dinkes, 2014).
287,000 women, which was caused by Preeclampsia and eclampsia are considered as
maternal health complications such as the second cause of maternal mortality after
hypertension in pregnancies occurred in 2-8% bleeding.
of pregnancies and associated with low birth
weight and maternal mortality (World Health, During pregnancy, a woman will experience
2013). According to Indonesia Demographic changes in both physical and psychological,
Survey (IDHS 2012), it shows that Maternal and nutritional intake determines the health of
Mortality Rate (MMR) in Indonesia reaches pregnant women and the fetus they contain.
359 per 100,000 live births, as the highest Nutritional needs during pregnancy will be
number in ASEAN (MOH, 2014). Based on increased by 15% compared to the needs of
Department of Health of Central Java normal women. Increased nutrition is required
Province, MMR in 2013 was 118.62 per for uterine growth, breast (mammae), blood
100,000 live births, increased to 126.55 per volume, placenta, amniotic fluid and fetal
100,000 live births in 2014. Of those, 57.95% growth. The food consumed by pregnant

Safitri, I. R., Supriyana., Bahiyatun. (2017)!
!
women will be used for fetal growth of 40% contained in the eggshell. The eggshell can be
and the remaining 60% is used for the a source of calcium carbonate (94%), calcium
mother's growth (Wiknjosastro, 2005). It phosphate (1%), magnesium carbonate (1%)
could be said that pregnant women essentially and organic (4%) (Than, Lawanprasert, &
need additional nutrients, however, most of Jateleela, 2012). Calcium carbonate as a
them often have a deficiency in protein energy pharmaceutical preparation is mainly used as
and some minerals such as iron and calcium a diluent of solid form. It is also used as a
(Guyton & Hall, 2012). basis for medicine and dental preparations,
buffering and dissolution for soluble tablets,
Calcium is a macro mineral that plays a very as well as food additives and calcium
important role in the body. More than 99% of supplements (Murakami, Rodrigues, Campos,
calcium is found in hard tissues of human & Silva, 2007). However, literature stated that
bones and teeth in the form of calcium the generic brand might not meet the standard
phosphate (Almatsier, 2002). Calcium intake requirements for tablet-crushed time (Susanto,
during pregnancy serves to maintain the 2010). In other words, the generic brand is
stability of the mother's condition. Calcium destroyed more slowly resulting in decreased
can help a number of physiological and effectiveness. Thus, this study aimed to
biochemical processes that include the work examine the eggshell flour as a calcium
of the blood clotting system, neuromuscular, supplementation to changes in blood calcium
and the activity of hormones and enzymes. A levels.
well-calculated need for calcium can also
prevent the occurrence of hypertension during
pregnancy, reducing the risk of death from METHODS
preeclampsia and possibly premature birth. Research design
WHO suggests calcium supplementation in This was a true experimental study with
antenatal care programs primarily to prevent pretest and posttest control group design to
preeclampsia; whereas inadequate determine the effect of eggshell flour on
consumption may have maternal and fetal calcium levels in pregnant rats.
effects, including osteopenia, tremor,
paresthesia, muscle cramps, tetanus, late Settings
growth, low birth weight, and poor fetal The research was conducted at the Nutrition
mineralization (World Health, 2013). Laboratory of the Center for Food and
Nutrition Studies, Gadjah Mada University on
Literature indicated that calcium intake of December 1, 2017 to December 31, 2017.
1500-2000 mg daily can reduce high blood
pressure in pregnancy up to 70% and Research subjects
preeclampsia by 50% (Mason, 2012). More There were 30 pregnant rats included in this
importantly, calcium also affects the future of study using simple random sampling, which
infant health. Sarwono reported that women assigned in five groups: 1) an experiment
who were given calcium supplements during group given standard feed treatment,
pregnancy have children who are adequately aquadest, and 5.4 mg of eggshell powder
protected from the risk of hypertension (K1); 2) An experiment group given standard
(Prawirohardjo, 2006). feed treatment, aquadest, and 10.8 mg of
eggshell powder (K2); 3) An experiment
According to the Data of the Indonesian Food group given a standard feed treatment,
Security Statistics, egg consumption in aquadest and 21.6 mg of eggshell powder
Indonesia is increasing every year as well as (K3); 4) A positive control group with
egg production. In 2014, the egg production standard feed treatment, aquadest, and generic
of layer chicken was 1764000 tons (Pangan, tablet of calcium powder of 21.6 mg/dl (K4) -
2015). The increasing production of laying The dose used to adjust to the maximum dose
eggs raises the number of eggshell wastes of humans is 1200 mg/dl converted in the
produced. According to Thapon and dose of mice obtained a maximum dose of
Bourgeois, the eggshell is 11% of the total 21.6 mg/dl (1200 mg/dl x 0.018); and 5) A
weight of the egg as a whole and the content
!
negative control group only given standard Ethical consideration

feed treatment and aquadest. This study has been approved by the Health
Research Commission of POLTEKKES
Intervention Kemenkes Semarang with number:
The eggshell used in this study used a chicken 021/KEPK/Poltekkes-SMG/EC/ 2017.
eggshell, in which each group was given Researchers have confirmed that each
treatment for 7 consecutive days from the 8th respondent has signed an informed consent.
to the 14th day of pregnancy.
Data analysis
Instrument Paired t-test was used to see the changes of
The instrument used in this study to measure calcium in blood, and One-way ANOVA was
blood calcium levels was using a used to see the difference among the groups.
spectrophotometer, as a tool used to measure
absorbance by passing light with a certain
wavelength on a glass or quartz object called RESULTS
quvet. Some of the light will be absorbed and Table 1 shows that the average weight of mice
the rest will be missed. The absorbance value in the five groups ranged from 201.5 to
of the light passed will be proportional to the 205.83 with p-value 0.516, which indicated
concentration of the solution present in the that there was no significant difference of
cuvette. Normal blood calcium level is 8.9- weight among the five groups.
10.1 mg/dl. Blood collection was done
through the plexus retro-orbitalis on the eyes.
Table 1 Characteristics of mice based on weight
Group Mean Minimum Maximum p-value

K1 205.83 201 210 0.516
K2 201.5 195 207
K3 205.83 201 209
K4 209.83 203 214
K5 204 198 212
Table 2 Blood calcium level before and after given intervention in the experiment and control group using
Paired t-test
Blood calcium
Group Mean Median Min – Max p-value
level
K1 Pretest 2.57 2.59 2.40 – 2.71
0.000
Posttest 6.04 6.03 5.87 – 6.20
K2 Pretest 2.49 2.45 2.19 – 2.90
0.000
Posttest 7.89 7.89 7.49 – 8.38
K3 Pretest 2.70 2.75 2.37 – 2.94
0.000
Posttest 10.09 10.2 9.47 – 10.76
K4 Pretest 2.62 2.62 2.30 – 2.93
0.000
Posttest 9.64 9.68 9.38 – 9.85
K5 Pretest 2.65 2.56 2.36 – 3.07
0.171
Posttest 2.79 2.84 2.55 – 2.96
Table 2 shows that the mean of blood calcium of 2.70 before intervention and became 10.09
level in the K1 group before intervention was after intervention; and K4 group was also
2.57 and then increased to 6.04 after given similar that there was an increase of blood
intervention, similar with the K2 group that calcium level to 9.64 after intervention from
has an increase of blood calcium level from 2.62. P-value in these four groups was 0.000,
2.49 during pretest to 7.89 during posttest; K3 which indicated that there were significant
group shows the mean of blood calcium level effects of eggshell flour with dose 5.4 mg/dl,

!
10.8 mg/dl, and 21.6 mg/dl, and generic tablet However, there was no significant difference
of calcium powder of 21.6 mg/dl in increasing of blood calcium level in the K5 group with p-
blood calcium level in pregnant rats. value 0.171.
Table 3 Blood calcium level differences among the groups using One way ANOVA
Group pair p-value

K1 vs K2 0.000 Significant
K3 vs K4 1.000 No Significant
One way Anova as shown in the table 3 potential of toxic elements such as aluminum,
indicated that there was significant difference cadmium, mercury and other substances
of blood calcium levels in all groups with p- (Neunzehn, Szuwart, & Wiesmann, 2015).
value 0.000 (<0.05), except in K3 and K4
group with p-value 1.000 (>0.05), which Eggshell flour proved able to increase blood
indicated that there was no significant calcium levels well after given consecutively
difference between K3 (eggshell flour for 7 days. However, increased blood calcium
21.6mg) with K4 (Calcium Generic 21.6). levels is influenced by several factors, one of
which is the presence of hormones contained
in the body serving to help the process of
DISCUSSION eggshell flavor absorption, then eggshell flour
The purpose of this study was to examine the enters into the process of metabolism of the
effect of eggshell flour in increasing blood body and blood flow system. The hormone
calcium levels in pregnant mice. Findings of includes parathyroid hormone, calcitonin, and
this study revealed that there was a significant 25-hydroxycholecalciferol; where eggshell
increase of blood calcium levels after given flour consumed by pregnant rats enter the
eggshell powder with dose 5.4 mg/dl, 10.8 body by 30% into the calcification process of
mg/dl, and 21.6 mg/dl. bone, teeth and cells (Meikawati & Suyanto,
2015). Calcium carbonate that has been
These results proved that changes in blood consumed begins with ingress into the
calcium levels in mice are caused by the high gastrointestinal tract, then Ca binds protein,
content of calcium in the eggshell. The absorbed by the intestinal mucosa, transported
chemical composition (by weight) of the in the cell cytoplasm, into the bloodstream
eggshell product is as follows: calcium system through the basolateral cells, causing
carbonate (94%), magnesium carbonate (1%), changes in calcium levels in the blood, and
calcium phosphate (1%) and other organic others about 70% are directly processed and
(4%) (Susanto, 2010). The main component expelled through sweat, urine, and feces
of eggshells is calcium carbonate, can be used (Guyton & Hall, 2012).
to replace calcium carbonate, which is used as
a pharmaceutical preparation, in solid dosage In addition, eggshell weigh 9-12% of total egg
forms. In addition, calcium carbonate from weight containing 94% calcium carbonate,
eggshells has an advantage because it does not 1% potassium phosphate, and 1% magnesium
contain elements of toxic substances such as carbonate. Calcium from eggshell is a perfect
calcium carbonate from oyster shells supplement for food and its calcium
containing residual substances with the bioaccumacy is quite high, at 93.80% (Ray,
!
Barman, Roy, & Singh, 2017). Many studies Guyton, A. C., & Hall, J. E. (2012). Sensasi Somatik:
have sought ways to utilize eggshell waste, Buku Ajar Fisiologi Kedokteran: Edisi
Kesebelas. EGC. Jakarta.
for example, using eggshell powder as a Hacker, A. N., Fung, E. B., & King, J. C. (2012). Role
stabilizing agent to improve soil properties, as of calcium during pregnancy: maternal and
a coating pigment for printing ink-jet paper, fetal needs. Nutrition reviews, 70(7), 397-409.
food additives and as a source of calcium in Mason, P. (2012). Dietary supplements: Pharmaceutical
Press.
animal and human nutrition (Hacker, Fung, & Meikawati, W., & Suyanto, A. (2015). Kadar Kalsium
King, 2012) (Neunzehn et al., 2015). Dan Fosfor Darah Pada Tikus Yang
Diberikan Mocaf Terfortifikasi Kalsium Dari
During this time, some people consider that Cangkang Telur Ayam Ras. Paper presented at
the eggshell is a waste that is not useful; the Prosiding seminar nasional &
internasional.
whereas in eggshells there are many benefits MOH. (2014). Health profile of Indonesia 2014: Menteri
for the health of the human body, animal Kesehatan Republik Indonesia, Jakarta.
health and for plant growth. Murakami, F. S., Rodrigues, P. O., Campos, C. M. T. d.,
& Silva, M. A. S. (2007). Physicochemical
study of CaCO3 from egg shells. Food
This study proves that eggshell can be used as Science and Technology (Campinas), 27(3),
an alternative substance of calcium 658-662.
supplements. However, this study also Neunzehn, J., Szuwart, T., & Wiesmann, H. P. (2015).
revealed that there was a significant effect of Eggshells as natural calcium carbonate source
generic tablet of calcium powder of 21.6 in combination with hyaluronan as beneficial
additives for bone graft materials, an in vitro
mg/dl in increasing blood calcium level in study. Head Face Med, 11. doi:
pregnant rats. Thus, it provides the options 10.1186/s13005-015-0070-0
whether to use generic tablet or eggshell, Pangan, B. K. (2015). Data statistik ketahanan pangan
which has the same effect on blood calcium tahun 2014. Jakarta (ID): Badan Ketahanan
Pangan.
level. Prawirohardjo, S. (2006). Buku acuan nasional
pelayanan kesehatan maternal dan neonatal
[National reference book of maternal and
CONCLUSION neonatal health services]. Jakarta: Yayasan
It can be concluded that there was significant Bina Pustaka.
Ray, S., Barman, A. K., Roy, P. K., & Singh, B. K.
effects of eggshell flour with dose 5.4 mg/dl, (2017). Chicken eggshell powder as dietary
10.8 mg/dl, and 21.6 mg/l as well as generic calcium source in chocolate cakes. The
tablet of calcium powder of 21.6 mg/dl in Pharma Innovation, 6(9, Part A), 1.
increasing blood calcium levels. Thus, Susanto. (2010). The Truth Benefits of Calcium
Supplements. Retrieved January 15, 2016
eggshell can be used as alternative for calcium Than, M. M., Lawanprasert, P., & Jateleela, S. (2012).
supplement. Further study is needed to Utilization of eggshell powder as excipient in
examine the effect of eggshell in human. fast and sustained release acetaminophen
tablets. Mahidol University Journal of
Pharmaceutical Sciences, 39(3-4), 32-38.
Wiknjosastro, H. (2005). Ilmu kebidanan. Jakarta:
REFERENCES Yayasan Bina Pustaka Sarwono
Almatsier, S. (2002). Prinsip dasar ilmu gizi: Gramedia Prawirohardjo, 45-51.
Pustaka Utama. World Health, O. (2013). Guideline: calcium
Dinkes. (2014). Health Profile of Central Java Province: supplementation in pregnant women: World
Department of Health of Central Java. Health Organization.
Cite this article as: Safitri, I. R., Supriyana., Bahiyatun. (2017). Effect of eggshell flour on blood
calcium levels in pregnant mice. Belitung Nursing Journal, 3(6), 791-795.

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Belitung Nursing Journal (BNJ) is a bi-monthly, International, peer reviewed journal

BNJ contributes to the advancement of evidence-based nursing, midwifery and healthcare by

The Official Publication of Belitung Nursing Journal – Belitung Raya Publisher-

ISSN: 2477-4073 (Online) | ISSN: 2528-181x (Print)

Belitung Raya Publisher

Library of Congress Catagloging-in-Publication Data

Copyright 2017, by Belitung Nursing Journal - Belitung Raya Publisher – Belitung

Advisory International Editorial Board

ITEM ANALYSIS AND INTERNAL CONSISTENCY OF CHILDREN’S SLEEP PDF

CAREGIVERS’ NEEDS IN CARING FOR RELATIVES WITH SCHIZOPHRENIA PDF

EFFECTIVENESS OF PROGRESSIVE MOBILIZATION LEVEL I AND II ON PDF

THE ASSOCIATION OF ISLAMIC BASED CARING MODEL AND PDF

EFFECT OF MULTI MICRONUTRIENT SUPPLEMENTATION ON PDF

DARK CHOCOLATE’S EFFECT ON MENSTRUAL PAIN IN LATE PDF

COMPARISON OF THE EFFECTIVENESS OF TWO LEVELS OF SUCTION PDF

EFFECT OF ACUPRESSURE THERAPY POINT LI 4, SP 6, AND BL 60 ON PDF

EFFECT OF YOGA ON DURATION OF THE SECOND STAGE OF LABOR AND PDF

EFFECT OF CONSUMING TOMATO (LYCOPERSIUM COMMUNE) JUICE IN PDF

HYPNODIALYSIS FOR ANXIETY RELIEF AND ADHERENCE TO PDF

EFFECT OF YOGA AND ACUPRESSURE ON PAIN AND FUNCTIONAL PDF

EFFECTIVENESS OF MUSIC THERAPY ON ANXIETY AND Β-ENDORPHIN PDF

EFFECT OF PSYCHOEDUCATION ON ANXIETY IN PATIENTS WITH PDF

EFFECTIVENESS OF LAVENDER AROMATHERAPY AND CLASSICAL MUSIC PDF

COMBINATION OF COLD PACK, WATER SPRAY, AND FAN COOLING ON PDF

EFFECT OF PREGNANCY EXERCISE ON DURATION OF THE FIRST AND PDF

EFFECT OF ROSELLE (HIBISCUS SABDARIFFA) ON CHANGES IN PDF

BINAHONG LEAVES (ANREDERA CORDIFOLIA TENORE STEEN) EXTRACT PDF

EFFECT OF COMBINATION OF BREAST CARE AND OXYTOCIN MASSAGE PDF

EFFECT OF EGGSHELL FLOUR ON BLOOD CALCIUM LEVELS IN PREGNANT PDF

© 2017 Belitung Nursing Journal

ORIGINAL RESEARCH ISSN: 2477-4073

IDENTIFICATION OF URINARY INCONTINENCE IN PEOPLE AGED 65

Birsel Canan DEMİRBAĞ1*, Gulpinar ASLAN2, Ayse Berivan BAKAN3

Keywords: Elderly, Prevalence, Urinary Incontinence

636 BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017

Urinary incontinence is defined by the

BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017! 637

data about gender, age, marital status, Data Analysis

Table 1 Descriptive Features of the Participants (N=1527)

638 BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017! !

BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017! 639

Table 3 Knowledge of Elderly People about Urinary Incontinence

Table 4 Type of Urinary Incontinence and ICIQ-SF Total Mean Scores

640 BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017! !

DISCUSSION Santos, Pereira, Zambon, & Marques, 2012).

BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017! 641

642 BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017! !

In their study conducted with women, Öztürk REFERENCES

BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017! 643

MUNICIPALITY. Ege Academic Review, activities of daily living. Archives of

644 BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017! !

Hartini S, et al. Belitung Nursing Journal. 2017 December;3(6):645-655

© 2017 Belitung Nursing Journal

ORIGINAL RESEARCH ISSN: 2477-4073

ITEM ANALYSIS AND INTERNAL CONSISTENCY OF CHILDREN’S

Sri Hartini1*, Sunartini2, Siti E. Herini2, and Satoshi Takada3

BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017 645

646 BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017

Table 1 Participants Background (n=305)

Instrument questionnaire was translated from English into

BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017 647

Statistical analysis RESULTS