Belitungnursing Journal

Volume 3 Issue 4: July - August 2017

BELITUNG NURSING JOURNAL https://belitungraya.org/BRP/index.php/bnj/index

Online ISSN: 2477-4073

Belitung Nursing Journal is a bi-monthly peer-reviewed, open access nursing journal devoted to publishing research papers and scholarship about nursing education, health care delivery, organization, management, workforce, policy and research methods relevant to nursing, midwifery and other health related professions. BNJ aims to provide an international forum for the exchange of ideas and findings from researchers across different cultures and encourages research on the impact of cultural factors on nursing theory and practice. It also seeks to promote the transfer of knowledge between professionals in academia and industry by emphasizing research in which results are of interest or applicable to nursing practices.

T HE O FFICIAL P UBLICATION OF BELITUNG RAYA FOUNDATION D EPARTMENT OF P UBLICATION

BELITUNG NURSING JOURNAL

Volume 3 Issue 4, July - August 2017

Launched in December 2015, Belitung Nursing Journal (BNJ) is a refereed international publication that provides a venue for nursing scholarship with an Asian focus and perspectives from the region. We aim to highlight research on nursing science, nursing management and policy, education and practice in the Asia-Pacific region and among Asian communities around the world to a wide international audience.

BNJ is an official publication of Department of Publication of Belitung Raya Foundation in Belitung Indonesia, jointly with Indonesian National Nurses Association of Belitung Indonesia (PPNI Belitung) and Prodi D3 Keperawatan Belitung Poltekkes Kemenkes RI Pangkal Pinang.

Belitung Raya Foundation is a non-profit organization which focuses on education, health, information technology, and social and empowerment of the community. Belitung Raya Foundation is established since 2015 with official license of establishment from the Ministry of Justice and Human Rights of Republic of Indonesia (MENKUMHAM RI) with No: AHU-0009599.AH.01.12.Year 2015 and Notarial Deed No: 12 on 06 July 2015 by SRI ARIYAWATI, SH.,M.KN.

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Volume 3 issue 4: July - August 2017 Library of Congress Cataloging-in-Publication Data Belitung Nursing Journal Volume 3 Issue 4 E-ISSN 2477-4073 P-ISSN 2528-181X

This issue is Open Access 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.

Editor’s Note: This issue has been corrected and updated with minor changes on 13 July 2020 according to BNJ Policy

EDITORIAL TEAM

Editor in Chief Pakamas Keawnantawat, PhD, RN, Ramathibodi School of Nursing Faculty of Medicine Ramathibodi Hospital Mahidol university, Thailand

Associate Editors Hasanuddin Nuru, S.Kep, Ners, M.Kes, PhD, Faculty of Health Science, University of Islam Makassar, Indonesia. Agianto, S.Kep.,Ns., MNS, School of Nursing, Lambung Mangkurat University, 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

International Editorial Board Virya Koy, RN, SNA, MNSc, MHPEd, PhD, President of Nursing Council of Cambodia and Vice Rector of Chenla University. Abdulkareem Suhel Iblasi, MSN, Nurse Manager - Wound Care. King Saud Medical City, Ministry of Health, Saudi Arabia, Saudi Arabia Kamolpoo Thanomsat, MNS, RN, Faculty of Nursing, NaKhon Pathom Rajabhat University, Thailand Rata Srisa-Art, RN, MNS, Saint Louis College, Thailand 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 Dyah Anantalia Widyastari, SKM.,M.Kes, Institute for Population and Social Research Mahidol University Thailand, Thailand

TABLE OF CONTENT

RELATIONSHIP BETWEEN NURSING AND ELDERLY CARE STUDENTS’ ATTITUDES 281-296 TOWARDS AGEISM Merve Çayir Yilmaz, Fatma Zehra İnce

CORRELATION BETWEEN FAMILY COMMUNICATION PATTERNS AND JUVENILE 297-306 DELINQUENCY IN JUNIOR HIGH SCHOOL Zurriyatun Thoyibah, Intansari Nurjannah, Sumarni D, W

THE IMPACT OF GENTLE HUMAN TOUCH IN INCREASING BABY WEIGHT, BODY 307-315 TEMPERATURE AND PULSE STABILITY ON PRETERM BABY Yennita Maharani, Ari Suwondo, Triana Sri Hardjanti, Suharyo Hadisaputro, Dyah Fatmasari, Imam Djamaluddin Mashoedi

CAREGIVERS’ EXPERIENCE IN MEETING SELF-CARE NEEDS OF ADOLESCENTS WITH 316-328 AUTISM SPECTRUM DISORDER: A QUALITATIVE STUDY Lilis Lestari, Elisabeth Siti Herini, Indria Laksmi Gamayanti

THE IMPACT OF COMBINATION OF ROLLING AND OKETANI MASSAGE ON PROLACTIN 329-336 LEVEL AND BREAST MILK PRODUCTION IN POST-CESAREAN SECTION MOTHERS Nia Dwi Yuliati, Hadi Hadi, Sri Rahayu, Noor Pramono, Donny Kristanto Mulyantoro

EFFECT OF OXYTOCIN MASSAGE USING LAVENDER ESSENTIAL OIL ON PROLACTIN LEVEL 337-344 AND BREAST MILK PRODUCTION IN PRIMIPAROUS MOTHERS AFTER CAESAREAN DELIVERY Panglukies Ratna Agustie, Suharyo Hadisaputro, Runjati Runjati, Ariawan Soejoenoes, Imam Djamaludin Mashudi, Melyana Nurul Widyawati

HOME CARE NURSES’ ROLES IN ENHANCING QUALITY OF NURSING CARE FOR PATIENTS 345-351 AT HOME: A PHENOMENOLOGICAL STUDY Titan Ligita

THE EFFECTIVENESS OF COMBINATION OF KANGAROO MOTHER CARE METHOD AND 352-359 LULLABY MUSIC THERAPY ON VITAL SIGN CHANGE IN INFANTS WITH LOW BIRTH WEIGHT Nuuva Yusuf, Suharyo Hadisaputro, Runjati Runjati, Ari Suwondo, Imam D Mashoedi, Supriyana Supriyana

EFFECT OF ACUPRESSURE ON QUALITY OF SLEEP AND PULSE RATE IN PATIENTS WITH 360-369 ACUTE MYOCARDIAL INFARCTION Eko Rustamaji Wiyatno, Rr. Sri Endang Pujiastuti, Titin Suheri, Djenta Saha

EFFECT OF FE-FORTIFIED TEMPE ON HEMATOLOGIC STATUS IN PREGNANT MOTHERS 370-375 WITH ANEMIA Anggraini Wulandhari, Supriyana Supriyana, Bahiyatun Bahiyatun, Soeharyo Hadisaputro, Imam Djamaluddin Mashoedi

RELATIONSHIP BETWEEN NURSE SUPPORTS AND FEARS OF HOSPITALIZED SCHOOL AGE 376-382 CHILDREN IN PKU MUHAMMADIYAH HOSPITAL, YOGYAKARTA, INDONESIA Istinengtiyas Tirta Suminar, Indria Laksmi Gamayanti, Lely Lusmilasari

EFFECT OF PROGRESSIVE MUSCULAR RELAXATION ON ANXIETY LEVELS IN PATIENTS 383-389 WITH CHRONIC KIDNEY DISEASE UNDERGOING HEMODIALYSIS IN THE GENERAL HOSPITAL OF TUGUREJO SEMARANG, INDONESIA Ary Astuti, Anggorowati Anggorowati, Andrew Johan

DEVELOPING A WEB-BASED INFORMATION SYSTEM IN DETECTION OF HIGH-RISK 390-398 PREGNANCIES IN SEMARANG, INDONESIA: ADDIE MODEL Ihsanti Indri Fajriya, Supriyana Supriyana, Bahiyatun Bahiyatun, Melyana Nurul Widyawati

iii

EFFECT OF CONSUMING TAMARIND AND TURMERIC DRINK ON THE LENGTH OF 399-404 PERINEAL WOUND HEALING IN POSTPARTUM MOTHERS Dewi Susanti, Onny Setiani, Umaroh Umaroh, Kun Aristiati, Imam Djamaluddin Mashoedi, Mardiyono Mardiyono

RELATIONSHIP BETWEEN DEMOGRAPHIC CHARACTERISTICS AND SPIRITUAL 405-411 WELLBEING AMONG CANCER SURVIVORS Eviwindha Suara, Mardiyono Mardiyono, Anggorowati Anggorowati

COMPARISON OF EFFECTS OF MASSAGE THERAPY ALONE AND IN COMBINATION WITH 412-419 GREEN COCONUT WATER THERAPY ON Β-ENDORPHIN LEVEL IN TEENAGE GIRLS WITH DYSMENORRHEA Fitria Hikmatul Ulya, Agus Suwandono, Ida Ariyanti, Ari Suwondo, Suryati Kumorowulan, Sri Endang Pujiastuti

LAVENDER (LAVANDULA ANGUSTIFOLIA) AROMATHERAPY AS AN ALTERNATIVE 420-425 TREATMENT IN REDUCING PAIN IN PRIMIPAROUS MOTHERS IN THE ACTIVE FIRST STAGE OF LABOR Hilda Yani Karo Karo, Noor Pramono, Sri Wahyuni, Imam Djamaluddin Mashoedi, Leny Latifah

FUNCTIONAL STATUS IN PATIENTS WITH CHRONIC KIDNEY DISEASE BEING TREATED 426-431 WITH HEMODIALYSIS IN PKU MUHAMMADIYAH HOSPITAL, YOGYAKARTA, INDONESIA Adiyati Mardiyah, Anggorowati Anggorowati, Andrew Johan

EFFECT OF CONSUMING RED SPINACH (AMARANTHUS TRICOLOR L) EXTRACT ON 432-437 HEMOGLOBIN LEVEL IN POSTPARTUM MOTHERS Resty Himma Muliani, Ariawan Soejoenoes, Titi Suherni, Soeharyo Hadisaputro, Imam Djamaluddin Mashoedi

EFFECT OF SOLUS PER AQUA (SPA) ON INFANT WEIGHT 438-442 Agrystina Ryma Melati, C Tjahjono Kuntjoro, Sri Sumarni, Kamilah Hidayati, Rr. Sri Endang Pujiastuti

PATIENT SATISFACTION AND ITS RELATIONSHIP WITH THE QUALITY OF 443-449 COMPREHENSIVE EMERGENCY OBSTETRIC AND NEONATAL CARE (CEmONC) IN THE GENERAL HOSPITAL OF PANEMBAHAN SENOPATI BANTUL Fitri Dian Kurniati, Lely Lusmilasari, Sri Mulatsih

iv Yilmaz MÇ, & İnce FZ. Belitung Nursing Journal. 2017 August;3(4):281-296 Received: 18 May 2017 | Revised: 30 May 2017 | Accepted: 18 June 2017 http://belitungraya.org/BRP/index.php/bnj/

© 2017 The Author(s) 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

RELATIONSHIP BETWEEN NURSING AND ELDERLY CARE STUDENTS’ ATTITUDES TOWARDS AGEISM

Merve Çayir Yilmaz*, & Fatma Zehra İnce

Ağrı İbrahim Çeçen University, Health Services Vocational High School, Ağrı, Turkey

*Corresponding author: Merve ÇAYIR YILMAZ Ağrı İbrahim Çeçen University, Health Services Vocational High School, Ağrı, 04100 Turkey E-mail: [email protected]

ABSTRACT Background: Perceptions of individuals and society about the elderly are reflected in the services provided to them. These reflections might be revealed in various fields such as health care services and sufficient job opportunities, or they could be revealed in the issue of discrimination against the elderly, which is a problem emerging in advanced ages. Objective: This study aims to identify the relationship between nursing and elderly care program students’ attitudes towards ageism. Methods: This study, which is descriptive and relational method, was conducted between November and December, 2016. The participants were 220 students. The data were collected through a questionnaire, and the Ageism Attitude Scale, and were analyzed using t-test, two-way multivariate analysis of variance (MANOVA) and one-way analysis of variance (ANOVA). Findings: Results show that the students generally had positive attitudes towards ageism. Nursing department students received significantly higher scores in the Limiting the Elderly Person’s Life sub-dimension and Ageism Attitude Scale in comparison to Elderly Care Program students. 3rd year nursing department students had higher scores in the Ageism Attitudes Scale in comparison to 1st and 2nd year nursing department students and students in the Elderly Care Program. “Positive Discrimination towards the Elderly” sub-dimension and the “Ageism Attitudes Scale” total scores were found to be significantly higher in nursing department students according to the variable of desire to work in a geriatric service in the future. (p<0.05). Conclusion: This study found that students had positive attitudes towards ageism, and nursing students’ Ageism Attitudes Scale mean scores were higher than those of elderly care program students. More comprehensive studies are needed in order to improve students’ attitudes towards elderly people.

Keywords: elderly, ageism, attitude

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Editor’s Note: This article has been updated on 10 July 2020 in terms of minor changes in the reference format. The update is according to BNJ Policy on article correction. INTRODUCTION Ageing of the population is one of the The effects of these demographic most prominent demographic phenomena changes, namely ageing of the population, of the 21st century. Population of the are seen in different dimensions in elderly within the world population has societies. Factors such as sociocultural been increasing due to factors such as structure of society and changes in the scientific and technological developments attitudes, behaviors, and perceptions of in the health field, application of early society about the elderly are reflected in diagnosis and treatment methods, increase the services provided to the elderly. These in the health protecting and improving reflections could reveal themselves in precautions, encouragement and adoption health care services, health expenses, of a healthy life style, and decrease in organization and financing of social birth rates. 1-5 Ageing phenomena, which security institutions, sufficient service and is usually more apparent in developed job opportunities, social support provided countries, is an issue that should be given to the elderly by family and relatives, importance by not only developed but also adjustment to the ageing process, developing countries. 2 obtaining sufficient income, and Parallel to the global ageing of the retirement and sheltering; or they could be world population, elderly population has revealed in “discrimination against the been increasing in our country, too. 6 elderly”, which is a problem that may Elderly population (65 and over) in our emerge in advanced ages. Discrimination country was 6,495,239 in 2015. While the against the elderly can be defined as proportion of elderly population in total discriminations against individuals population was 8% in 2014, it increased to through different attitudes, prejudices, 8,2% in 2015. Elderly population behaviors, actions or institutional composed 8,5% of the world population in regulations generally merely because of 2015. Turkey has been ranked 66th among their age. 6, 10-12 167 countries in terms of elderly Review of discrimination against the population proportion. 7According to the elderly issue shows that positive and Definition of the United Nations, a negative attitudes are addressed together. proportion of elderly population between While positive attitudes towards ageism 8% and 10% in the total population include items such as kindness, wisdom, indicates that the country has “old” trustworthiness, wealth, political power, population, and that of over 10% indicates freedom, and happiness; negative attitudes “very old” population. Population involve items such as sickness, incapacity, projections for Turkey show that elderly ugliness, deterioration in mental population proportion will increase to functions, mental illnesses, uselessness, 10,2 % in 2023, 20,8% in 2050, and isolation, poverty, and depression. Fields 27,7% in 2075. Thus, it is estimated that that have the most common discrimination Turkey will be among the countries with against the elderly attitudes are known to “very old” population. 8 As to the world, it be work life, family life, social life, sexual is estimated that 2 billion people will be life, and health care systems. 5, 11, 13, 14 over 60 by 2050, 80% will live in middle Discrimination against the elderly in and low income countries, and life health care services, one of the fields expectancy will increase 7.5 years. 9 where discrimination against the elderly is quite common, is reported to be done

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 282 mainly by young people. 15-17 It is also options. Validity and reliability of the reported that young people’s attitudes scale was performed, and Cronbach’s towards the elderly should primarily be alpha reliability level was found 0.80. The improved through the identification of scale has positive and negative attitudes young people’s attitudes and views about statements. Positive attitudes statements the elderly.5 This study aims to identify are scored as 5=I totally agree, 4=I agree, the relationship between the nursing and 3= I am not sure, 2= I disagree, and 1=I elderly care program students’ attitudes totally disagree. Limitations of life and towards ageism. negative attitudes statements about discrimination against the elderly are METHODS scored reversely. Scores to be obtained Study Design from the scale range between 23 and 115. This study adopted a descriptive and The scale has no cut-off point. Thus, relational method in order to identify the assessment of the data obtained from the relationships between nursing and elderly scale is performed according to the care program students’ attitudes towards highest score to be obtained from the scale ageism. (115). Scores below the mean score are regarded negative and those above the Target Population and the Participants mean score are considered positive. Target population of the study was 124 Higher scores indicate more positive students enrolled in the Nursing attitudes towards ageism. Department in the Health High School of The scale has 3 sub-dimensions that Ağrı İbrahim Çeçen University and 176 have positive and negative attitudes students in the Elderly Care Program of statements. These sub-dimensions Health Services Vocational School. No include; sampling was performed, we aimed to 1. Limiting the Elderly Person’s Life: reach all the target population. The This sub-dimension indicates the beliefs participants were 220 students who and attitudes of society about limiting attended these schools and volunteered to elderly people’s social life. The maximum participate in the study. score to be obtained from this sub- dimension is 45, and the minimum score Data Collection Tools is 9. The items in this sub-dimension are The data were collected through a Item 1, 5, 12, 14, 17, 19, 21, 22, and 23. questionnaire and the Ageism Attitudes 2. Positive Discrimination towards Scale. The questionnaire, which was the Elderly: This sub-dimension indicates prepared in line with the related literature, positive beliefs and perceptions of society included personal questions related to the about elderly individuals. The maximum descriptive characteristics of the score to be obtained from this sub- participants (e.g. age, gender, class level) dimension is 40, and the minimum score and their desire to provide care to the is 8. Items in this sub-dimension include elderly. 18-20 item 2, 4, 6, 7, 8, 9, 13, and 20. Ageism Attitudes Scale (AAS): The 3. Negative Discrimination towards 23-item scale developed by Vefikuluçay the Elderly: This sub-dimension indicates (2008) is a 5-point Likert scale and has “I the negative beliefs and perceptions of totally disagree” “I disagree”, “I am not society about elderly individuals. The sure” “I agree” and “I totally agree” maximum score to be obtained from this

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 283 sub-dimension is 30, and the minimum study was conducted. The students were score is 6. Items in this sub-dimension informed about the purpose of the study, include Item 3, 10, 11, 15, 16, and 18. 5, 11 and their verbal consent was obtained.

Data Collection Analysis of the Data The data collection tools, delivered The collected data were analyzed using a between November 2016 and December statistical package programming. 2016, were administered to the students Analyses included t-test, two-way by the researchers in their classrooms multivariate analysis of variance after the teacher’s approval was obtained. (MANOVA) and one-way analysis of The students were asked to fill in the variance (ANOVA). questionnaires, which were subsequently recollected by the researchers. Filling in FINDINGS the questionnaire forms took about 10 to Table 1 displays t-test results about the 15 minutes. differences between nursing department and elderly care program students in terms Ethical Considerations of their attitudes towards ageism. Prior to the study, written approval was obtained from the institution where the

Table 1 Differences between Nursing Department and Elderly Care Program Students in terms of their Attitudes towards Ageism

Department N  S.D. t p Limiting the Elderly Nursing 71 37.49 3.393 3.294 .001 Person’s Life Elderly Care 149 35.52 4.478 Positive Discrimination Nursing 71 31.99 4.238 .066 .947 towards the Elderly Elderly Care 149 31.94 5.131 Negative Discrimination Nursing 71 17.24 3.556 1.669 .096 towards the Elderly Elderly Care 149 16.28 4.162 Ageism Attitudes Scale Nursing 71 86.72 7.616 2.467 .014 Total Score Elderly Care 149 83.74 8.711

As it is shown in Table 1, while were higher than those of elderly care there were significant differences between program students (=35.52); and nursing nursing department and elderly care students’ “AAS Total” scores were program students in terms of “Limiting significantly higher than those of elderly the Elderly Person’s Life” and “AAS care program students (=83.74). Total” scores, the difference between Table 2 displays two-way “Positive Discrimination towards the multivariate analysis of variance Elderly” and “Negative Discrimination (MANOVA) results about AAS and sub- towards the elderly” dimensions indicated dimensions of AAS according to age and no significant differences. department variables. “Limiting the elderly person’s life” sub-dimension scores (t=3.294, p<.05) of nursing department students (=37.49)

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Table 2 MAVOVA Analysis results of Attitudes towards ageism Scores according to Department and Age Variables

Wilks’λ F Hypothesis Error SD p ƞ2 SD Department .957 3.138 3 210 .026 .043 Age .965 .848 9 511 .572 .012 Age x .949 1.240 9 511 .268 .017 Department

As it is seen in Table 2, an analysis to 21, 22 to 24, and 25 and over. It thus of the co-effects of department and age can be said that nursing department and indicated no differences in the dependent elderly care program students’ attitudes variables (Wilks’ λ =.949; F (9;511) =1.240, towards ageism scores showed no p>.05, ƞ2=.017). In this regard, linear differences according to the age variable. component scores obtained from the sub- Table 3 displays one-way analysis dimensions of AAS and total scores of variance (ANOVA) results about sub- indicated no differences between nursing dimensions of AAS and “AAS Total” department and elderly care program variables. students in the age groups of 16 to 18, 19

Table 3 Analysis Results regarding the Differences between Nursing Department and Elderly Care Program Students’ Attitudes towards Ageism

F p ƞ2 Limiting the Elderly Person’s life 5.460 .020 .025 Negative Discrimination towards the Elderly .809 .369 .004 Department Positive Discrimination towards the Elderly 5.590 .019 .026 AAS Total 7.856 .006 .036 Age Limiting the Elderly Person’s life 1.037 .377 .014 Negative Discrimination towards the Elderly 1.339 .263 .019 Positive Discrimination towards the Elderly .574 .633 .008 AAS Total 1.010 .389 .014 Department Limiting the Elderly Person’s life .914 .435 .013 x Age Negative Discrimination towards the Elderly .965 .410 .013 Positive Discrimination towards the Elderly 1.494 .217 .021 AAS Total 1.084 .357 .015

One-way analysis of variance “Limiting the Elderly Person’s life” (ANOVA) results showed significant sub-dimension scores (F (1,212) = 5.460, differences between nursing department p<.05, ƞ2=.025) of nursing department and elderly care program students in the students (=37.49) were higher in “Limiting the Elderly Person’s life” and comparison to elderly care program “Positive Discrimination towards the students (=35.52). “Positive Elderly” and “AAS Total” scores, but no Discrimination towards the Elderly” sub- significant differences were detected in dimension scores (F (1,212) = 5.590, p<.05, the “Negative Attitudes towards the ƞ2=.026) of nursing department students Elderly” dimension. (=17.24) were higher in comparison to elderly care program students (=16.28).

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“AAS Total” scores (F (1,212) = 7.856, One- way analysis of variance p<.05, ƞ2=.036) of nursing students (ANOVA) results indicated no significant (=86.72) were significantly higher in differences between “Limiting the Elderly comparison to elderly care students Person’s Life”, “Negative Discrimination (=83.74). towards the Elderly”, and “Positive One-way analysis of variance Discrimination towards the Elderly” (ANOVA) results show that no significant dimensions and “AAS Total” levels differences existed between “Limiting the according to students’ age and Elderly Person’s Life”, “Negative departments. Discrimination towards the Elderly”, and Table 4 displays two-way “Positive Discrimination towards the multivariate analysis of variance Elderly” dimensions and “AAS Total” (MANOVA) results of nursing levels according to the age groups of the department and elderly care program students. students’ AAS sub-dimension scores and AAS total scores according to gender and department variables.

Table 4 MANOVA Analysis results of the Attitudes towards Ageism Scores according to Department and Gender Variables

Wilks’λ F Hypothesis SD Error SD p ƞ2 Department .958 3.134 3 214 .026 .042 Gender .982 1.279 3 214 .283 .018 Gender x Department .990 .687 3 214 .561 .010

An analysis of the co-effects of department and elderly care program department and gender in Table 4 students in terms of “Limiting the Elderly indicated no differences in terms of the Person’s Life” dimension and “AAS dependent variables (Wilks’ λ =.990; F Total” levels, but “Negative 2 (3;214) =0.687, p>.05, ƞ =.010). Discrimination towards the Elderly” and Accordingly, the linear component scores “Positive Discrimination towards the obtained from the sub-dimensions of AAS Elderly” dimensions indicated no and AAS total scores indicated no significant differences. significant differences between female “Limiting the Elderly Person’s Life” and male nursing department and elderly sub-dimension scores (F (1,212) = 8.078, care program students. It seems that p<.05, ƞ2=.036) of nursing students nursing department and elderly care (=37.42) were higher in comparison to program students’ attitudes towards elderly care program students (=35.65); ageism scores did not show differences and AAS total scores (F(1,212) = 7.856, according to the gender variable. p<.05, ƞ2=.020) of nursing students Table 5 displays one-way analysis (=86.72) were higher in comparison to of variance (ANOVA) results about the elderly care program students (=83.74). sub-dimensions of AAS and “AAS Total” The table also demonstrates that variables. one-way analysis of variance (ANOVA) One-way analysis of variance results indicate no significant differences (ANOVA) results indicated significant in the “Limiting the Elderly Person’s differences between the nursing Life”, “Negative Discrimination towards

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 286 the Elderly” and “Positive Discrimination Elderly” dimensions and “AAS Total” towards the Elderly” dimensions and levels according to gender and department “AAS Total” levels according to the variables. gender variable. Table 6 displays two-way One-way analysis of variance multivariate analysis of variance (ANOVA) results show that there were no (MANOVA) results in relation to AAS significant differences in the “Limiting the sub-dimension scores and AAS total Elderly Person’s Life”, “Negative scores of nursing department and elderly Discrimination towards the Elderly” and care program students according to class “Positive Discrimination towards the and department variables.

Table 5 Analysis Results about the Differences between Nursing and Elderly Care Students’ Attitudes towards Ageism

F p ƞ2 Limiting the Elderly Person’s Life 8.078 .005 .036 Negative Discrimination towards the Elderly .006 .941 .000 Department Positive Discrimination towards the Elderly 2.487 .116 .011 AAS Total 4.465 .036 .020 Gender Limiting the Elderly Person’s Life .061 .805 .000 Negative Discrimination towards the Elderly 2.020 .157 .009 Positive Discrimination towards the Elderly 2.003 .158 .009 AAS Total .001 .976 .000 Department x Limiting the Elderly Person’s Life 1.711 .192 .008 Gender Negative Discrimination towards the Elderly .014 .904 .000 Positive Discrimination towards the Elderly .543 .462 .003 AAS Total .861 .355 .004

Table 6 MANOVA Analysis Results of the Attitudes towards Ageism Scores according to Department and Class Variables

Wilks’λ F Hypothesis SD Error SD p ƞ2 Department .970 2.192 3 213 .090 .030 Class (year) .980 .721 6 426 .633 .010 Class (year) x Department .950 3.736 3 213 .012 .050

Table 6 displays co-effects of Tukey HSD Post Hoc test results department and class variables, which show that attitudes towards ageism scores indicates significant differences in the of 3rd year nursing department students dependent variables (Wilks’ λ =.950; were higher than those of 1st and 2nd year 2 F(3;213)=3.736, p<.05, ƞ =.050). nursing department students and elderly Accordingly, linear component scores care program students. obtained from the sub-dimensions display Table 7 demonstrates one-way differences between nursing department analysis of variance (ANOVA) results of and elderly care program students AAS sub-dimensions and “AAS Total” according to the variable of attending 1st, variables. 2nd and 3rd years.

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Table 7 Analysis results regarding the Differences between Nursing Department and Elderly Care Program Students in terms of their Attitudes towards Ageism

F p ƞ2 Limiting the Elderly Person’s Life 5.015 .026 .023 Negative Discrimination towards the Elderly .311 .578 .001 Department Positive Discrimination towards the Elderly 1.457 .229 .007 AAS Total 1.840 .176 .008 Class Limiting the Elderly Person’s Life 1.084 .340 .010 Negative Discrimination towards the Elderly .882 .415 .008 Positive Discrimination towards the Elderly .672 .512 .006 AAS Total 1.768 .173 .016 Department x Limiting the Elderly Person’s Life 1.377 .242 .006 Class Negative Discrimination towards the Elderly .055 .815 .000 Positive Discrimination towards the Elderly 10.998 .001 .049 AAS Total 3.962 .048 .018

One-way analysis of variance Total” dimension levels, no significant (ANOVA) results showed significant differences were found in the “Limiting differences between nursing department the Elderly Person’s Life” and “Negative and elderly care program students in the Discrimination towards the Elderly” “Limiting the Elderly Person’s Life” dimensions. dimension; however, no significant Results show that “Positive differences were found in the “Negative Discrimination towards the Elderly” sub- Discrimination towards the Elderly” and dimension scores (F(1,212)= 10.988, p<.05, “Positive Discrimination towards the ƞ2=.049) are =17.77 in 1st year students, Elderly” dimensions and “AAS Total” =16.13. in 2nd year students, =17.86 in score levels. 3rd year students, =14.93 in 1st year “Limiting the Elderly Person’s Life” elderly care program students and sub-dimension scores (F(1,212)= 5.015, (=17.45) in 2nd year students. “Positive 2 p<.05, ƞ =.023) of nursing students Discrimination towards the Elderly” sub- (=37.54) were found to be significantly dimension scores of 1st and 3rd year higher than those of elderly care program nursing department students were students (=35.50). significantly higher than those of 2nd year One-way analysis of variance students; and as for the elderly care, 2nd (ANOVA) results in the table indicate no year elderly care program students’ scores significant differences in the “Limiting the were significantly higher than those of 1st Elderly Person’s Life”, “Negative year students. Discrimination towards the Elderly” and The table also shows that AAS total 2 “Positive Discrimination towards the scores (F(1,212)= 3.962, p<.05, ƞ =.018) Elderly” dimensions and “AAS Total” were =86.92 in 1st year students, levels according to the class variable. =84.042 in 2nd year students, =89.52 As it is seen in the table, while one- in 3rd year students, =82.39 in 1st year way analysis of variance (ANOVA) elderly care program students, and results showed significant differences =84.90 in 2nd year students. AAS total according to the class and department scores of 1st and 3rd year nursing students variables in the “Positive Discrimination were found to be significantly higher in towards the Elderly” dimension and “AAS

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 288 comparison to 2nd year students; and 2nd (MANOVA) results of AAS sub- year elderly care program students’ scores dimensions and AAS total scores of were significantly higher than 1st year nursing and elderly care students students. according to the department and providing Table 8 demonstrates two-way care to the elderly in clinics variables. multivariate analysis of variance

Table 8 MAVOVA Analysis Results of Attitudes towards Ageism Scores according to the Department and Providing Care to the Elderly Variables

Wilks’λ F Hypothesis Error SD p ƞ2 SD Department x .951 3.674 3 214 .013 .049 Providing care to the elderly in clinics .983 1.265 3 214 .287 .017 Providing care to the elderly in clinics .999 .045 3 214 .987 .001 x Department

An analysis of co-effects of who do not and elderly care program department and providing care to the students. elderly in clinics indicates no differences It seems that there are no differences in the dependent variables (Wilks’ λ between nursing department and elderly 2 =.999; F(3;214)=0.045, p>.05, ƞ =.001). care program students’ attitudes towards Accordingly, linear component scores ageism according to providing care to the obtained from sub-dimensions of AAS elderly in clinics or not. were found to demonstrate no significant One-way analysis of variance differences between nursing students who (ANOVA) results of AAS sub-dimension provide care to the elderly in clinics and and “AAS total” variables are shown in Table 9.

Table 9 Analysis Results of the Differences between Nursing Department and Elderly Care Program Students in terms of the Attitudes towards Ageism

F p ƞ2 Limiting the Elderly Person’s Life 8.454 .004 .038 Negative Discrimination towards the Elderly .000 .982 .000 Department Positive Discrimination towards the Elderly 4.571 .034 .021 AAS Total 5.950 .016 .027 Limiting the Elderly Person’s Life .091 .763 .000 Providing care Negative Discrimination towards the Elderly .107 .743 .000 to the elderly in Positive Discrimination towards the Elderly 3.327 .070 .015 clinics AAS Total .269 .604 .001 Department x Limiting the Elderly Person’s Life .047 .829 .000 Providing care Negative Discrimination towards the Elderly .029 .864 .000 to the elderly in Positive Discrimination towards the Elderly .013 .910 .000 clinics AAS Total .002 .964 .000

One-way analysis of variance nursing and elderly care students’ scores (ANOVA) results show that while there about “Limiting the Elderly Person’s were significant differences between Life”, “Positive Discrimination towards

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 289 the Elderly” dimensions and “AAS Total” comparison to elderly care program scores, no significant differences were students (=83.68). found in the “Negative Discrimination The table also shows one-way towards the Elderly” dimension. analysis of variance (ANOVA) results “Limiting the Elderly Person’s Life” according to providing care to the elderly sub-dimension scores (F(1,212)= 8.455, in clinics; no significant differences were p<.05, ƞ2=.038) of nursing department found in the “Limiting the Elderly students (=37.42) were higher in Person’s Life”, “Negative Discrimination comparison to elderly care program towards the Elderly” and “Positive students (=35.52). “Positive Discrimination towards the Elderly” Discrimination towards the Elderly” sub- dimensions and “AAS Total” levels. dimension scores (F(1,212)= 4.571, p<.05, One-way analysis of variance ƞ2=.021) of nursing students (=17.50) (ANOVA) results according to providing were significantly higher compared to care to the elderly in clinics and elderly care program students (=16.18); departments indicated no significant and “AAS Total” scores (F(1,212)= 5.950, differences in the “Limiting the Elderly p<.05, ƞ2=.027) of nursing students Person’s Life”, “Negative Discrimination (=86.88) were significantly higher in towards the Elderly” and “Positive Discrimination towards the Elderly” dimensions and “AAS Total” levels.

Table 10 MANOVA analysis results of Attitudes towards Ageism according to the Department and Desire to work in Geriatric Service in the Future Variables

Wilks’λ F Hypothesis Error SD p ƞ2 SD Department x .940 4.531 3 214 .004 .060 Desire to work in the Geriatric Service .959 3.063 3 214 .029 .041 in the Future Desire to work in the Geriatric Service .994 .433 3 214 .730 .006 in the Future x Department

Co-effects of department and desire elderly care program students. It seems to work in the geriatric service in the that there were no differences between future variables indicated no differences nursing and elderly care students’ in dependent variables (Wilks’ λ =.994; attitudes towards ageism according to the 2 F(3;214)=0.433, p>.05, ƞ =.006). desire to work in the Geriatric Service in Accordingly, linear component scores the future variable. obtained from the sub-dimensions and Table 11 displays one-way analysis total scores of AAS showed no of variance (ANOVA) results of AAS differences between nursing department sub-dimensions and “AAS total” students who want to work in geriatric variables. service in the future and who do not and

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Table 11 Analysis Results of the Differences between Nursing Department and Elderly Care Program Students’ Attitudes towards Ageism

F p ƞ2 Limiting the Elderly Person’s Life 11.107 .001 .049 Negative Discrimination towards the Elderly .214 .644 .001 Department Positive Discrimination towards the Elderly 5.027 .026 .023 AAS Total 9.108 .003 .040 Desire to work Limiting the Elderly Person’s Life 3.526 .062 .016 in the Geriatric Negative Discrimination towards the Elderly 2.533 .113 .012 Service in the Positive Discrimination towards the Elderly 4.903 .028 .022 Future AAS Total 8.636 .004 .038 Department x Limiting the Elderly Person’s Life .978 .324 .005 Desire to work Negative Discrimination towards the Elderly .002 .969 .000 in the Geriatric Positive Discrimination towards the Elderly .098 .755 .000 Service in the AAS Total Future .137 .712 .001

According to one-way analysis of (ANOVA) results, there were significant variance (ANOVA) results, there were differences in the “Positive significant differences between nursing Discrimination towards the Elderly” department and elderly care program dimension and “AAS Total” score levels, students in the “Limiting the Elderly but no significant differences were found Person’s Life” and “Positive in the “Limiting the Elderly Person’s Discrimination towards the Elderly” Life” and “Negative Discrimination dimensions and “AAS Total” score levels; towards the Elderly” dimensions. however, no significant differences were “Positive Discrimination towards detected in the “Negative Discrimination the Elderly” sub-dimension scores 2 towards the Elderly” dimension levels. (F(1,212)= 4.903, p<.05, ƞ =.022) of nursing “Limiting the Elderly Person’s Life” students (=17.22) were significantly sub-dimension scores (F(1,212)= 11.107, higher than elderly care program students 2 p<.05, ƞ =.049) of nursing department (=15.89). AAS Total scores (F(1,212)= students (=37.49) were significantly 8.636, p<.05, ƞ2=.038) of nursing students higher in comparison to elderly care (=86.64) were significantly higher in department students (=35.37). comparison to elderly care program “Positive Discrimination towards students (=82.93). the Elderly” sub-dimension scores One-way analysis of variance 2 (F(1,212)= 5.027, p<.05, ƞ =.023) of nursing (ANOVA) results indicated no significant students (=17.23) were higher in differences in “Limiting the Elderly comparison to elderly care program Person’s Life”, “Negative Discrimination students (=15.88); and AAS total scores towards the Elderly” and “Positive 2 (F(1,212)= 9.108, p<.05, ƞ =.040) of nursing Discrimination towards the Elderly” department students (=86.69) were dimensions and “AAS Total” levels significantly higher in comparison to according to the desire to work in the elderly care program students (=82.88) geriatric service in the future and The table also indicates that department variables. according to one-way analysis of variance

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DISCUSSION care program students according to This study, which was conducted with attending 1st, 2nd, and 3rd year. 3rd year participants enrolled in two different nursing department students were found to health departments, found that students have higher attitudes towards ageism had generally positive attitudes towards scores than 1st and 2nd year nursing ageism. The literature has studies which department students and elderly care similarly report positive attitudes towards program students. It seems that positive discrimination against the elderly 1, 21-31, attitudes towards the elderly increase with and some others which indicate negative the increases in class level. While some or neutral attitudes.35 studies in the literature report similar Comparison of the attitudes towards findings1, 11, 22, 26, 34, 40-44, there are some ageism of the two groups show that others which show that attitudes scores nursing department students’ “Limiting decrease with the increase in class level. the Elderly Person’s Life” sub-dimension 24, 38, 45-47 scores and AAS total scores were Our results show that “Positive significantly higher than those of elderly Discrimination towards the Elderly” sub- care program students. Contrary to our dimension scores and “AAS Total” scores findings, Köse et al. (2015) found that of 1st and 3rd year nursing department nursing students had lower AAS total students were significantly higher in scores.3 Similarly, Zambrini et al. (2008), comparison to 2nd year students. Yılmaz in their study conducted with students and Özkan (2010) reported findings from 7 different departments related to similar to the ones in our study.1 As for health care services, found that nursing the elderly care program, 2nd year elderly department students had less positive care program students’ “Positive attitudes towards the elderly. 36 In their Discrimination towards the Elderly” sub- study conducted with medical and nursing dimension scores and “AAS Total” scores department students, Ayoğlu et al. (2014) were significantly higher in comparison to found that medical students had more 1st year students. Soyuer et al. (2010), in positive attitudes towards the elderly in their study conducted with health high comparison to nursing students 37. Unlike school students, reported different results Ayoğlu et al., Wang et al. (2009) found from the one ones in our study; “Positive that nursing students had more positive Discrimination towards the Elderly” sub- attitudes than medical students38; and dimension scores and “AAS Total” scores Zverev (2013) found no significant of 1st year students were significantly differences between the two student higher in comparison to 2nd year groups in terms of their attitudes towards students.45 In their study conducted with the elderly.39 Ayoğlu et al. (2014), elderly care program students, Özbek conducted a study with medical and Yazıcı et al (2015) reported no significant nursing department students and found differences in “AAS Total” scores; 2nd that medical department students had year students were found to have more positive attitudes towards the significantly higher “Limiting the Elderly elderly. Person’s Life” sub-dimension scores in Linear component scores obtained comparison to 1st year students. 19 from the sub-dimensions and total scores “Positive Discrimination towards of AAS displayed significant differences the Elderly” sub-dimension scores and between nursing department and elderly “AAS Total” scores of nursing department

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 292 students were found to be significantly elderly, which could be achieved through higher in comparison to elderly care more comprehensive studies on the issue. program students according to desire to work in the geriatric service. Altay and Declaration of Conflicting Interest Aydın (2015) reported significant None declared. differences in students’ “Positive Discrimination towards the Elderly” sub- Author Contribution dimension and “AAS Total” scores Both authors contributed equally in this study. according to the desire to provide care to References the elderly after graduation variable. In 1. Yılmaz E, Özkan S. Hemşirelik their study conducted with nursing öğrencilerinin yaşlı ayrımcılığına ilişkin students, Bleijenberg et al. (2012) found tutumları [Nursing students' attitudes that students did not want to work with towards age discrimination]. Maltepe elderly people in the future42, Sheikh et al. Üniversitesi Hemşirelik Bilim ve Sanatı (2013) found that medical department Dergisi / Journal of Nursing Science and students did not plan to do a career in Art of Maltepe University. 2010;3(2):35- geriatrics44, Shen and Xiao (2012) found 53. that geriatric care was preferred by 2. General Directorate of Social Sectors and nursing students less than other care Coordination. Türkiye'de Yaşlıların Durumu ve Yaşlanma Ulusal Eylem fields. 47 Planı [Status of elderly people in Turkey and national action plan on aging]. LIMITATIONS OF THE STUDY Turkey: Sosyal Sektörler ve Kordinasyon Limitations of this study are that it was Genel Müdürlüğü. 2007; conducted with students in only one http://eyh.aile.gov.tr/data/544f6b29369dc university, not all the students in the 328a057d006/yaslanma_ulusal_eylem_pl departments could be reached, and there ani.pdf. Accessed 22 March 2017. were no 4th year nursing department 3. Köse G, Ayhan H, Taştan S, İyigün E, students. Hatipoğlu S, Açıkel CH. Sağlık alanında farklı bölümlerde öğrenim gören CONCLUSION öğrencilerin yaşlı ayrımcılığına ilişkin tutumlarının belirlenmesi [Determining Students were found to have generally attitudes of students studying in different positive attitudes towards ageism. departments in the field of health Comparison of the two groups’ attitudes regarding age discrimination]. Gülhane towards ageism showed that nursing Tıp Dergisi / Gülhane Medical Journal. department students had higher mean 2015;57:145-51. scores, students’ positive attitudes towards 4. World Health Organization. Global the elderly increased with the increase in health and ageing. Geneva: World their class level, and nursing students Health Organization; 2011. were more willing to work in geriatric 5. Yılmaz Vefikuluçay D, Terzioğlu F. service in the future in comparison to Üniversite Öğrencilerinde Yaşlı elderly care program students. Ayrımcılığı Tutum Ölçeğinin Geliştirilmesi ve Psikometrik Identification of the attitudes and Değerlendirmesi [Development and views of nursing and elderly care program psychometric evaluation of elderly students who will work in the health field discrimination attitude scale in university in the future might enable to eliminate students]. Turkish Journal of Geriatrics. negative discrimination towards the 2011;14(3):259-68.

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41. Lambrinou E, Sourtzi P, Kalokerinou A, demografik değişkenlerle ilişkisi Lemonidou C. Attitudes and knowledge [Attitudes of health vocational students of the Greek nursing students towards towards elderly discrimination and their older people. Nurse Education Today. relationship with some demohgraphic 2009;29:617–22. variables]. Mersin Üniveristesi Sağlık 42. Bleijenberg N, Jansen MJM, Schuurmans Bilimleri Dergisi / Mersin Üniveristesi MJ. Dutch nursing students’ knowledge Journal of Health Sciences. and attitudes towards older people-A 2010;3(2):20-25. longitudinal cohort study. Journal of 46. McCracken A, Fitzwater E, Lockwood Nursing Education and Practice. M, Bjork T. Comparison of nursing 2012;2(2):p1. students’ attitudes toward the elderly in 43. Hughes NJ, Soiza RL, Chua M, Hoyle Norway and the United States. GE, MacDonald A, Primrose WR, Educational Gerontology. 1995;21:167- Seymour DG. Medical student attitudes 80. toward older people and willingness to 47. Shen J, Xiao LD. Factors affecting consider a career in geriatric medicine. nursing students' intention to work with Journal of the American Geriatrics older people in China. Education Today. Society. 2008;56(2):334-38. 2012;32(3):219-23. 44. Sheikh RB, Mathew E, Rafique AM, Suraweera RSC, Khan H, Sreedharan J. Attitude of medical students toward old Cite this article as: YILMAZ MÇ, İNCE people in Ajman, United Arab Emirates. FZ. Relationship between nursing and elderly Asian Journal of Gerontology and care students’ attitudes towards ageism. Geriatrics. 2013;8:85-89. Belitung Nursing Journal. 2017;3(4):281- 45. Soyuer F, Ünalan D, Güleser N, Elmalı 296. https://doi.org/10.33546/bnj.83 F. Sağlık meslek yüksekokulu öğrencilerinin yaşlı ayrımcılığına ilişkin tutumları ve bu tutumların bazı

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Thoyibah Z, et al. Belitung Nursing Journal. 2017 August;3(4):297-306 Received: 16 June 2017 | Revised: 3 August 2017 | Accepted: 21 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

CORRELATION BETWEEN FAMILY COMMUNICATION PATTERNS AND JUVENILE DELINQUENCY IN JUNIOR HIGH SCHOOL

Zurriyatun Thoyibah1, Intansari Nurjannah2*, Sumarni DW3

1Master of Nursing, Faculty of Medicine, Universitas Gadjah Mada, Indonesia 2Psychiatric and Community Nursing Department, Faculty of Medicine, Universitas Gadjah Mada, Indonesia 3Department of Psychiatry, Universitas of Gadjah Mada, Indonesia

*Corresponding author: Intansari Nurjannah, S.Kp., MN.Sc., Ph.D Associate Professor, Psychiatric and Community Nursing Department, Faculty of Medicine, Universitas Gadjah Mada. Jl. Farmako, Senolowo, Sekip Utara, Kec. Depok, Kabupaten Sleman, Daerah Istimewa Yogyakarta 55281, Indonesia E-mail: [email protected]

ABSTRACT Background: Adolescents who are in transition period have high risk behavior of juvenile delinquency. Communication between parents and adolescents effectively and openly could help adolescents to avoid delinquency behavior. Objective: This study aims to examine the relationship between family communication patterns and juvenile delinquency in junior high school. Methods: This research employed a cross-sectional design with correlation description approach. There were 243 students selected using simple random sampling from the 7th and 8th grade students of junior high school. A questionnaire of juvenile delinquency and family communication pattern were used in this study. Data were analyzed using Chi Square test. Result: The research showed that the majority juvenile delinquency category was low (65%) and the majority of communication pattern was in functional category (73.3%). There was a significant relationship between family communication pattern and juvenile delinquency (p<0.05). Conclusion: Communication pattern within family have significant association with juvenile delinquency.

Keywords: family communication pattern, juvenile delinquency, adolescent

INTRODUCTION Adolescence is a transitional period in adolescents to have a high risk of which adolescents experience emotional behavioral disturbance, delinquency, and transitions, social transitions, family the occurrence of violence both as victims relations transitions, and morality and as perpetrators of violence.2 The transitions.1 This period causes transition period can cause a crisis if

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Editor’s Note: This article has been updated on 11 July 2020 in terms of the completeness of the correspondence address. supported by a less conducive School of Gunungsari, West Lombok environment and a less good personality Regency, Indonesia. There were 234 will trigger the emergence of various students selected using simple random behavioral aberrations. These behaviors sampling. include teenagers involved in fighting, drugs, promiscuity, even to criminal acts, Instruments where those example can be categorized as Two instruments were used in this a form of juvenile delinquency.3 research, namely: a questionnaire of Juvenile delinquency is not a new juvenile delinquency and family phenomenon of adolescence but a communication pattern. The juvenile continuation of the pattern of asocial delinquency questionnaire was designed behavior that begins in childhood. A social by the researchers and modified from behavior is influenced by parenting and other researches.8,9 In this instrument, communication in the family, therefore, is there are three different scores as the required an effective communication following: 0 means never been done, score between children and parents since early 1 means have been done for 1-2 times, stage. The role of communication within score 2 means have been done for > 1 the family is very important for times. While family communication transferring values and culture.4 Lack of pattern’s questionnaire was also designed intimacy of parents and adolescents, lack by the researchers based on family of parental involvement, lack of guidance, communication theory,10 using four blame, and scolding adolescents can lead options: 4 means always; 3 means often; 2 to juvenile delinquency behavior.5 The means sometimes; and 1 never. Both support of parents through communication instruments were tested for reliability with and supervision is believed to reduce the Cronbach's Alpha value of juvenile use of drugs and juvenile delinquency.6 delinquency questionnaire was 0.942, and Parental and juvenile communication family communication patterns was 0.901. problematic is consistently associated with improvement in three types of risk Data Analysis behavior in adolescents such as juvenile The data were analyzed using Chi Square delinquency, drug abuse, and sexual test using SPSS 16. behavior risky.7 Ethical Consideration METHODS The study was approved from the Ethics Design Commission of the Faculty of Medicine, This research used a cross-sectional design Universitas Gadjah Mada. with correlation description approach.

Setting RESULTS The research was carried out in Junior Results showed that that juvenile High School of Gunungsari, West Lombok delinquency was mostly in low level of Regency, Indonesia. delinquency which was 65.0%. The number of females and males respondents Target Population and Sample were almost equal. The majority of The target population of this study was all respondents have parents who are not students from grade 7 and 8 Junior High divorced 80.2% (see Table 1).

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Table 1 Characteristics of Respondents based on Research Variables (n=243)

Variable Category Frequency Percentage (%) High 19 7.8 Juvenile delinquency Medium 66 27.2 Low 158 65.0 Dysfunctional 65 26.7 Communication Pattern Functional 178 73.3 Male 120 49.4 Gender Female 123 50.6 Divorced 48 19.8 Marital status of parents Not divorced 195 80.2

The functional communication for the opinions of family members, and pattern shows that most respondents’ the existence of honesty and openness had parents had free time to communicate not been implemented optimally. The next with family members (58.4%) and teach indicator showed that some parents deliberation and solve problem calmly (50.6%) paid attention to the child by (69.9%). The next indicators were related contacting the child by phone if they were to tolerance, mutual respect, and respect late returning home (see Figure 1).

25.1 Never Attention 24.3 24.3 26.3 Sometime

14.5 Often Honesty and openness 49.7 20 15.8 Always

22.4 Tolerance, respect and respect the 48.6 opinions of family members 17.7 11.3

6.4 Teach deliberation & solve problems 23.7 calmly 31 38.9

3.7 There is free time to communicate 37.9 26.7 31.7

0 20 40 60

Figure 1 Description of functional communication pattern

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The description of dysfunctional communication patterns can be seen in Figure 2 below.

34.3 42.2 Never Less empathy and no tolerance 15.3 8.2 Sometimes 24.6 Low self-esteem and self-centeredness 36.9 Often 19.6 18.9 Always 13.58 Parents make decisions about the child's 39.09 problem 23.46 23.87

16.46 Parents are not open to the child about a 38.68 problem 28.81 16.05

46.09 Parents do not advise children's 26.75 problems 13.17 13.99

22.8 Inability to express opinions and needs 54.1 17.8 5.3

0 20 40 60

Figure 2 Description of disfunctional communication pattern

The description of dysfunctional making decisions on the problems facing communication patterns shows that only a the child. small percentage of respondents are Most respondents showed juvenile unable to express opinions and wishes to delinquency, such as: using uniforms and their parents as well as lack of empathy attributes that do not fit school rules, and tolerance. watching pornographic images, fighting, Dysfunctional communication is and disrespect and denied the elderly, also characterized by almost half the reaching 71.21%, only 2.87% of parents of respondents not being open in respondents who engage in promiscuity communicating with their child and and consume drugs (see Figure 3).

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Figure 3 Description of juvenile delinquency

The dependent variable in this study was between high and low delinquency consisted of 3 categories of high, medium, and low and average delinquency, so the and low juvenile delinquency. Therefore, result of analysis consisted of 2 OR to see the value of Odds Ratio (OR) values, they were OR for high and OR for researchers used dummy variable refer to medium delinquency. The result of the group that did have any risk such as bivariate analysis can be seen in Table 2 low juvenile delinquency. The grouping below.

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Table 2 Results of Cross-tabulation of Independent and Outside Variables Against Adolescent Delinquency Level (n=243)

Juvenile Delinquency Level P Odds Ratio (OR) Variable High Medium Low X2 value n % n % n % High Medium Communication Pattern 1. Dysfunctional 13 20.0 25 38.5 27 41.5 28.5 0.001 10.5 2.9 2. Functional 6 3.4 41 23.0 131 73.6 Gender 1. Male 16 13.3 51 42.5 53 44.2 45.6 0.001 10.5 6.7 2. Female 3 2.4 15 12.2 105 85.4 Marital status of parents 1. Divorced 11 22.9 14 29.2 23 47.9 20.2 0.001 8.1 1.6 2. Not Divorced 8 4.1 52 26.7 135 69.2

The results of analysis in table 2 Previous research found that juvenile shows that there was significant relation delinquency in children at the ages of 10- between communication pattern, gender, 14 is about 28%, while 72% are from the marital status of parent and juvenile 15-18 age group.12 delinquency (p<0.05). Dysfunctional Low juvenile delinquency rates communication patterns, male sex, and might also be attributed to other factors divorce of parents cause teenage such as school factors.13 The subjects in opportunities to experience higher levels this study were from a fairly good school of delinquency to be greater. Adolescents with an accreditation, which has the with a dysfunctional communication facilities and complete in infrastructure pattern have a 10.5 chance of aspect and adequate learning process. This experiencing high levels of delinquency school also actively accommodates compared to adolescents with functional learners with a variety of extracurricular communication patterns. Male adolescents activities. The school environment is one have a 10.5 chance of experiencing high of the factors that influence the happening levels of delinquency compared to female of juvenile delinquency, because the adolescents. school is a second place of education for adolescents after their family DISCUSSION environment.13,14 Bad school conditions Description of juvenile delinquency will cause teenagers to act delinquent. The results showed that the majority of These conditions include the lack of juvenile delinquency rates were at a low learning facilities such as tools of practice, level. This might be influenced by the age arts tools, and sports can also lead to factor of respondents; 12-14 years. At the various negative behaviors in the age of 12-14 years is puberty phase which students.3 is also called "negative phase", in which Another factor that affects the low the behavior of children become level of juvenile delinquency in this study unpredictable and often against the was family factor. Most respondents’ prevailing social norms.11 The children at parents (81.2%) were not divorced. The age of 12-14 years are an early period for results of this study were supported by children to try to do misbehavior so that research which explains that intact the frequency of delinquency was low. families produce less juvenile delinquency

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 302 compared with separated families.15 can have a negative impact on adolescent Gibson (1969) cited in Ramadhani, also development. confirmed the same thing in which 55% of teenagers from separated families engage Relationship of pattern communication juvenile delinquency.16 and juvenile delinquency The result of analysis showed that there Parents communication pattern was a significant correlation between The results showed that most of the juvenile delinquency level and family respondents' family communication communication pattern, where the chance patterns were categorized as functional of adolescent with dysfunctional patterns. The high functional communication pattern to experience high communication pattern in the research can degree of delinquency equal to 10.5 times be influenced because the respondent lives compared to adolescent with functional with the parents. There were 79.4% (193) communication pattern in family. These respondents living with their parents. This findings support the previous research allows parents to have free time to which showed that adolescents with less communicate with their children. Staying open communication and many with both parents who have free time to communication problems with parents had communicate becomes an important factor higher rates of delinquency and more because the child will have the same serious forms of delinquency.19 socio-cultural background, the similarity Aggressive behavior and high juvenile of values, environment, and distance. delinquency influenced directly by low Socio-cultural factors, values, parent and juvenile communication.20 environment, and distance are factors Communication problems between influencing interpersonal communication parents and adolescents are identified as in the family.17 These factors will risk factors for delinquency behaviors minimize the differences in perception such as consume drugs and promiscuity, that can lead to errors in communication. and open communication between parents Thus, effective and functional and adolescents is a protective factor for communication patterns in the family can risk behavior.21 take place well. The juvenile delinquency can be Although most of communication caused by internal factors include identity pattern was functional, however there crisis, negative self-concept and lack of were also respondents who were having self-control, and external factors comes dysfunctional communication pattern. from the family environment is less This pattern may resulted there is no open effective communication in the family. communication between respondents and Adolescence is at the stage of identity their parent as we know that one of the crisis versus identity diffusion.1 tasks of family development with Therefore, in the search for identity of adolescent children is to communicate adulthood, adolescents need parents who openly.18 Without open communication can guide them by using effective between teenagers and parent there will be communication, so that messages are no good relationships between them.19 If delivered properly and correctly. parents are not open in communicating Adequate communication between parents with teenagers, children will learn from and teens where children can express their the environment outside the family, which opinions and feelings freely will

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 303 effectively reduce the stress experienced divorce also have significant association of adolescents in their daily lives, so that with juvenile delinquency. it can establish a positive identity in adolescents.22 Teens who have a positive Declaration of Conflicting Interest self-concept will be able to carry out the None declared. demands given by the environment. Conversely, when adolescents have a Acknowledgments negative self-concept, the teenagers see We thank the Department of Nursing, Universitas Gadjah Mada, Junior High School the environment, parents and life in Gunungsari, and all respondents for negatively, so often violate the rules and providing an opportunity to complete this norms that exist in society that leads to research. 23 juvenile delinquency. The functional communication Author Contribution pattern in the family is very important for All authors contributed equally in this study. adolescent development, this pattern leads to open and effective communication so References that it can guide the child to achieve a 1. Santrock JW. Life-span development. positive identity and develop good self- New York: Mc Graw Hill; 2010. control.24 While dysfunctional 2. Soetjiningsih. Tumbuh kembang remaja dan permasalahannya [Adolescents communication patterns cause an growth development and its problem]. uncomfortable family atmosphere and Jakarta: Sagung seto; 2004. poor family communication relationships 3. Willis SS. Remaja dan masalahnya. may pose a danger to adolescents, as they Mengupas berbagai bentuk kenakalan will affect adolescent social development. remaja: narkoba, free sex, dan Dysfunctional communication causes the pemecahannya [Adolescents and their child to fail to attain a positive self- problem. Reviewing various juvenile identity, thus losing self-control over the delinquency: drugs, free sec, and negative effects of the environment and solution]. Bandung: Alfabeta; 2012. falling into a variety of delinquency. Lack 4. Runcan P, Constantineanu C, Ielics B, of communication will make parents fail Popa D. The role of communication in the parent-child interaction. Procedia- to understand what children will, and this Social and Behavioral Sciences. will lead to the difficulty to monitor 2012;46:904-908. children's behavior and resulted in 5. Poduthase H. Parent-adolescent 25 children to be involved in delinquency. relationship and juvenile delinquency Communication pattern in the family have in Kerala, India: A qualitative study. significant role in teaching, guiding, Utah: College of Social Work, determining behavior, and shaping the University of Utah; 2012. child's perspective of values prevailing in 6. Tolou SM, Hadley W, Conrad SM, society, so children can filter out the Brown LK. The role of family affect in negative environmental influences and juvenile drug court offenders’ substance use and HIV risk. Journal of avoid juvenile delinquency behavior. Child and Family Studies.

2012;21(3):449-456. CONCLUSION 7. Wang B, Stanton B, Li X, Cottrell L, Communication pattern within family Deveaux L, Kaljee L. The influence of have significant association with juvenile parental monitoring and parent- delinquency. Male adolescent and parents' adolescent communication on

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bahamian adolescent risk involvement: komunikasi positif [Sharpen potential A three-year longitudinal examination. and positive personality of children Social Science & Medicine. trough positive communication]. 2013;97:161-169. Yogyakarta: Bookmarks; 2008. 8. Wahidah N. Pola komunikasi dalam 17. Potter PA, Perry AG. Fundamentals of keluarga [Communication pattern in nursing concept, process and practice. family]. Jurnal Musawa. 3 ed. Missouri: Mosby Year Book; 2011;3(2):163-178. 1993. 9. Palupi AO. Pengaruh religiusitas 18. Andarmoyo S. Keperawatan keluarga: terhadap kenakalan remaja pada siswa Konsep teori, proses, dan praktik Kelas VIII SMP Negeri 02 Slawi keperawatan [Family nursing: Kabupaten Tegal [Effcet of religiousity Concept, theory, process, and nursing on juvenole deliquency in students class practice]. Yogyakarta: Graha Ilmu; VIII Senior High School No 2 Slawi 2012. Tegal]. Semarang: Jurusan Psikologi 19. Clark RD, Shields G. Family Fakultas Ilmu Pendidikan, Universitas communication and delinquency. Negeri Semarang; 2013. Adolescence. 1997;32(125):81-92. 10. Friedman M, M, Bowden V, R, Jones 20. Puspitawati H. Pengaruh komunikasi E, G. Buku ajar keperawatan keluarga: keluarga, lingkungan teman, dan Riset, teori dan praktik [Family nursing sekolah terhadap kenakalan pelajar dan textbook: Research, theory, and nilai pelajaran pada sekolah menengah practice] . Jakarta: EGC; 2010. di Kota Bogor [Effect of family 11. Hurlock EB. Child development. communication, peer enviornment, and Tjandrasa M, translator. 6th ed. Jakarta: school on juvenile delinquency and Penerbit Erlangga; 2005. learning score in senior high school at 12. Sahmey K. A study on factors Bogor City]. Jurnal Ilmiah Pekerjaan underlying juvenile delinquency and Sosial. 2008;7(2). positive youth development programs. 21. Yu S, Clemens R, Yang H, et al. Youth India: National Institute of Technology and parental perceptions of parental Rourkela; 2013. monitoring and parent-adolescent 13. Hayati SH. Remaja dan communication, youth depression, and problematikanya. Menyingkap youth risk behaviors. Social Behavior berbagai persoalan kenakalan remaja, and Personality: an international narkoba, dan peyimpangan seksual journal. 2006;34(10):1297-1310. [Adolescents and their problems. 22. Wahyuning PB, Puspita I. Hubungan Disclosing various juvenile antara komunikasi orang tua-remaja delinquencies, drugs and free sex]. dengan regulasi emosi pada remaja di Yogyakarta: Beranda; 2013. Sekolah Menengah Atas DKI Jakarta 14. Sudarsono. Kenakalan remaja, [Relationship of parent-adolescent prevensi, rehabilitasi, resosialisasi communication and emtional [Juvenile delinquency, prevention, regulation in adolescents at Senior rehabilitation,resosialization]. Jakarta: High School of Jakarta], Jakarta: Rineka Cipta; 2012. BINUS; 2013. 15. Kierkus CA, Baer D. A Social control 23. Maria U, Nuryoto S. Peran persepsi explanation of the relationship between keharmonisan keluarga dan konsep diri family and delinquent behavior. terhadap kecenderungan kenakalan Canadian Journal of Criminology. remaja [Role of family harmony, self- 2002;44:425. concept, and juvenile delinquency] . 16. Ramadhani S. The art of positive Yogyakarta: Universitas Gadjah Mada; communicating, Mengasah potensi dan 2007. kepribadian positif pada anak melalui

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24. Farley JP, Kim SJ. The development of Utara]. eJournal Ilmu Komunikasi. adolescent self-regulation: Reviewing 2013;1(4):200-209. the role of parent, peer, friend, and romantic relationships. Journal of Cite this article as: Thoyibah Z, Adolescence. 2014;37(4):433-440. Nurjannah I, Sumarni D. Correlation 25. Hatuwe NQ. Pola komunikasi keluarga between family communication dalam mencegah kenakalan remaja patterns and juvenile delinquency in (Studi pada remaja di Kelurahan Gresik junior high school. Belitung Nursing Kabupaten Penajam Paser Utara) Journal. 2017;3(4): 297-306. [Family communication pattern in https://doi.org/10.33546/bnj.114 preventing juvenile delinquency (Study of adolescents in Gresik enajam Paser

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Maharani Y, et al. Belitung Nursing Journal. 2017 August;3(4):307-315 Received: 1 March 2017 | Accepted: 31 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

THE IMPACT OF GENTLE HUMAN TOUCH IN INCREASING BABY WEIGHT, BODY TEMPERATURE AND PULSE STABILITY ON PRETERM BABY

Yennita Maharani1*, Ari Suwondo2, Triana Sri Hardjanti1, Suharyo Hadisaputro1, Dyah Fatmasari1, Imam Djamaluddin Mashoedi1

1Magister Applied Midwifery, Poltekkes Kemenkes Semarang, Indonesia 2Faculty of Public Health, Diponegoro University, Semarang, Indonesia

*Corresponding author: Yennita Maharani Magister Applied Midwifery, Poltekkes Kemenkes Semarang Jl. Tirto Agung, Pedalangan, Banyumanik, Kota Semarang, Jawa Tengah, Indonesia (50268) E-mail: [email protected]

ABSTRACT Background: Touch is crucial for optimal growth and development of preterm babies. Gentle human touch is considered as a complementary treatment to spur their growth and development. Objective: To determine the effect of gentle human touch on weight gain, body temperature and pulse rate stability in preterm babies. Methods: This was a Randomized Controlled Trial (RCT) with pretest-posttest with control group. Thirty- nine respondents were selected by consecutive sampling, assigned into two treatment groups and one control group. Data were analyzed using MANOVA . Results: The results showed that there was statistically significant difference in body weight (p = 0.047), body temperature (p = 0.021), and pulse rate stability (p = 0.001) in preterm babies. Conclusion: Gentle human touch therapy twice a day is more effective in improving body weight, body temperature, and pulse rate stability in premature babies. It is recommended that gentle human touch be applied as an operational standard for premature baby care.

Keywords: premature babies, gentle human touch, body weight, body temperature, and pulse rate stability

INTRODUCTION The number of premature babies is infants or 7-14% were born prematurely increasing. WHO stated that one in ten or in low birth weight,2 which is still births is a premature baby.1 In Indonesia, relatively high compared to some it is estimated that approximately 350,000 developing countries that have 5-9% of

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Editor’s Note: This article has been updated on 11 July 2020 in terms of minor changes in the reference format. The update is based on BNJ policy on article correction. preterm infants, 12-13% in the United The intervention that has been done States.3,4 in the General hospital of Pariaman shows One of the highest incidence rate of is still conventional, which is to let the premature and low birth weight (LBW) baby in the incubator, provide the usual infants is in the province of West care, prepare milk as needed, minimally Sumatera.2 Pariaman city is a contributor hold the baby, allow the baby to grow by of 10% of premature cases in this themselves, and perform physician advice. province.2 The General Hospital of These interventions might be good Pariaman recorded data of premature enough, but alternative treatment should infants and low birth weight in 2007 as be performed to support the growth and much as 5.1% of cases, which is increased development of the babies. to 7.7% in 2008 and 11.4% in 2013.5 This According to literature, various percentage remains steadily in 2014, interventions for premature infants are which was 11.7% in 2014, and drastically being developed to spur growth and increased to 19.5% in 2015.5 Report from development and shorten the duration of Perinatology ward of the General Hospital treatment, such as tactile, kinesthetic, of Pariaman between January to July 2016 vestibular, oral, auditory and other indicated that as many as 113 of 493 stimulations, which are required for babies (22.9%) are prematures.5 extrauterine development of premature Premature infants are babies born infants as well as helping infants adapt to with gestation less than 37 weeks and with the extrauterine environment.10 The low body weight.6 In premature infants, intervention proposed in this study is the maturation of all organs has not been touch therapy (Gentle Human Touch). achieved properly. Thus, they are at risk Studies show that Gentle Human of health problems. Due to birth weight Touch will produce beta endorphin that less than 2500 grams, the baby does not affects future growth mechanisms in have or only have a few subcutaneous fat infants.11 In Gentle Human Touch, infants deposits, limited brown adipose tissues, experience increased vagus nerve tone and weak sucking reflexes and (10th nerve brain), which will lead to swallowing.7 increased levels of gastrin absorption In addition, premature babies are enzyme and insulin secretion, thereby required to be treated in incubators, as better absorption of food, so that the low-weight babies do not yet have the weight of infants receiving touch therapy ability to adapt to ambient temperatures. increases more than those without it.11 The incubator is useful for keeping the Therefore, this study aims to determine baby's temperature steady, due to an the effect of Gentle Human Touch on inadequate regulatory system in the weight gain, body temperature, and pulse premature infant body, which may rate stability in preterm babies. compromise his or her health condition.8 Another problem that often arises is in the METHODS respiratory system, since premature babies Design are in need of higher oxygen, which is This Randomized Controlled Trial (RCT) three times more compared to babies who was conducted in the General Hospital of are old enough.9 Thus, these conditions Pariaman, West Sumatera Province in tell the treatment of premature infants between October 2016 and January 2017. should be performed well.

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Sample Intervention Thirty nine respondents were selected In this study, the treatment A group using consecutive sampling method, received gentle human touch once a day which randomly assigned to three groups, for 15 minutes, treatment B group namely: 1) treatment A group who received gentle human touch twice a day received gentle human touch once a day for 15 minutes per each intervention, and for 15 minutes (13 respondents), 2) the control group received Kangaroo treatment B group who received gentle Mother Care (KMC) once a day for 30 human touch twice a day for 15 minutes minutes. A gentle human touch therapy is per each intervention, and 3) control an act or activity performed by group (13 respondents) received practitioners or therapists on premature Kangaroo Mother Care (KMC) once a day infants, involving physical contact, with for 30 minutes. slow and gentle movements using herbal The inclusion criteria to select massage oil in the area of head, shoulders, sample were: a) Infants with gestational back, hands and feet. This therapy age ranged between 28 weeks to less than consisted of 3 phases. The first and the 37 weeks, b) Infant birth weight before third phases are called tactile stimulation, intervention was from 1400 grams to 2500 and the second phase is called kinesthetic grams, c) infants who had no congenital stimulation. Intervention was performed abnormalities based on medical records, for 1 hour after morning and evening bath d) premature infants who did not receive for 5 days intervention. The oxygen therapy either by O2 hose, implementation of touch therapy (Gentle ventilator, or CPAP (Continuous Positive Human Touch) was carried out by the Airway Pressure), e) no dehydration based researchers themselves who had on medical records, f) Incubator competency and certified. For control temperature and food intake were adjusted group, KMC (Kangaroo Mother Care) based on the needs according to age and was given as a treatment for premature weight of each premature infant and babies by making skin-to-skin contact standard of the hospital, g) no experience between the baby’s front and the mother’s complications such as respiratory distress chest. Implementation of KMC was syndrome, anemia, intracranial performed by the infant mothers with the hemorrhage, Necrotizing enterocolitis help of researchers and enumerators. (NEC), Patent Ductus Arteriosus (PDA), active infection, and prematurity apnea Instrument (characterized by baby blue skin, Body weights were measured by increased respiratory frequency and the researchers using digital scales in grams. presence of chest wall). Temperature was measured using a digital The exclusion criteria in this study thermometer with a normal temperature included: a) the infant underwent ranged between 36.5 ° C - 37.5 ° C, and phototherapy treatment or transfusion pulse rates were measured using pulse exchange, b) experienced vomiting / oximetry with normal pulse of 120 – 160 regurgitation during the course of the beats per minute. intervention, and c) the infant's parents asked for forced return home during the Ethical consideration intervening period. The research has been ethically approved by Politeknik Kesehatan Kementrian

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Kesehatan Semarang with No. 222/KEPK/ Data analysis Poltekkes-SMG/EC/2016. The study Univariate and bivariate analyses were permission was also obtained from the performed in this study. The univariate Director of the General Hospital of analysis was to describe each of the Pariaman. Informed consent was variables studied in the study using conducted on all respondents' mothers by descriptive statistics, while bivariate explaining the purpose, benefits, duration analysis using ANOVA and MANOVA to of study, procedures and responsibilities examine the effect of interventions and of the participants. It was also explained determine which intervention is the best that the confidentiality of the data was among all the interventions provided. highly addressed, and the compensation was provided for the respondents.

RESULTS Characteristics of the respondents

Baby weight 3000

2500

2000

Baby weight (gr) 1500

1000

500

0 Day 1 Day 2 Day 3 Day 4 Day 5 Treatment A 2150 2170 2176 2188.5 2200.3 Treatment B 1997.69 2120 2207 2269 2407.31 Control 2233.08 2204 2196 2202 2194.62

Graphic 1 Frequency distribution of baby weight in the treatment and control group

As shown in the graphic 1, the average weight on the fifth day was 2407.31 gr. weight on the treatment B on the first day There was an increase of 409.62 gr in five was 1997.69 gr and the average body days.

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Body temperature 37.2 37.1 37 36.9 36.8 36.7 Baby temperature 36.6 36.5 36.4 36.3 36.2 36.1 Day 1 Day 2 Day 3 Day 4 Day 5 Treatment A 36.64 37.02 37.03 36.86 36.96 Treatment B 36.7 36.9 37 36.93 36.83 Control 36.47 36.9 36.9 36.85 37.06

Graphic 2 Frequency distribution of baby temperature in the treatment and control group

Graphic 2 shows that the mean 36.83 ° C on the fifth day. There was an temperature in the treatment B on the first increase of 0.13 ° C in five days. day was 36.7 ° C and increased to be was

Pulse rates 146 144 142 140 138 136

Pulse rate 134 132 130 128 Day 1 Day 2 Day 3 Day 4 Day 5 Treatment A 137.08 139.8 143.2 140 143.38 Treatment B 136.15 139 143 133.7 133.69 Control 135.69 145 142 142.2 143.69

Graphic 3 Frequency distribution of baby pulse rates in the treatment and control group

Graphic 3 shows that the average 133.69 on the fifth day. There was a pulse in the treatment B on the first day decrease of 2.46 in five days. was 136.15 beats per minute, decreased to

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Table 1 Effect of Gentle human touch on weight, temperature, and pulse rates in preterm infants

Variable Group Pre Post Delta P-value Post Hoc

Body Treatment A 2150 2200.38 50.3 Treatment A Treatment B 0.034 weight Treatment B 1997.69 2407.31 409.62 0.047* Treatment B Control 0.029 Control 233.08 2194.62 -38.46 Treatment A 26.64 36.96 0.32 Treatment B Control 0.006 Body Treatment B 36.70 36.83 0.138 0.021* 0.000** temperature Control 36.47 37.06 0.599 Treatment A 137.08 143.38 6.3 Treatment A Treatment B 0.001 Pulse Treatment B 136.15 143.69 -2.46 0.001* rate Control 135.69 143.68 8 Treatment B Control 0.001 *ANOVA **MANOVA Significant value <0.05

Table 1 shows that there was The increase of weight gain in statistically significant difference among premature infants after given gentle the treatment A, treatment B, and control human touch is due to the production of group in terms of body weight (p= 0.047), endorphin beta that can affect future temperature (p= 0.021), and pulse rate (p= growth mechanisms in infants.12 The 0.001). This finding was supported by the impact of this therapy increases the vagus result of MANOVA test, which showed p- nerve tone (10th nerve brain) which lead value 0.000, indicated that there was a to increased levels of enzyme absorption significant effect of gentle human touch of gastrin and insulin secretion, thus the on body weight, body temperature and absorption of food will be better.13 pulse rates. Human touch also stimulates blood Based on the descriptive statistic circulation and increases energy because test, it could be seen the effectiveness of more oxygen is sent to the brain and the treatment B, which showed that the throughout the body. Improved sleep body weight in the treatment B group was quality in infants given the touch is due to higher compared to the body weight of the an increase in serotonin secretion levels other groups. Similar with the body produced during the therapy.13 In addition, temperature and pulse rates, the treatment a gentle suppression by the mothers to the B group showed the significant decrease baby causes the nerve endings on the of temperature and pulse rates than the surface of the skin reacted to the touch. other groups. Furthermore, the nerve sends messages to the brain through the neural network DISCUSSION located in the spinal cord. The process This study aimed to determine the effect may cause stimulation of peripheral of Gentle Human Touch on weight gain, sensory nerve receptors, especially body temperature and pulse rates in pressure receptors.13 This stimulation premature infants. Findings of the study activates the parasympathetic nervous showed significant effects of this system. The most important treatment statistically on infant weight parasympathetic nerve stimulation gain, body temperature and pulse rates involved in sleep processes is that some stability. areas within the parasympathetic autonomic nerve of raphe nuclei and

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 312 nucleus tractus solitarius, which are the In addition, the serotonin sensory regions of the medulla and the neurotransmitter system also increases the pons passed by the visceral sensory capacity of receptor cells to bind signals entering the brain through the glucocorticoids (adrenaline to a stress vagus and glosovaryngeal nerves.14 hormone) that causes a decrease in the Gentle human touch also increases levels of the adrenal hormone (hormone vagal tone to stimulate the vagus nerve. cortisol). This process causes feelings of The supply of parasympathetic nerves is relaxation in the infant to feel more delivered to and from the abdomen comfortable and quiet during sleep.12,16 through the vagus nerve.13,14 Vagus nerve At the touch, there is a change of is the nerve of the tenth head that brain waves that is the decrease of alpha regulates the function of organs including waves and the increase of beta waves and the chest and abdomen. Stimulation of the theta that can be seen through the use of vagus nerve stimulates enterochromaffin EEG (Electroencephalography).17 cells in the gastrointestinal tract to secrete Changes in brain waves are caused by the the hormone serotonin.13,14 arousal activity of parasympathetic Theoretically, it can be explained nervous system of raphe nuclei. Raphe that in humans more than 90% of nuclei is a nucleus derived from the raphe serotonin in the body is found in medial of the brainstem and projectes in enterochromaffin cells in the most regions of the brain, especially those gastrointestinal (duodenal) channel. The leading to the dorsal root of the spinal enterochromaffin cells are the principal cord and to the hypothalamus where one synthesis and storage site of serotonin in of its functions is secreting the hormone the body. Serotonin is also found in the serotonin. raphe cells in the brain stem, there are Raphe nuclei is the most striking serotoninergic neurons that synthesize, stimulant area that can cause a natural store, and release serotonin as sleep state. Parasympathetic nerve neurotransmitters.14 Serotonin can induce stimulation of the raphe nuclei will result drowsiness and provide comfort in decreased metabolism, pulse, blood (antidepressant). The release of serotonin pressure, respiratory rate and increased is stimulated by the presence of food and serotonin secretion.14 Raphe nuclei also stimulation of the vagus nerve. Serotonin projected into the hypothalamus, so is the major neurotransmitter associated stimulation of the raphe nuclei will also with the onset of sleep by suppressing the lead to stimulation of the hypothalamus, activity of the reticular activation system and cause secretion of Corticotropin as well as other brain activity.14 Releasing Factor (CRF). Further, CRF Serotonin synthesized from the stimulates the pituitary gland to increase tryptophan amino acid is converted to 5- proopiomelanocortin (POMC) production hydroxytriptophan (5HTP) then becomes so that the production of enkephalin by N-acetyl serotonin which eventually turns the adrenal medulla increases. The into melatonin. Melatonin has a role in pituitary gland also produces endorphins sleep and makes sleep longer and deeper as neurotransmitters that can affect the at night. This is because more melatonin mood to relax. Increased endorphins and is produced in the dark when the light enkephalin cause the body to relax, and entering the eye is reduced.15 create a sense of calm so that tension

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 313 diminishes and allows the baby to fall References asleep.14 1. World Health Organization. World With the feeling of relaxed and calm health statistics 2009. Geneva: World the baby will be easier to get a sound Health Organization; 2009. sleep and quality. The state of calm and 2. Ministry of Health. Basic Health Research 2010. Jakarta: Badan relax causes the brain waves to slow Penelitian dan Pengembangan down, the slower it ends up making a Kesehatan Kementerian Kesehatan person able to rest and fall asleep. Indonesia; 2010. Changes in brain waves that occur is the 3. Bowden VR, Greenberg CS. Children decrease of alpha waves and increase and their families: The continuum of theta beta waves, where the brain waves care. Philadelphia: Lippincott are very influential in the process of sleep, Williams & Wilkins; 2010. so that the stability of the pulse and 4. Kulkarni A, Kaushik JS, Gupta P, temperature can be maintained. Therefore, Sharma H, Agrawal RK. Massage and the gentle human touch is very effective touch therapy in neonates: The for the premature infants in gaining current evidence. Indian Pediatrics. 2010;47(9):771-776. weight and maintaining temperature and 13,17 5. General Hospital of Pariaman. pulse rates. Medical record of General Hospital of Pariama 2013-2015. Padang, CONCLUSION Indonesia: Rumah Sakit Umum There is a significant effect of Gentle Daerah Pariaman;2015. Human Touch therapy performed two 6. Hockenberry MJ, Wilson D. Wong's times a day to increase body weight, nursing care of infants and children- temperature and pulse rate stability in e-book. Philadelphia: Elsevier Health preterm babies. It is suggested that this Sciences; 2014. therapy can be a guidance of care in the 7. Bobak IM, Lowdermilk DL, Jensen premature babies in addition to the regular MD. Maternity nursing textbook. Jakarta: EGC; 2005. care in the hospital. Further research is 8. Benson RC, Pernoll ML. Buku saku needed related to the perinatal stress obstetric and gynekology handbook. levels with PIPP (Premature Infant Pain Jakarta: EGC; 2008. Profile) Assessment Tool, sleep quality, 9. Hurlock EB, Istiwidayanti, Sijabat length of stay in the hospital, and stress RM, Soedjarwo. Psikologi hormone levels (cortisol saliva). perkembangan: Suatu pendekatan sepanjang rentang kehidupan Declaration of Conflicting Interest [Developmental psychology: An None declared approach throughout the life span]. Jakarta: Erlangga1990. Funding 10. Diego MA, Field T, Hernandez‐Reif This study was supported by Magister M, Deeds O, Ascencio A, Begert G. Applied Midwifery, Poltekkes Kemenkes Preterm infant massage elicits Semarang, Indonesia. consistent increases in vagal activity and gastric motility that are associated Author Contribution with greater weight gain. Acta All authors contributed equally in this study. Paediatrica. 2007;96(11):1588-1591. 11. Rosalina I. Fisiologi pijat bayi [Baby massage physiology]. Bandung: Trikarsa Multi Media. 2007.

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12. Roesli U. Pedoman pijat bayi 16. Scafidi FA, Field TM, Schanberg SM, prematur dan bayi usia 0-3 bulan et al. Massage stimulates growth in [Guideline for masage of premature preterm infants: A replication. Infant baby and 0-3-month baby]. Jakarta. Behavior and Development. Trubus Agro Wijaya; 2007. 1990;13(2):167-188. 13. Guyton AC. Human physiology and 17. Yahya N. Spa bayi dan anak [Baby mechanisms of disease. Mosby: WB and children Spa]. Solo: Metagraf. Saunders Co; 1992. 2011. 14. Mas’ud I. Fisiologi: Persepsi kerja otak [Physiology: Perception of brain works]. Malang: UM Press Malang; Cite this article as: Maharani Y, Suwondo 2001. A, Hardjanti TS, Hadisaputro S, Fatmasari 15. Harrison LL, Williams AK, Berbaum D. The Impact of gentle human touch in ML, Stem JT, Leeper J. Physiologic increasing baby weight, body temperature, and behavioral effects of gentle and pulse stability on preterm baby. human touch on preterm infants. Belitung Nursing Journal. 2017;3(4):307- Research in Nursing & Health. 315. https://doi.org/10.33546/bnj.153 2000;23(6):435-446.

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Lestari L, et al. Belitung Nursing Journal. 2017 August;3(4):316-328 Received: 20 June 2017 | Revised: 3 August 2017| Accepted: 18 August 2017 | Corrected: 19 June 2020 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

CAREGIVERS’ EXPERIENCE IN MEETING SELF-CARE NEEDS OF ADOLESCENTS WITH AUTISM SPECTRUM DISORDER: A QUALITATIVE STUDY

Lilis Lestari1,4*, Elisabeth. S. Herini2, Indria Laksmi Gamayanti3

1Master of Nursing, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia 2Division of Neurology, Department of Child Health, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia 3Division of Developmental and Social Pediatrics, Department of Child Health, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia 4STIK Muhammadiyah Pontianak, Indonesia

*Corresponding author: Lilis Lestari, BSN, MSN Master of Nursing, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia; STIK Muhammadiyah Pontianak. Jl. Sungai Raya Dalam, Sungai Raya, Kec. Sungai Raya, Kabupaten Kubu Raya, Kalimantan Barat 78117, Indonesia E-mail:[email protected]

ABSTRACT Background: Autism spectrum disorder is a complex developmental disorder, which increased rapidly than other developmental disorders in the world. This complex disorder affects a child’s self-autonomy, which has become a challenge for their parents or caregivers. Objective: This study is to explore main caregivers’ experience to meet self-care needs of adolescents with autism spectrum disorder in Pontianak, West Borneo, Indonesia. Methods: This study employed a qualitative design with semi-structured in-depth interviews. Seven main caregivers who are living together and taking care of the adolescents with autism spectrum were selected using a purposive sampling. Triangulation was conducted to ensure the trustworthiness of this study, including interviews, observations of self-care activities, documents such as photos, learning reports, and field notes. Participants’ statements were recorded using a voice recorder, and then transcribed, coded, interpreted, and categorized to form main themes and sub-themes. Results: The study identified three main themes: 1) autonomy in self-care, 2) care effort, 3) feelings, supports, and expectations. These findings emphasize the potentials of the children with autism to be autonomous in their daily self-care. Conclusions: Adolescents with autism spectrum disorder can potentially meet the needs of their daily care independently.

Keywords: caregiver experience, main caregiver, adolescent, autism spectrum disorder, self-care, basic needs

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 316 Editor’s Note: This article has been updated on 19 June 2020. A separate erratum can be seen at https://doi.org/10.33546/bnj.1146

INTRODUCTION The increasing number of children with will feel burden to meet the self-care autism spectrum disorder (ASD) is the needs for their children. fastest in the world compared to other This dilemma exists because a child developmental disorders. Three to six with ASD will continue to develop their children are diagnosed with ASD sexual organs and have puberty like everyday per 1000 neonates.1 In normal adolescents.4-10 Some stated that Indonesia, the number of children with children with ASD cannot be independent autism cannot be known exactly, but the from the results of quantitative research, Center for Health Statistics (or called but Smith et al. in 2012 revealed that the Badan Pusat Statistik) in 2010 predicted children with ASD have capacity in that the increase of children with autism is meeting self-care needs autonomously if 1.14% of the total population of 237.5 they were taught about self-care since million people or the total reached 2.4 their childhood through the early period of million people with an increase of 500 adolescence. However, this quantitative children with autism each year.2 This study might have limitations in exploring condition encouraged the Central environmental factors and how parents Government through the Ministry of taught and meet the self-care needs of the Education and Culture of the Republic of children with ASD.11 Indonesia to develop the program of Given that reason, our research aims building 24 autism centers in several to explore main caregiver’s experiences to provinces, including in Pontianak meet the self-care needs of adolescents Municipality, West Borneo Province, with ASD in Pontianak Municipality, Indonesia.3 In 2014, 81 children were West Borneo, Indonesia. diagnosed to suffer ASD in Pontianak Municipality. In 2015, the number with ASD in Pontianak Municipality reached METHODS 130 people, including 61 children (<10 Study Design years old), 66 adolescents (10-19 years The study was conducted using a old), and three adults (> 19 years old). qualitative method with the aim to explore The data were based on reports from four main caregiver’s experiences in meeting schools of children with special needs and self-care needs of adolescents with ASD. one of the autism centers in Pontianak Several demographic data including status Municipality, West Borneo Province. of relationship between caregiver and It is believed that genetic factor children were also collected for purposive causing cerebral structure disorder is one sampling with maximum variation. of the main underlying causes of autism among children. Consequently, children Population and Sample tend to suffer cognitive, affective and The population in the study is the main psychomotor disorders throughout their caregivers that met self-care needs for life. The disorder causes children with adolescents with ASD in Pontianak autism to be unable to meet the needs for Municipality, West Borneo Province, self-care autonomously, and their parents Indonesia. We collected data on the will face challenges, increase stress, number of children with ASD in three tension, unpreparedness, and most likely schools that accepted students with ASD diagnosis, one clinic that supported the

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 317 growth and development of children with study were collected by interviews to autism, and one autism center in explore the main caregiver’s experience in Pontianak Municipality in order to locate meeting self-care needs in adolescents sufficient and suitable samples in with ASD. The topics for interview accordance with the criteria of the study. included main caregiver’s knowledge on The study used two specific places for self-treatment in adolescents with ASD, sampling, i.e. informal special needs and main caregiver’s skills and concerns schools in Pontianak. in meeting self-care needs in adolescents The inclusion criteria of the sample with ASD. were main caregivers who are living Interviews were implemented in together and taking care of adolescents comfortable, quiet, and safe places with ASD aged 10-19 years old. All the selected for the participants’ privacy. The adolescents were diagnosed with ASD by selection of place for interviews was a qualified physician or psychologist in based on agreement between the accordance with the Diagnostic and researcher and the participants, such as in Statistical Manual of Mental Disorders-4th public place (cafe), personal house, Edition (DSM-4), certified with a proof of workplace, mosque, and special meeting official diagnosis explanation letter, room around school area. The interviews agreed with approval sheet (informed were done by using both local Malay consent form), and able to tell the story language and Indonesian language. about their own experiences with the In-depth interviews using semi- Indonesian language or Pontianak Malaya structured questions and filed notes were language clearly. The exclusion criteria of done with seven participants. The the sample were the main caregivers who participants’ statements were recorded take care adolescents with ASD aged 10- using a recording device in Samsung 19 years old with double handicap and Galaxy Tab 4. The results of the in-depth severe conditions such as infection, interviews were transcribed, coded, surgery, and trauma. interpreted, and categorized to form main The study was conducted for two topics and subtopics. months, from March to April 2016. The total number of the caregivers that met the Data Analysis inclusion criteria was seven. The majority Data were analyzed using Colaizzi’s of the main caregivers worked as civil content analysis model with the following servants, two caregivers were hired, and steps: 1) transcribing the interview result one was a housewife. The participants in narrative form, 2) filtering/coding of consisted of two biological mothers, one words associated with phenomenon, 3) biological father, one aunt, two formulating or interpreting meaning from caregivers, and one couple (a father and a the significant statements, 4) classifying foster mother). the interpretive results of any statements that are significant for determining the Data Collection appropriate sub themes/themes, 5) The study was approved by the Medical integrating the findings of the study into and Health Research Ethics Committee an exhausted description of the (MHREC) Faculty of Medicine phenomenon, 6) describing the Universitas Gadjah Mada, registration fundamental structure of the phenomenon, number KE/FK/94/EC/2016. Data in this and 7) validating the findings by

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 318 comparing the transcripts of the research ensured by discussing among researchers participants and the researcher’s about personal biases, and experiences descriptive results.12,13 with the research topic.

Trustworthiness Ethics Consideration Triangulation method was performed The study conforms to the principles using several methods of data collections, outlined in the Declaration of Helsinki such as interviews and observations on the 2008 and was approved by Medical and same phenomenon with the aim to Health Research Ethics Committee evaluate whether the phenomenon that the (MHREC) Faculty of Medicine participants described having a Universitas Gadjah Mada (registration relationship or correspondence with. number KE/FK/94/EC/2016). Written Member checking or peer checking were informed consent was obtained from all also conducted as ways of ensuring that participants prior to any data collection. the researchers analyzed the data correctly.14,15 In this study, the issues of RESULTS trustworthiness were addressed through The results of the study showed three internal member checking during the main themes: 1) autonomy in self-care; 2) interview by the principle investigator and care efforts; 3) feelings, support and through the verification of the participants expectations. Those themes are illustrated by face-to-face discussion. Peer-review below with exemplars from the was done by an independent person or an informants’ stories using pseudonyms for experienced researcher to compare and the informants. contrast of the data quality, methodology, and interpretations. Bracketing was

Table 1 Main Themes and Sub-themes from Data

Themes Sub Themes Explanations Autonomy in The main caregivers’ • Elimination: defecation and urination. self-care knowledge about the kind • Personal hygiene. of self-care • Eating and drinking. • Wearing clothes. Fulfillment of self-care • Partial compensatory. • Supportive educative. • Independence. The ways to teach self- • Seeing the child's ability and initiative. care • Giving an example. • Gradual, diligent and patient. • Providing business and responsibility. • Be firm. • Showing attitude if unhappy, providing explanations, and giving punishment. • Giving rewards for success to child. The length of time to • Elimination: urination = 2 years. teach self-care • Elimination: defecation = majority of the children were not independent for defecation until adolescence. One participant revealed that it took two years and two months after replacing the old squat toilet closet.

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Themes Sub Themes Explanations • Personal hygiene = 4 years. • Eating and drinking = 3 months – 1 years. • Wearing clothes = 1-2 years. Factors that influence • Handling late professional decision due to a lack independence in self-care knowledge. • Emotional closeness. • Concerns parents. • The parents’ perception of cognitive, motor, and sensory ability and sensitivity of child. • The child’s emotional state fluctuates. Care efforts Increase knowledge about • Utilizing the print media. autism • Following training. • Observing and understanding attitudes and behavior of children with autism, during staying over and living together. • Taking advantage of technology (use Wi-Fi, TV). • Following the seminar. • Brainstorming with friends that have the same experience. Utilize health services • Consultation and treatment with the doctor. • Consultation with a psychologist. • Alternative therapies. Implement diet • Dietary resources: doctor, psychologist, seminar. • The content of information on dietary submitted on diet food such as milk, chocolate, instant noodles, food from wheat flour and flavorings. Meet the needs of • Formal. education. • Informal. Meet the needs of self- • Elimination: defecation and urination. care and autonomy • Personal hygiene. • Eating and drinking. • Wearing. • Cooking. • Shopping. • Clean the house. Feelings, Feelings of primary • Denial, feel love, gratitude, pride, despair and support and caregivers caring for resignation. expectations children with ASD Support and resistance to • Sources of support: yourself, couples’ life, friends, and parenting family (parents, nephew and cousin). with ASD • Source of obstacles: family (satire about the condition of the child), and environment community (verbal abuse, behavior unpleasant, and threatening acts of child abuse). • Caregivers response to the obstacles: angry, sad, hurt, protective and leave warning. Main caregiver’s hope to • Independent, continuing education until college, and children with ASD getting married. Main caregiver’s hope to • Providing information through health education and health worker seminars about ASD • Holding a special program with services for health

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Themes Sub Themes Explanations checks, periodic health, medicine, nutritional status examination and appropriate diet nutrient supplements for children with ASD. Main caregiver’s hope to • Improving the quality of human resources (teacher school. should improve their competence to teach children with ASD). • Improving facilities and infrastructure (tool practice, a decent school building, extra supervision), subjects taught more emphasis on the child's independence and the corresponding interest and talents. Main caregiver’s hope to • Providing financial assistance, and setting up better government. programs with special schools for students with ASD. • Holding a consistent program.

Autonomy in self-care Teaching also includes giving a task to The results of the study revealed the make something, but it should be potentials of children with ASD to supervised to avoid inappropriate autistic become more autonomous in meeting behavior. daily self-care needs. This autonomy can “...responsibilities, we should be alert about be seen from the statement of a participant him....” (P5) that the child she cared for could do self- care activities autonomously, and two Caregivers should give some punish- participants said that they only help by ments if children did inappropriate giving instruction to the children: behavior. “...all done by himself.....” (P3) “...sometimes I pinch her thigh movement ...” “...I do not want to help him again... I do not (P2) want to help, just drive him...” (P5) The caregivers also give reward such as The study showed that four participants approbation if children did something stated that they still provide some help good: for children to meet daily self-care “...it is vital that he do good .. if we thumb, activities: nice...” (P4) “...I think not yet... he still has many shortcomings.” (P1) To maximize the effort to make children autonomous, the caregivers should realize The study also revealed several aspects to and avoid some factors that can affect give special attention in terms of teaching children’s autonomy, such as delay in autonomy for children, such as patience, recognizing any developmental disorders diligence, and teaching gradually. and appropriate decision making to “...yes (gradually) ... all have to use an examine children: example. He is newly taught. Slowly all .. very “...firstly do not want to say ... do not say ... slowly ...” (P5) then finally ... a year I did not even say wait two years .. not too...” (P3) The teaching was given by providing some examples, then asking children to The caregivers sometimes give excessive repeat the activities. help due to emotional attachment. “...slowly teaching... Given the example first..” “I was washing, I had to do it, probably (P1) because it was too love...” (P1)

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The caregivers sometimes were afraid The treatment effort could be done by about something: meeting the needs for formal educations “...I'm afraid if I teach this, if I am not at home, (kindergarten, elementary school, junior he's like cooking for himself...” (P4) high school, and senior high school) and informal educations (courses in The caregivers also often perceived the accordance with children’s talent and limitation of cognitive, affective, and interest): psychomotor capacity of children. “...when second-graders, we moved to this “...obstacles sometimes he does not focus ... (P4) school, school-based specialty...” (P5) “...because my son was feeling disgusted ...” (P1) “...his motoric responses are not well The treatment efforts could be done by coordinated...(P6) realizing the importance of social interaction for children: The children’s emotional condition was “...l am also often encouraged by all community solidarity such as Java community associations, “...moody...” (P1) often fluctuating: neighbors, friends… chatting with friends also...” (P6)

Care efforts The treatment efforts could be further The participants of the study revealed that done by meeting the needs for autonomy they did six treatment activities to (elimination, clothing, having foods and improve the children’s quality of life, such beverage, and self-cleanliness). as by improving knowledge on ASD. The “...I help sometimes, I like it (demonstrating improvement of knowledge was done by how to clean up feces in hand rubbing buttocks) the participants through utilizing the ...” (P2) printed media such as books and “...we also take (rice)...” (P5) newspapers, learning children’s behavior The results of this study showed a by observation, utilizing technology such duration required by the caregivers to as the Internet and TV broadcast, opinion teach autonomy in self-treatment to exchange, and attending training and children. Time required for teaching seminars. “...information from the Internet only...” (P2) elimination was about 2 years. “…I usually just read from a book...(P4) “…I taught from the age of nine to eleven... (2 “...It was also obtained from newspaper...” years)...” (P3) (P7) “...television...” (P4) The participants argued that the most difficult skill to teach was elimination. The treatment efforts could be done by Five caregivers stated that children were utilizing health services (consultation as still unable to loosen the bowels or well as medical and alternative urinate in an autonomous manner. treatments). “Defecation is the most difficult to teach him... “…we consult a doctor for the first time...” (P2) yet ..during these 13 years, I still have to “...we have to see a psychologist...” (P7) wash....” (P1)

The treatment effort could also be done Only one participant stated that the child by regulating diet. was able to loosen the bowls “...he had to diet, and couldn’t eat sugar, like autonomously. The skill was gained after shiitake, later he was getting hyper...” (P6) the caregiver had an initiative to replace the toilet from squatting closet to sitting

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closet. The sitting closet meant that the Feelings, support, and expectations child did not see the feces. The caregiver The results of the study revealed perceived that the child will not learn the emotional attachment between the main skill to loosen the bowl because of caregivers and children. This ‘tingling on mushy thing’ or focusing on attachment can be seen in the stages of the feces, not the process. This idea is felt grieving undergone by the care to be useful. The caregiver said that the providers such as denial, hopelessness, child was autonomous and only required sadness, relentlessness, gratefulness, the time of approximately 2 months to and pride: teach to be autonomous (after the child “...give up...” (P1) had previous urinating skill). “...thankful for God it is like this ...” (P4) “...not too long ... about two months...” (P7) “…Poor child...” (P6) “...sad .. not like the other children..” (P7)

Three participants revealed that the time The participants gained some supports required in learning to be autonomous from themselves, couple, friends and wearing clothes was between 1-2 years. “Probably about a year (children can wear family in going through the grieving their own clothes)...” (P3) stages: “I still support my own heart and my wife only...” (P2) The time required by children to learn “...friends (teachers) showed attention...I feel eating and drinking skills was between 3 overwhelmed...” (P3) months–1 year. “...I got the support from my younger brothers... “It was a year... one year...” (P4) it encouraged me...” (P4) “..it was about three months...” (P6) In addition to support, the participants The time required for children with ASD also got difficulty in caring for children to learn autonomy in self-cleanliness was with ASD. The constraint was from the 4 years. family, such as insinuation, and from the “Yeah... eight and nine years old began to be surrounding community, such as verbal taught, he was also the first to use bathroom. At age 12 he was able to completely do...” (P5) violence, violent threat, and keeping away from children with ASD. “…oh no ... if they didn’t get offended, the In addition, the participants also revealed family would not be far away...” (P2) that there were other skills that could be “...a neighbor told to hit the boy. If it happened done by children, such as cooking skills to him, they would deal with me and the that require time of 3-6 years to be police…” (P3) autonomous: “...This was the scene I would not bring him “…nine years ... twelve years already...” (P3) another nanny... same people said, are you “a .. age .. ten years old… it appears he's crazy? ...” (P5) good at it…” (P4) The caregivers expressed their The shopping and house cleaning skills expectations to the children with ASD, are still learned by the child to this date: health personnel, school, and “…By himself he took the trolley... l was still government. The highest expectation of paying...” (P4) the caregivers to the children is that they “...she can help us clean...(P5) were able to be autonomous in self- treatment activity, attending higher

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 323 education, working, and then getting DISCUSSION married. This section discusses the three main “I wish that he will be independent, could take themes found in this study: (1) autonomy care of himself...” (P1) in self-care, (2) care efforts, and (3) “...for example, he can work alone, looking for money or anything...” (P3) feelings, support and expectations. The “.. I believe my son could... God willing, I will results of the study revealed that the teach him this...” (P4) children with ASD have potentials to be “...so, she can get married to a husband who autonomous in meeting the daily needs for can guide...” (P7) self-care. The results of the study were in line with those of a study by Smith el al. The caregivers expected that health in 2012 that revealed that autism children personnel hold specific health service could have the ability of meeting the programs (such as treatment, examination needs for self-care autonomously if they of nutrient status, and diet in accordance were taught the ways to do self-care with the needs of children with ASD), activities under 20 years old.11 providing the newest information about ASD through seminars. Autonomy in self-care “…there should be a counseling, for example, why there is an increasing number of children The factors found to affect the autonomy with autism? Why? Anything during I was of children with autism in the study were pregnant and nutritional problem....” (P4) as follows: 1) the delay of main caregivers “...How to diet. Nutritional intake each child is in recognizing developmental disorder different....” (P7) and retardation and in making the decision to examine the child caused by lack of The caregivers expected that school knowledge of caregiver, the input given could improve human resources’ quality, by others, and difficulty to access distant facilities, and try providing more subjects health service, 2) excessive help given by on children’s autonomy. the main caregivers to the child due to “…Teachers here do not understand children with autism...” (P2) emotional attachment such affection, “...it can be infrastructures or tools to help worry to leave the child having difficulty teachers to teach children with ASD...” (P6) in doing him/herself, always want to “…There should be monitoring of CCTV. We protect, and only have one child, 3) the cannot let students unsupervised. Sometimes main caregivers’ anxiety if the children there are students who try to run out...” (P7) “...we expect him to be independent. It is did dangerous activity that harms important than academic...(P7) themselves when the caregivers were not at home, and afraid that the children got The caregivers expected that the lost away if they were left to go alone, 4) government could give funds and The main caregivers’ perceptions about consistent programs for children with the cognitive capacity of children with ASD. ASD, thus affecting the children to learn “…Seriously deal with this ... funded. Teachers and do self-care, 5) the main caregivers’ should also understand and are competent perception on the children sensory toward autism...” (P2) sensitivity on mushy things, thus causing “...I ask the government to pay attention to children's special needs. Have free school like them to try not seeing, taking hold of, and other public elementary school...” (P4) expelling anything that is mushy in nature, for example, the child has ‘tingling feces’ when losing the bowels, 6) caregivers’

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 324 perception on the children motor capacity assumption was supported by Hesse et al, that was not coordinated well, and 7) 2005 indicating that one of the factors fluctuating emotional condition of the affecting the caregiver’s talent and effort children. to seek health information is educational On the other hand, the results of the background. The caregiver with high study were different from those of a study education had higher talent and interest to conducted by DePape and Lindsay in seek health information.16 2014 indicating that children with ASD Second, caregivers also did efforts by were unable to meet the need for self-care utilizing health service such as seeking autonomously because of some cognitive, any consultations about the children’s affective and psychomotor disorders health by visiting a psychologist and a during their life. This difference was due physician as well as doing any medical to differences in inclusion criteria.5 The and alternative treatments. The results of present study was conducted among main the study showed the main caregivers’ caregivers living together with children disaffection about treatment given to with ASD (no parent or others with children with ASD. The caregivers stated familial relationship with children), while that at the initial treatment the child was the DePape and Lindsay study was very compliant with any forms of conducted with parents of children with suggestions and treatment. However, at ASD (both father and/or mother).5 The the middle part of the treatment, the researchers assumed that the opportunity caregivers often stop the medication by of children with autism to be more their own initiative. They assessed that the autonomous in doing self-care would be treatment done to children with ASD by higher if they were cared for by others, giving drugs was not the best way to cure and not their biological parents or the child. The drugs are assessed to cause relatives. worse impact for the child’s health, such as the decrease or increase of body Care efforts weight, weakness of body, and the child The results of the study revealed that the often slept. Raising Children Network in treatment efforts to improve quality of life 2013 stated that the treatments done for children with ASD were done through children with autism are the ways that can five ways, including: reduce autism behaviors, but not cure the First, improving knowledge about autism itself. Familial education and ASD. The caregivers tried to improve intensive behavioral direction are the knowledge about ASD by utilizing the efforts for health that can give better printed media such as reading books and results in terms of overcoming autism newspaper that contain information about behavior compared to drugs ASD, learning children’s behavior when administration. If the drugs must be used living together, utilizing technology, for the children with ASD, it is important exchanging opinions, and attending for the caregiver to discuss with a training and seminars. The researchers physician on medical treatment, as well as assumed that the lack of the caregivers’ the benefit and effect for the child.17 interest and effort to improve knowledge Third, regulating diet. The participants about autism was because of the effect of also made the treatment efforts by educational background, such as junior regulating the diet. The information about high school and senior high school. The diet is obtained by the caregivers from

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 325 health personnel such as a psychologist, a social interaction for children, the physician, and through health seminar. caregivers have an initiative to involve The results of the study showed children in some social activities such as satisfaction that was felt by participants visiting friend’s house, attending related to diet given to the children. Foods neighborhood events and local community as diet menu for children with autism that meetings or leaving them to play with were selected by the caregivers were milk, other children in neighbor with chocolate, snack as sachet beverage and supervision. However, the results of the noodle, foods from wheat flour and study show that there were caregivers not flavoring. The selection of diet as the leaving them to socialize with new social efforts to reduce autism symptoms is one environment outside school and house, of the appropriate options. This finding although they actually realized the was in line with results of the study by children’s needs for social interaction with Matthews,18 indicated that diet can help others in the new environment. The children to have the better quality of limitation of social interaction to children sleeping and better cognitive capacity, with ASD had negative effects that can reduce misery and skin eruption, cause retardation in children’s develop- improving digestion, and children’s ment and skills.20 behavior. Glutein and casein are the most Fifth, meeting the needs for autonomy. common substance of foods to be avoided This research revealed that the need for for the autistic children’s consumption. child self-reliance can be done in three Matthews in 2013 stated that the objective ways with the help of part, direction and of diet is to be committed to the selection independence. This study also found the of the most appropriate food for children time span of the child needs to be by adding or substituting certain foods.18 completely independent, such as Autism Research Institute in 2016 showed elimination of urination for 2 years, that both glutein and casein-free diets help elimination of bowel movements, which in reducing many autism symptoms the majority of children were not among 65% children, while for the independent until the age of adolescence, remaining 35% it did not help. This result one participant expressed the required confirmed the approach that a decision time was 2 years 2 months, personal about diet to be given to children with hygiene for 4 years, eating and drinking autism cannot be generalized among all for 3 months and 1 year, and dressing for children. The caregivers should actually 1 to 2 years. consider whether or not the diet is an effective intervention for specific Feelings, support, and expectations children.19 The results of this study found grieving Fourth, meeting the needs for felt by the caregivers, such as denial, education. The main caregivers also tried hopelessness, sadness, relentlessness, to meet children’s need for education by gratefulness and pride during the giving formal education (kindergarten, treatment of children with ASD. Such elementary school, junior high school, and grieving feelings were caused by the lack senior high school) as well as informal of preparedness of the main caregivers for school (non-scholastic courses that are dealing with autistic children’s condition appropriate with children’s talent and and the emotional attachment felt by interest). Realizing the importance of caregivers when living together with

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 326 them. The grieving stage felt by the needs of children with ASD. This caregivers in this study was in line with provision of clear information about the grieving stage as stated by Bowlby, autism could improve the knowledge of consists of denial (shock and distrust), people about ASD itself. sadness and relentlessness feeling, It is expected that the local thinking disorder and hopefulness, and government can give more attention to the recollection of self-confidence to survive development and welfare of children with compared to the grieving stage as shown ASD. The attention can be given by by Kubler-Ross’s consisting of denial providing aids, both funds and facilities (shock and distrust), angry, hard bargain, that support the special needs of these and accepting.21 This study did not find special children’s education and welfare. the open stage such as anger and hard bargain mentioned separately as in the CONCLUSION open stage according to Kubler-Ross. It is The results of the study showed that assumed that the stage of anger and hard children with ASD had the potentials to be bargain simultaneously occurred with a autonomous in meeting the daily needs for denial stage felt by the caregivers. self-treatment activities. Such autonomy can be achieved with main caregivers’ Limitation of the study commitment to teach skills to children The study had several limitations: first, it with ASD. The commitment is shown in only mentioned the underlying causes and the treatment efforts in accordance with the factors affecting the reduced intensity the children’s needs. of autism behavior among adolescents. It is expected that further study can study Declaration of Conflict of Interest more deeply about the underlying causes None declared. and the factors affecting the reduced Acknowledgment intensity of autism behavior among The authors thank the local education office, adolescents with ASD. Also, it is also Chairman of the School for Children with important for further studies to explore special needs and Pontianak Autism Center, cultural and legal aspects that affect diet West Borneo, Indonesia. Special thanks to the compliance and the patterns of rejection participants who are willing to be participants by public schools not to accept any in this study. children with autism diagnosis. It is expected that health personnel Authorship Contribution could provide more health information The authors equally contributed in this study. holistically about children with ASD in accordance with the authority. The References 1. Levey AS, Coresh J. Chronic kidney provision of sufficient information could disease. The Lancet. 2012;379(9811): be provided such as clear explanation 165-180. given when there are health consultations, 2. Stevens LA, Levey AS. Current status treatment, seminars, extension or health and future perspectives for CKD testing. service programs for children with ASD. American Journal of Kidney Diseases. It is expected that the provision of 2009;53(3):S17-S26. information could emphasize the newest 3. United States Renal Data System. 2016; aspects of evidence-based research about http://www.usrds.org/2016/view/v2_01.a autism and in accordance with the actual spx. Accessed 25 August, 2016.

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4. Ministry of Health. Basic health research renal disease. Journal of Advanced 2013. Jakarta: Ministry of Health of Nursing. 2005;51(6):577-586. Indonesia; 2013. 11. Brunier GM, Graydon J. The influence of 5. Nitta K, Okada K, Yanai M, Takahashi physical activity on fatigue in patients S. Aging and chronic kidney disease. with ESRD on hemodialysis. Anna Kidney and Blood Pressure Research. Journal. 1993;20(4):457-461;462, 521. 2013;38(1):109-120. 12. Jhamb M, Weisbord SD, Steel JL, Unruh 6. Sathvik BS, Parthasarathi G, Narahari M. Fatigue in patients receiving MG, Gurudev KC. An assessment of the maintenance dialysis: A review of quality of life in hemodialysis patients definitions, measures, and contributing using the WHOQOL-BREF factors. American Journal of Kidney questionnaire. Indian Journal of Diseases. 2008;52(2):353-365. Nephrology. 2008;18(4):141. 13. Murtagh FEM, Addington-Hall J, 7. Doran D. Nursing outcomes: The state of Higginson IJ. The prevalence of the science. Burlington: Jones & Bartlett symptoms in end-stage renal disease: A Publishers; 2010. systematic review. Advances in Chronic 8. Safarudin S. Hubungan pola terapi, nilai Kidney Disease. 2007;14(1):82-99. ureum kreatinin plasma dan hemoglobin 14. Stone P, Richards M, Hardy J. Fatigue in dengan kualitas hidup pasien patients with cancer. European Journal hemodialisis di RSUD Dr Soedarso of Cancer. 1998;34(11):1670-1676. Pontianak [Relationship of therapic 15. Chen YS, Wu SC, Wang SY, Jaw BS. pattern, plasma ureum creatinin and Depression in chronic haemodialysed hemoglobin, and quality of life of patients. Nephrology. 2003;8(3):121-126. patients with hemodyalisis at RSUD Dr 16. De Sousa A. Psychiatric issues in renal Soedarso Pontianak]. Jakarta: failure and dialysis. Indian Journal of Universitas Indonesia; 2012. Nephrology. 2008;18(2):47. 9. Garg AX, Papaioannou A, Ferko N, Campbell G, Clarke J-A, Ray JG. Cite this article as: Lestari L, Herini Estimating the prevalence of renal ES, Gamayanti IL. Caregivers' insufficiency in seniors requiring long- experience in meeting self-care needs of term care. Kidney International. adolescents with autism spectrum 2004;65(2):649-653. disorder: A qualitative study. Belitung 10. Cleary J, Drennan J. Quality of life of Nursing Journal. 2017;3(4): 316-328. patients on haemodialysis for end‐stage https://doi.org/10.33546/bnj.123

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Yuliati ND, et al. Belitung Nursing Journal. 2017 August;3(4):329-336 Received: 18 February 2017 | Accepted: 31 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

THE IMPACT OF COMBINATION OF ROLLING AND OKETANI MASSAGE ON PROLACTIN LEVEL AND BREAST MILK PRODUCTION IN POST-CESAREAN SECTION MOTHERS

Nia Dwi Yuliati1*, Hadi2, Sri Rahayu3, Noor Pramono4, Donny Kristanto Mulyantoro5

1Magister Terapan Kesehatan, Poltekkes Kemenkes Semarang, Indonesia 2KSM Forensik RSUP Dr. Kariadi Semarang, Indonesia 3Jurusan Kebidanan, Poltekkes Kemenkes Semarang, Indonesia 4 KSM Obstetri-Ginekologi RSUP Dr. Kariadi Semarang, Indonesia 5Magister Terapan Imaging Diagnostik, Indonesia

*Corresponding author: Nia Dwi Yuliati Magister Terapan Kesehatan, Poltekkes Kemenkes Semarang Jl. Tirto Agung, Pedalangan, Banyumanik, Kota Semarang, Jawa Tengah, Indonesia (50268) E-mail: [email protected]

ABSTRACT Background: Normal childbirth or cesarean section has an effect on the initiation of early breastfeeding. Thus, rolling massage and oketani massage are considered helpful for milk production. However, little is known about the combination of rolling and oketani massage. Objective: To examine the effect of combination of rolling and oketani massage on the levels of prolactin and milk production in post-caesarian section mothers. Methods: A quasi-experimental study with pretest-posttest control group design. Thirty-six samples were selected using consecutive sampling, with 18 each assigned to an experiment and control group. Breast milk production was measured based on the baby's weight, while prolactin levels were measured using ELISA method. Data were analyzed using univariate and bivariate analysis. Results: Results showed that there was a statistically significant difference of prolactin levels after intervention in the experiment and control group with p-value 0.035 (<0.005), and significant difference in breast milk production in both groups in posttest 1 and posttest 2 with p-value 0.000 (<0.05). Conclusion: There was statistically significant effect of the combination of rolling and oketani massage on the increase of prolactin levels and breast milk production. It is suggested that this intervention can be applied in midwifery care in post-cesarean section mothers.

Keywords: rolling massage, oketani massage, breast milk production, prolactin, post-caesarian section mother

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Editor’s Note: This article has been updated on 11 July 2020 in terms of minor changes in the reference format. The update is based on BNJ policy on article correction. INTRODUCTION in 2012, which was 80% of coverage.6 Exclusive breastfeeding is breast milk Preliminary study at the General Hospital given to infants since birth for six months, of Ambarawa revealed that the number of without adding and/or replacing with deliveries in 2014 - 2015 had a significant other foods or beverages, except drugs, increase of 29.50%. The data of caesarean vitamins and minerals.1 Literature section patients were 54.81% in 2015, and indicated that school children who there were 333 caesarean section patients exclusively breastfed 6-7 months are 8.5 at the first semester of 2016.7 times more likely not to be overweight Total hospital care of post-cesarean and obese than those who did not section and early breastfeeding patients exclusively breastfeed.2 have been activated since January 2016, Breast milk production is affected and performed in the maternity unit of by prolactin reflexes and let down Ambarawa General Hospital. Most of the reflexes.3 The prolactin reflex is affected patients had a problem with breast milk by the infant's suction that will stimulate production after 4 hours after cesarean the receptor on the nipple and the breast, section, which caused dehydration, fever and then the stimulation is directed to the and hyperbilirubin in the babies.7 In sensory nerve, and then to the hypo- addition, infant fever rates in 2016 were thalamus via the spinal cord and 20 babies per month, and babies who mesencephalon to stimulate the prolactin- experienced hyperbilirubin for photo- secreting adeno hypophyses and stimulate therapy reached 15 babies per month. The the alveoli to produce milk.4 The oxytocin hospital only provides breast care to or let down reflex is derived from the address breast milk production, which infant's suction, which continues into the may not be effective enough to deal with neurohypophyses (posterior hypophonia) this problem.7 Thus, the alternative that that secretes oxytocin resulting in can be used to accelerate breastfeeding in contraction of the myoepithelial cells of the post-cesarean section besides breast the alveoli wall with mamae cells, which care, early breastfeeding and maternal then enter the ductular system, and the nutrition is to provide massage stimu- milk will flow through the lactiferous lation or massage. ducts. This oxytocin reflex is affected by Rolling massage is a spinal massage maternal psychological factors. If there is (costae 5-6 to a scapula in a circular anxiety, stress and doubt occur, the motion) performed on mothers after expenditure of breast milk can be delivery that can help the hormone hampered.3 oxytocin work in breast milk, speeding up Cesarean section mothers often have the parasympathetic nerves delivering a problem in the initiation of early signals to the back of the brain to breastfeeding due to rooming-in factors, stimulate oxytocin drain the milk out.4 weakness as an effect of anesthesia, and Mothers who are given rolling massage incisions on the mother's abdomen.5 earlier than 12 hours after the cesarean Therefore, patients with new caesarean section are having breast milk secretion section can successfully breastfeed after a (18 hours) quickly compared with mothers few hours postpartum. who have the provision of rolling massage In Semarang regency, from 2013 to more than 24 hours after the cesarean 2014, the coverage rate of breast milk has section.8 Another study also stated that increased from 36.29% to 44.3%. rolling massage has 6 times faster in However, this is still far from the breast milk secretion compared to mothers coverage target of exclusive breastfeeding who are not given the intervention.4

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 330 On the other hand, Oketani massage alive and normal with weight >2500 is also one of the breast care methods that grams, 5) mother and baby were in health do not cause pain and is popular in Japan.9 condition, 6) baby had a good suction This massage stimulates the pectoralis reflex, 7) had normal breast condition, and muscle strength to increase milk produc- 8) willing to be respondent. tion and make the breasts become softer and elastic so as to facilitate the baby to Intervention suck milk.10 Oketani massage has been Intervention was given to the post- shown to be very effective in reducing cesarean section mothers in 12 hours for 3 breast pain and increasing the pH of days in the morning and afternoon. Each breastmilk and the speed of neonatal intervention was performed for 45 suction reflex.11 In addition, this massage minutes. Massage was done alternately, can also improve the quality of colostrum. which performing the rolling massage Previous studies have been examined the first, then continued to oketani massage. effect of oketani massage and oxytocin For the control group, breast care was massage on milk production in post- given every morning for 3 days, with 15 caesarean section mother, and showed that minutes in each intervention. Inter- there were different frequency of ventions were provided by researchers and breastfeeding, frequency of defecation and trained and certified enumerators. urination in respon-dents.12,13 However, Interventions were given in each patient little is known about the combination of room. The obstacles that researchers rolling massage and oketani massage. experienced in providing intervention Therefore, this study aimed to examine were the fear of early mobilization, but the effect of the combination of rolling this could be overcome by motivation and and oketani massage on the breast milk encouragement. production and prolactin levels in post- cesarean section mothers. Instruments Prolactin levels were measured by the ELISA (Enzyme-Linked Immunosorbent METHODS Assay). Researchers took venous blood of Design each respondent for three times: 1) before This research was a quasi-experiment with intervention, 2) after three days treatment pretest and posttest control group design. at twelve hours post-caesarean sections, This research was conducted in the and 3) the third day of the afternoon General Hospital of Ambarawa Semarang before the patient returned. Breastmilk Regency from 16 September to 30 production was measured based on the October 2016. baby's weight difference before and after breastfeeding in every 24 hours; in the Population and sample first 24 hours or before treatment (pretest), The population in this study was all post- in 24 hours in the 2nd day (posttest 1), and caesarian section mothers. Thirty-six in 24 hours in the 3rd day (posttest 2). The samples were selected using consecutive difference in weight was measured by a sampling, with 18 each assigned to an digital baby scales with a precision of 5 experiment and control group. The grams that have been calibrated. inclusion criteria of the samples were: 1) mother with post-caesarean section day-1, Data analysis 2) aged 20-35 years, 3) exclusive Data were analyzed using SPSS series 21. breastfeeding for 3 days, 4) baby born The analysis of this study was univariate

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 331 and bivariate, in which bivariate analysis examined the effect of combination of RESULTS rolling massage and oketani massage on Table 1 shows that the majority of prolactin level and milk production. respondents in the experiment group and control group 20-25 years old. Chi Square Ethical consideration test showed p-value 0.735 (> 0.05), which Ethical consideration was obtained from indicated that there was no age difference the Health Research Ethics Committee in the experiment and control group. Most (K.E.P.K) of Health Polytechnic of of respondents in the experiment group Ministry of Health (Poltekkes) of and control group had given birth more Semarang with No. 128 / KEPK / than 1 time but not more than 4 times. Poltekkes-SMG / EC / 2016. This study Levene's test results showed that the p- was also obtained permission from the value was 0.738 (> 0.05) so there was no General Hospital of Ambarawa Semarang. parity difference in both groups. Informed consent has been performed for all respondents.

Table 1 Characteristics of the respondents based on age and parity Group Variable Intervention Control p-value N (%) N (%) Age (year) 20-25 9 (50 %) 8 (44.4 %) 0.735a 26-30 4 (22.2 %) 6 (33.3 %) 31-35 5 (27.8 %) 4 (22.2 %) Parity Primipara 8 (4.4 %) 7 (38.9 %) 0.738 Multipara 9 (50 %) 10 (55.6 %) Grand multipara 1 (5.6 %) 1 (5.6%) aChi Square

Table 2 Difference of prolactin level and milk production in the intervention and control group Variable Treatment Group N Mean ± SD p-value Prolactin Pretest Intervention 18 214.11 ± 23.449 0.114b level (ng/ml) Control 18 211.62 ± 41.426 Posttest Intervention 18 235.64 ± 20.874 Control 18 225.89 ± 20.050 0.035b Mean Intervention 18 21.56 (14.920) 0.000c difference Control 18 2.08 (38.248) Breast milk Pretest Intervention 18 46.06 ± 17.881 0.071c production Control 18 36.05 ± 13.909 (gr) Posttest1 Intervention 18 189.12 ± 46.056 0.000c Control 18 89.84 ± 25.551 Posttest2 Intervention 18 339.33 ± 62.849 0.000c Control 18 173.67 ± 48.723 bIndependent t-test, cMann Whitney Test

Table 2 shows that there was no However, there was a statistically difference of prolactin levels before significant difference of prolactin levels intervention between the intervention and after intervention with p-value 0.035 control group with p-value 0.114 (>0.05). (<0.005), which indicated that the

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 332 combination of rolling and oketani statistically significant difference in milk massage had a significant effect on the production in the two groups in posttest 1 increase of prolactin levels. and posttest 2 with p-value 0.000 (<0.05), For breast milk production, both which indicated that the combination of groups had no difference before rolling and oketani massage had a intervention with p-value 0.071 (>0.05), significant effect on the increase of milk however Mann Whitney test showed a production.

Table 3 Mean difference of breast milk production between intervention and control group using Friedman test Variable Group Treatment N Mean ± SD p-value Pre-test 18 46.06 ± 17.881) Breast Intervention Posttest 1 18 189.12 ± 46.056) 0.000 milk Posttest 2 18 339.33 ± 62.849) production Pre-test 18 36.05 ± 13.909) (gr) Posttest 1 18 89.84 ± 25.551) 0.000 Control Posttest 2 18 173.67 ± 48.723)

Friedman test as shown in table 3 Similar result with the Wilcoxon test in indicated that there was a statistically the table 4 shows that there were significant difference of breast milk significant differences in all times of the production in the intervention and control treatment between the intervention and group between pretest, posttest 1, and control group with p-value 0.000 (<0.05). posttest 2 with p-value 0.000 (<0.05).

Table 4 Breast milk production in the intervention and control group using Wilcoxon test Variable Group Treatment p-value Pretest – Posttest 1 0.000 Intervention Pretest – Posttest 2 0.000 Breast milk Posttest 1– Posttest 2 0.000 production (gr) Pretest – Posttest 1 0.000 Control Pretest – Posttest 2 0.000 Posttest 1– Posttest 2 0.000

400 339.33

300 189.12 200 173.67 gram 89.84 100 46.06 Intervention 36.05 0 Control Pretest Posttest 1 Posttest 2

Figure 1 Graphic of mean difference of breast milk production in the intervention and control group before and after the treatment

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 333 Figure 1 shows that there was a significant transmission of pain through fibers C and increase of breast milk production in the delta-A with a small diameter so that the intervention and control group before and synapse gate closes the transmission of after intervention. However, breast milk the pain impulse. Cutaneous stimulation production in the intervention group has a of the body is generally centered on the higher increase compared to breast milk in back and shoulders. It will stimulate the control group. peripheral fibers to transmit impulses through the dorsal horn of the spinal cord. DISCUSSION When the impulse carried by the A-Beta Findings of this study revealed that there fibers dominates, the gate mechanism was statistically significant effect of the closes so that the pain impulse is not combination of rolling and oketani delivered to the brain, and ultimately massage on the increase of prolactin gives a relaxed sensation to the body.17 levels and breast milk production. This is On the other hand, giving oketani consistent with the previous studies stated massage can stimulate the pectoralis that prolactin levels increase after given a muscle strength to increase milk variety of massages such as Woolwich production and make the breasts soft and massage and endorphin massage, oxytocin elastic, so it makes it easier for the baby to massage and aromatherapy in postpartum suck milk. Oketani massage will also mothers because the effects of massage provide a sense of relief and overall will give comfort, relax and more comfort to the respondents, improve the confidence.14 In addition, this finding is quality of breast milk, prevent nipples and also in line with previous research mastitis, and can improve / reduce conducted in Muhammadiyah hospital of lactation problems caused by flat nipples Palembang, revealed that there was a and inverted nipples.9 significant difference of milk production In addition, oketani massage can among post-caesarian mothers after doing also cause mamae glands to become rolling massage between control and mature and wider, resulting in more milk intervention group with p-value 0.001.15 produced. Previous research suggests that Rolling massage can stimulate the oketani massage has been shown to body to release endorphin compounds that increase milk production, and the quality are natural pain relievers.16 For post- of breast milk is to increase levels of caesarean section mothers who breastfeed, protein and milk carbohydrates.12 massage helps mothers feel more relaxed The rolling and oketani massage are and comfortable. The touch of someone a great combination to increase breast who cares and wants to help is a source of milk production and prolactin levels, strength when the mother is sick and tired. provide stimulation reflex of breastmilk Body parts that can be massaged are formation and let down reflex. This starting from the head, neck, back and combination can provide a relaxed legs. However, when massaging, the sensation to the mother and smooth the masseuse should pay attention to the flow of nerves and breast milk channels mother's response, whether the pressure (duct system)in both breasts.18 given is correct.16 Gate control theory says that the Limitation of this study stimulation of the skin surface (sub Not all confounding variables that affect cutaneous) activates transmission cells (T) milk production and prolactin levels can of sensory A-Beta nerve fibers larger and be controlled such as maternal faster.17 This process decreases the psychological factors and family support,

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 334 which could be considered as the 6. Muchacha M, Mtetwa E. Social and limitation of the study. economic barriers to exclusive breast feeding in Rural Zimbabwe. CONCLUSION International Journal of MCH and It can be concluded that there was AIDS. 2015;3(1):16. 7. Thomas JV. Barriers to exclusive statistically significant effect of the breastfeeding among mothers during combination of rolling and oketani the first four weeks postpartum. massage on the increase of prolactin Minnesota: Walden University, College levels and breast milk production. of Health Sciences; 2016. Therefore, it is suggested that the 8. Kementerian Kesehatan Republik combination of rolling and oketani Indonesia. Basic health research report massage can be applied in midwifery care 2013. Jakarta: Kementerian Kesehatan in post-caesarean section mothers. Further Republik Indonesia; 2013. study is needed to deal with all 9. Hajeebhoy N. The Lancet breastfeeding confounding variables. series. Geneva: World Health Organization; 2016. Declaration of Conflicting Interest 10. Department of Health of East Java. None declared Health profile of Kediri City. East Java: Department of Health of East Java Funding Indonesia; 2016. This study was supported by Magister 11. Munir M. Infantile diarrhoea: Breast Terapan Kesehatan, Poltekkes Kemenkes and bottle feeding compared with Semarang, Indonesia. special reference to their clinical role. Paediatrica Indonesiana. 1985;25(5- Author Contribution 6):100-106. All authors contributed equally in this study. 12. Nindiyaningrum RA. Pengaruh pemberian ekstrak daun katuk terhadap References produksi ASI pada ibu post partum 1. Leung AKC, Sauve RS. Breast is best [Effect of katuk leaves extract on breast for babies. Journal of the National milk production in postpartum Medical Association. 2005;97(7):1010. mothers]. Jurnal Ilmu Keperawatan 2. Martin CR, Ling P-R, Blackburn GL. dan Kebidanan. 2014;1(6). Review of infant feeding: Key features 13. Turlina L, Wijayanti L. Pengaruh of breast milk and infant formula. pemberian serbuk daun pepaya Nutrients. 2016;8(5):279. terhadap kelancaran ASI pada ibu nifas 3. WHO. The optimal duration of di BPM Ny. Hanik Dasiyem, Amd. Keb exclusive breastfeeding. A systematic di Kedungpring Kabupaten Lamongan review. Geneva, WHO; 2001. [Effect of papaya leaf powder on breast 4. Thet MM, Khaing EE, Diamond-Smith milk production in postpartum mothers N, Sudhinaraset M, Oo S, Aung T. at BPM Ny. Hanik Dasiyem, Amd. Keb Barriers to exclusive breastfeeding in in Kedungpring Kabupaten Lamongan]. the Ayeyarwaddy Region in Myanmar: Jurnal Media Komunikasi Ilmu Qualitative findings from mothers, Kesehatan. 2015;7:01. grandmothers, and husbands. Appetite. 14. Syarief H, Damanik RM, Sinaga T, 2016;96:62-69. Doloksaribu TH. Pemanfaatan daun 5. Agunbiade OM, Ogunleye OV. bangun-bangun dalam pengembangan Constraints to exclusive breastfeeding produk makanan tambahan fungsional practice among breastfeeding mothers untuk ibu menyusui [Utilization of in southwest Nigeria: implications for bangun-bangun leaves in development scaling up. International Breastfeeding of functional additional food product in Journal. 2012;7(1):5. breastfeeding mothers]. Jurnal Ilmu Pertanian Indonesia. 2014;19(1):38-42.

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 335 15. Wahyuni E, Sumiati S, Nurliani N. 17. Soetjiningsih D. ASI: Petunjuk untuk Pengaruh konsumsi jantung pisang batu tenaga kesehatan [Breast milk: terhadap peningkatan produksi ASI di Guideline for health workers]. Jakarta: wilayah Puskesmas Srikuncoro, EGC; 1997. Kecamatan Pondok Kelapa, Bengkulu 18. Sulistyawati A. Buku ajar asuhan Tengah tahun 2012 [Effect of banana kebidanan pada ibu nifas [Textbook of stone heart on breast milk production in Midwifery care for postpartum the area of Public Health Center of mothers]. Yogyakarta: Andi Offset; Srikuncoro, Kecamatan Pondok 2009. Kelapa, Bengkulu Tengah in 2012]. 19. Kumar KPS, Bhowmik D. Traditional Buletin Penelitian Sistem Kesehatan. and medicinal uses of banana. Journal 2013;15(4), 418-424. of Pharmacognosy and Phytochemistry. 16. Mamuaja CF, Aida Y. Karakteristik 2012;1(3), 57-70. gizi abon jantung pisang (Musa Paradisiaca) dengan penambahan ikan Cite this article as: Yuliati ND, Hadi, layang (Decapterus sp) [Nutritional Rahayu S, Pramono N, Mulyantoro DK. The characteristics abon of banana impact of combination of rolling and oketani inflorescence (Musa Paradisiaca) with massage on prolactin level and breast milk addition of scad fish (Decapterus sp)]. production in post-caesarean section mothers. Jurnal Ilmu dan Teknologi Pangan. Belitung Nursing Journal. 2017;3(4):329- 2014;2(2):28. 336. https://doi.org/10.33546/bnj.150

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 336 Agustie PR, et al. Belitung Nursing Journal. 2017 August;3(4):337-344 Accepted: 28 February 2017 | Accepted: 31 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

EFFECT OF OXYTOCIN MASSAGE USING LAVENDER ESSENTIAL OIL ON PROLACTIN LEVEL AND BREAST MILK PRODUCTION IN PRIMIPAROUS MOTHERS AFTER CAESAREAN DELIVERY

Panglukies Ratna Agustie1*, Suharyo Hadisaputro1, Runjati2, Ariawan Soejoenoes1, Imam Djamaludin Mashudi1, Melyana Nurul Widyawati1

1Magister Applied Midwifery, Poltekkes Kemenkes Semarang, Indonesia 2Midwifery Department, Poltekkes Kemenkes Semarang, Indonesia

*Corresponding author: Panglukies Ratna Agustie Magister Applied Midwifery, Poltekkes Kemenkes Semarang Jl. Tirto Agung, Pedalangan, Banyumanik, Kota Semarang, Jawa Tengah, Indonesia (50268) E-mail: [email protected]

ABSTRACT Background: Low milk production is one of the barriers to exclusive breastfeeding. Oxytocin massage is considered as an alternative treatment, which combined with lavender essential oil as an aromatherapy. Objective: This study aims to examine the effect of oxytocin massage using lavender essential oil on the increase of levels of prolactin and milk production in primiparous mothers after caesarean section. Methods: This was a quasi-experimental study with non-equivalent control group design conducted in October- December 2016 at the General Hospital of Dr.H. Soewondo Kendal, Indonesia. There were 32 recruited by consecutive sampling, divided to be intervention (16 participants) and control group (16 participants). Prolactin hormone levels were measured using Enzyme-linked immunosorbent assay (ELIZA), breast milk production was measured based on the indicators of milk volume, urination and defecation frequency and sleep duration of babies; and infant’s weight was also measured by digital scale. Data were analyzed using Mann Whitney and Wilcoxon test. Results: The mean difference of prolactin hormone level in control group was 17.82 ng / ml while mean of difference of hormone prolactin level in intervention group was 132.13 ng / ml. There were statistically significant differences between intervention and control group in prolactin levels (p-value 0.000), milk volume (p-value 0.000), infant weight (p-value 0.000), urination frequency (p-value 0.017), defecation frequency (p- value 0.002), and infant sleep duration (p-value 0.000). Conclusion: There was a significant effect of the oxytocin massage using lavender essential oil on the increase of breast milk production and prolactin levels. Therefore, oxytocin massage using lavender essential oil can be used as an alternative treatment for midwives and other health professionals in an effort to increase milk production in postpartum.

Keywords: oxytocin massage, lavender essential oil, prolactin, milk production

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Editor’s Note: This article has been updated on 11 July 2020 in terms of minor changes in the reference format. The update is based on BNJ policy on article correction. INTRODUCTION Exclusive breastfeeding means that the of them feel that the milk they produce is infant receives only breast milk. No other still insufficient to inhibit breastfeeding.2 liquids or solids are given, not even water Studies show that mothers with first parity with the exception of oral rehydration will have a slow process in administration solution, or drops/syrups of vitamins, and breast milk compared with multiparous minerals or medicines.1 mothers.8 The successful exclusive Inability to breastfeed make mothers breastfeeding is strongly influenced by the increasingly feel less confident and amount of breastmilk production. Less anxious, so that milk production milk production in the first few days after decreases.9 Today, the pharmacologic birth has been an obstacle in treatment has been given to the mothers breastfeeding. While there is also a lack of who have disorder by giving drugs, such understanding of mothers, families, and as metoclopramide, domperidone, and communities about breastfeeding such as chlorpromazine, but these drugs cause the habit of providing food early, thus this side effects such as fatigue, skin irritation, encourages mothers to stop breastfeeding headache, thirst, diarrhea, and dry mouth. and replace it with formula milk.2,3 Alternatively, an oxytocin massage, the At the 65th World Health Assembly, massage along the spine (vertebrae) to the WHO member states set targets by 2025 fifth-sixth costae bone, is an attempt to that at least 50% of infants under six stimulate the hormone prolactin and months of age are exclusively breastfed.4 oxytocin after delivery.10 The massage Based on Indonesia Health Profile data in can significantly affect the peripheral 2014, the percentage of breastfeeding nervous system, increase stimulation, and coverage in Indonesia amounted to reduce the pain. For this, study, Lavender 52.3%,5 the coverage of breastfeeding in is used for massage.10 Kendal regency was 57.8% while Lavender is one of the most popular Indonesia's target was 80%.6 essential oils and is widely used in the The implementation of early field of clinical health, especially breastfeeding should be possible in any overcoming psychosomatic problems in labor process, either normal (pervaginam) gynecology.11 The largest content of the or cesarean section.7 However, one of the lavender oil is linalool of 26.12% which causes of the failure to breastfeed is has the anti-anxiety effect.12 Research cesarean section surgery. Labor with suggests that by inhaling lavender caesarean section may cause drowsiness aromatherapy can have a relaxing effect and lazy suckling in infants due to drug or on the central nervous system,13 and the anesthetic effects given to the mother.7 As use of lavender essential oil in massage many as 68% of post-caesarean section can also help postpartum women increase women have difficulty in moving up and relaxation and comfort, so milk down from bed and setting up a production is expected to increase.12 comfortable position during breastfeeding Therefore, this study aims to examine the due to an increase in pain intensity after effect of oxytocin massage using surgery.7 In addition, the failure of Lavender essential oil on prolactin level breastfeeding is also due to the lack of and breast milk production in primiparous breastfeeding information and experience mothers after caesarean delivery. in primiparous mothers which causes most

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METHODS for the intervention group, with 10% Design lavender essential oil and 90% sunflower This was a quasi-experimental study with oil. The intervention was performed by non-equivalent control group design. researcher and enumerators that have been trained before intervention. Intervention Setting was performed two times a day combined This research was conducted in October- with breast care in the morning and December 2016 in the General Hospital of evening session, for 15 minutes in each Dr.H. Soewondo Kendal. treatment. While the control group only received breast care two times per day. Population and sample The population in this study were all Instruments postpartum mothers of cesarean Prolactin hormone levels were measured primiparas. The inclusion criteria in this using Enzyme-linked immunosorbent study were mothers aged 20-35 years, assay (ELIZA). Blood sampling was gestational age 37-42 weeks, infant performed by researchers and enumerators weight ≥ 2500-4000 gram, normal and analyzed in the GAKI laboratory of mother's nipple, good suction reflex, no Diponegoro University, Semarang. While consuming cigarettes and alcohol, and breast milk production was measured with willing to be respondents. While the the indicators of the volume of breast exclusion criteria in this study were milk, urination and defecate frequency, mothers who did not like aromatherapy and sleep duration. The volume of breast perfume, used contraception after giving milk which was pumped by researchers birth, had another way to increase and enumerator once a day before feeding breastfeeding such as: consumption of for 15 minutes on each breast of the breast milk and herbal medicine, warm mother. In addition, infant’s weight was compress, other massages, etc. The also measured by digital scale, and 24- number of sample size in this study was hours observation was also performed, 32 recruited by consecutive sampling, including urination and defecate divided to be intervention (16 frequency, and sleep duration recorded in participants) and control group (16 the observation sheet. participants). The selection of the sample was categorized with the odd and Ethical consideration sequence number. Those who came with This research was approved by the Health sequence number order were included in Research Ethics Committees (K.E.P.K) of the intervention group, and those who the Health Polytechnic of Semarang with came with odd number were included in No.184 / KEPK / Poltekkes-Smg / EC / the control group. 2016. The research permission was also obtained by Kesbangpol of Kendal Intervention District and the General Hospital of Dr. H. Intervention was performed after Soewondo Kendal. obtaining written approval from respondents by signing informed consent. Data analysis The Young Living 100% was used as a Mann-Whitney and Wilcoxon test were lavender essential oil. The essential oil of performed to analyze the effect of lavender was mixed with sun flower oil lavender massage on prolactin levels and

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 339 milk volume, while urination and defecate control group was performed using the frequency, and sleep duration were Levene’s test and showed p-value of age analyzed using Independent t-test and (0.983), moths psychological factor paired t-test. (0.333), and frequency of feeding (0.378); while chi-square test showed p-value of education was 0.693 and employment was RESULTS 0.446 (>0.05), which indicated that there The homogeneity test for characteristics was no difference of the characteristics of of the respondents in the intervention and the respondents between the two groups.

Table 1 The difference of prolactin hormone in the intervention and control group Group Prolactin level Intervention Control p-value (N=16) (N=16) Mean±SD Mean±SD Before intervention 199.41±58.036 171.50±60.94 0.2281 After intervention 331.54±84.603 189.33±57.151 0.0001 Difference 132.13±47.52 17.82±22.686 0.0001 p-value 0.0002 0.0002 1Wilcoxon Test 2Mann-Whitney Test

Table 1 shows that there was no was 17.82 ng / ml while mean of difference in prolactin level before difference of hormone prolactin level in intervention between the intervention and intervention group was obtained 132.13 control group with p-value 0.228 (>0.05). ng / ml. There was statistically significant However, there was a significant difference in prolactin levels between difference after intervention with p-value intervention and control group with p- 0.000 (< 0.05). The mean difference of value 0.000 (<.005) prolactin hormone level in control group

Table 2 Breast milk production (milk volume, baby’s weight, urination frequency, defecation frequency, sleep duration) between intervention and control group Group Variable Intervention Control p-value (N=16) (N=16) Mean ± SD Mean ± SD Breast Milk Volume Before intervention 3.00±0.730 2.63±0.619 0.1841 After intervention 139.69±17.366 121.56±10.602 0.0011 Difference 136.69±17.723 118.94±10.402 0.0021 p-value 0.0002 0.0002 Infant weight Before intervention 2799.38±247 2688.13±170.1 0.1483 After intervention 3067.81±249.9 2895.23±169.0 0.0293 Difference 268.44±22.929 207.19±7.521 0.0001 p-value 0.0004 0.0004

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Infant defecation frequency Before intervention 1.63±0.500 1.56±0.512 0.7801 After intervention 5.44±0.814 4.56±0.629 0.0041 Difference 3.81±0.655 3.00±0.516 0.0021 p-value 0.0002 0.0002 Infant urination frequency Before intervention 5.31±0.479 5.25±0.447 0.7801 After intervention 9.63±1.204 8.56±0.814 0.0081 Difference 4.31±1.302 3.31±0.479 0.0171 p-value 0.0002 0.0002 Infant sleep duration Before intervention 16.38±0.500 16.63±0.806 0.5391 After intervention 19.69±1.014 18.56±0.892 0.0031 Difference 3.31±0.946 1.94± 0.772 0.0001 p-value 0.0002 0.0002 1Mann-Whitney test 2 Wilcoxon test 3Independent t test 4Paired t test

Table 2 shows that the mean difference of The mean difference of infant sleep milk volume in the control group was duration in the control group was 1.94 118.94 ml while the mean difference of hours per day while in the intervention milk volume in the intervention group was group was 3.31 hours per day. There was 136.69 ml. There was statically significant statistically significant difference of breast difference of breast milk volume between milk volume between intervention and intervention and control group with p- control group with p-value 0.000 (<0.05). value 0.002 (<0.05). On the other hand, the mean difference of infant weight in DISCUSSION control group was 207.19 gram while Oxytocin massage is one of the solutions mean difference in intervention group was to overcome the insufficiency of breast 268.44 gram. There was statistically milk production.14 Aromatherapy is a way significant difference of breast milk of treating diseases by using the smells of volume between intervention and control fragrant plants such as lavender, which group with p-value 0.000 (<0.05). can be absorbed into the body through the The mean difference of infant skin or olfactory system.12 The essential defecation frequency in control group was oil of lavender massage provides a 3 times per day while in the intervention relaxation effect on the central nervous group was 3.81 times per day. There was system helping to increase the production statistically significant difference of breast of the oxytocin, which increase milk milk volume between intervention and production.13 control group with p-value 0.002 (<0.05). Lavender is one of the aromatherapy The mean difference of infant urination that has an effect on the amygdala in the frequency in the control group was 3.31 brain and is capable of producing a times per day while in the intervention sedative effect.15 Doing the massage twice group was 4.31 times per day. There was a day may affect breast milk in statistically significant difference of breast postpartum mothers.16 The results of this milk volume between intervention and study indicated that the treatment of control group with p-value 0.017 (<0.05). oxytocin massage using lavender essential

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 341 oil was proved to increase the prolactin The baby will sleep soundly 2-3 levels due to the increase of stimulation of hours after feeding. The adequacy of afferents nerve so that the hormone breastfeeding is also demonstrated by oxytocin increases, which also increase infant behavior that is usually quiet and the prolactin levels.17 Studies show that non-fussy.10 In this regard, mothers should postpartum mothers who are given not schedule breastfeeding, but rather massage in the back area from the breastfeeding based on the demand of the neckline to the lower border of the scapula babies. Breast milk production is strongly around the vertebrae for 15 minutes can influenced by the frequent feeding of increase the levels of oxytocin and babies.21 The more often babies suckle on prolactin in the blood.18 the mother's breast, the more the On the other hand, the increase of production and expenditure of breast milk breast milk production can be identified will be.22 Lavender essential oil in from the milk volume, baby’s weight, massage in this study can help postpartum urination and defecation, and baby’s sleep women increase relaxation and comfort so duration. The volume of breast milk milk production are increased.13 Thus, it produced and excreted by the breast could be said that there is an effect of glands may differ by influencing factors.15 oxytocin massage using Lavender If there is an adequate nipple suction, on essential oil on the increase of mother's the first day of life, the baby will get milk production with increasing indicator breast milk 50-100 ml per day, and the of milk volume, body weight, defecation number will continue to grow to 400- 450 and urination frequency, and duration of ml per day during the second week.19 baby’s sleep, which is in line with Breast milk is a liquid formed from previous study indicated that primiparous a mixture of two substances, namely fat postpartum mothers who were given back and water contained in protein, lactose massage for 15 minutes experienced and inorganic salts produced by the improved milk fluids.22 mother's breast gland, and useful as baby food.20 If the baby's nutritional needs are Limitation of the study met, The baby's weight will increase.20 In this study, foods were only subjectively However, breastfed babies will be controlled by asking respondents with different from formula-fed babies. criteria of mothers not to abstain from Infants who were given eating during the study. While the cultural breastfeeding, the pattern of defecation aspects of food avoided after childbirth was 2-5 times per day with yellow stool, were not asked in detail. In addition, the not too thin and not too thick; while physical condition of each mother was babies who get milk formula had 1 time different. There were mothers who could defecation per day with pale stool.10,16 In not deal with pain might slow the addition, it is because breast milk is so recovery and affect or inhibit the amount easy to digest, then the babies will have of hormone prolactin and milk production. more frequent bowel movement. Baby’s elimination frequency depends on the CONCLUSION intake that babies get. Babies who drink Based on the findings of this study, it breastmilk may have urination at least 8- could be concluded that there was a 10 times a day with clear color and typical significant effect of the oxytocin massage urine smell.10 using lavender essential oil on the

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 342 increase of breast milk production and 7. Chertok IR, Shoham-Vardi I. Infant prolactin levels. Therefore, oxytocin hospitalization and breastfeeding post- massage using lavender essential oil can caesarean section. British Journal of be used as an alternative treatment for Nursing. 2008;17(12). midwives and other health professionals 8. Desmawati D. Efektifitas kombinasi areolla massage dengan rolling massage in an effort to increase milk production in terhadap pengeluaran ASI secara dini postpartum. However, further studies are pada ibu postpartum di Puskesmas needed, especially to control the dietary Pamulang dan Cikupa Banten factors using 24-hour food recall sheets, [Effectiveness of combination of areolla and the measurement of the intensity of massage and rolling massage on early pain level in the puerperal mothers. breast milk production in postpartum mothers at Public Health Center of Declaration of Conflicting Interest Pamulang dan Cikupa Banten]. Jakarta: None declared Program Pasca Sarjana Fakultas Ilmu Keperawatan Universitas Indonesia; Funding 2008. This study was supported by Magister 9. Flanders D, Lowe A, Kramer M, et al. A Applied Midwifery, Poltekkes Kemenkes consensus statement on the use of Semarang, Indonesia. domperidone to support lactation. 2012. https://kindercarepediatrics.ca/ wp- Author Contribution content/uploads/Domperidone- All authors contributed equally in this study. Consensus-Statement-Final-May-11- 2012.pdf References 10. Bobak IM, Lowdermilk DL, Jensen MD. 1. Cadwell K, Turner-Maffei C. Buku saku Buku ajar keperawatan maternitas manajemen laktasi [Lactation [Maternity nursing textbook]. Jakarta: management handbook]. Jakarta: EGC; EGC; 2005. 2011. 11. Kramer MS, Chalmers B, Hodnett ED, 2. Cox S. Breastfeeding with confidence: Sevkovskaya Z, Dzikovich I, Shapiro S, Panduan untuk belajar menyusui dengan Collet JP, Vanilovich I, Mezen I, Ducruet percaya diri [Guideline to learn T, Shishko G. Promotion of breastfeeding confidently]. Gracinia J, Breastfeeding Intervention Trial translator. Jakarta: Gramedia; 2006. (PROBIT): A randomized trial in the 3. Ministry of Health. Basic health research Republic of Belarus. JAMA. 2001 (Riskesdas) 2013. Jakarta: Ministry of 24;285(4):413-420. Health of Indonesia. 2013. 12. Matsumoto T, Asakura H, Hayashi T. 4. World Health Organization. WHO child Does lavender aromatherapy alleviate growth standards: Length/height for age, premenstrual emotional symptoms?: A weight-for-age, weight-for-length, randomized crossover trial. weight-for-height and body mass index- BioPsychoSocial Medicine. for-age, methods and development. 2013;7(1):12. Geneva: World Health Organization; 13. Koulivand PH, Khaleghi Ghadiri M, 2006. Gorji A. Lavender and the nervous 5. Ministry of Health. Health profile of system. Evidence-Based Complementary Indonesia 2013. Jakarta: Ministry of and Alternative Medicine. 2013; 2013. Health of Indonesia. 2014. 14. Department of Health of Indonesia. 6. Department of Health of Central Java. Pedoman penyelenggaraan pelatihan Health profie of Central Java in 2014. konseling menyusui dan pelatihan Semarang: Department of Health of fasilitator konseling menyusui [Guideline Central Java; 2014. of the implementation of training of

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counseling of breastfeeding and its application concept]. Jakarta: EGC; facilitator]. Jakarta: Department of 2004. Health of Indonesia; 2011. 20. Wambach K, Riordan J. Breastfeeding 15. Lindquist R, Snyder M, Tracy MF. and human lactation: Burlington: Jones Complementary & alternative therapies & Bartlett Publishers; 2014. in nursing. United States: Springer 21. Suradi R, Tobing HK. Lactation Publishing Company; 2013. management. Jakarta: CV Sagung Seto; 16. Biancuzzo M. Breastfeeding the 2004. newborn: clinical strategies for nurses. 22. Patel U, Gedam DS. Effect of back United States: Mosby Incorporated; massage on lactation among postnatal 2003. mothers. International Journal of 17. Hockenberry MJ, Wilson D. Wong's Medical Research and Review. nursing care of infants and children-e- 2013;1(01). book. Philadelphia: Elsevier Health Sciences; 2014. Cite this article as: Agustie PR, Hadisaputro 18. Morhenn V, Beavin LE, Zak PJ. Massage S, Runjati, Soejonoes A, Mashudi ID, increases oxytocin and reduces Widyawati MN. Effect of oxytocin massage adrenocorticotropin hormone in humans. using lavender essential oil on prolactin level Alternative Therapies in Health and and breast milk production in primiparous Medicine. 2012;18(6):11. mothers after caesarean delivery. Belitung 19. Hubertin SP. Konsep penerapan ASI Nursing Journal. 2017;3(4): 337-344. eksklusif [Exclusive breastfeeding https://doi.org/10.33546/bnj.151

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Ligita T. Belitung Nursing Journal. 2017 August;3(4):345-351 Received: 29 May 2017 | Revised: 2 August 2017 | Accepted: 6 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

HOME CARE NURSES’ ROLES IN ENHANCING QUALITY OF NURSING CARE FOR PATIENTS AT HOME: A PHENOMENOLOGICAL STUDY

Titan Ligita* School of Nursing, Faculty of Medicine, University of Tanjungpura, West Kalimantan, Indonesia

*Corresponding author: Titan Ligita, S. Kp, MSN School of Nursing, Faculty of Medicine, University of Tanjungpura Jalan Profesor Dokter Haji Hadari Nawawi, Pontianak Tenggara, Bansir Laut, Kec. Pontianak Tenggara, Kota Pontianak, Kalimantan Barat 78115, Indonesia E-mail: [email protected]

ABSTRACT Background: Provision of health care service at home is one of the advanced forms of care for patients being discharged from hospitalization. Little is known about the experience of nurses providing home care services through a nursing home-care model especially in Indonesian context. Objective: This study aims to explore the experience in order to increase understanding on the form of home care provision, and consequently the nurses may understand the form of home care globally. Methods: This study employed a phenomenological design and performed interview in the process of data collection. Data were analysed by using content analysis. Results: The main contexts of home care nurse experiences were generated. There were definition and role of home care nurses, the involvement of family members in the provision of care, the facilitating and hindering factors contributed to home care provision as well as manual on providing home care nursing. Conclusion: The implication from this study is that nursing care should be given to the patients continuously and consequently the need for family involvement is important. Additionally, in providing the home care, a proper manual is needed by home care nurses as the guidance to give best quality of care to patients.

Keywords: home care nurses, quality of nursing care, phenomenology

INTRODUCTION Nursing care aims to fulfil patients’ needs aspects of patients such as psychology, on health and provides response to illness social, culture and spirituality. Moreover, condition experienced by patients as the provision of nursing care is not only individuals, families or communities. The applied at the hospital area but also in nature of nursing care is holistic where the either community settings or at the focus is not only limited to biological patients’ houses. Several factors influence condition but also considering other the provision of nursing care in

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Editor’s Note: This article has been updated on 11 July 2020 in terms of the completeness of correspondence address. The update is based on BNJ policy on article correction. community settings. One factor is that the important to explore because through population in the world increase gradually these experiences, the appropriate and and thus people needs certain type of feasible model of service can be nursing care that provided at home. Other identified. Then, it will allow home care factor is that both elderly and younger nurses to implement a standard model of patients are considered to have lack of healthcare service in Indonesia. benefits when admitted to hospitals. The There is a need for an agreement on decrease in the availability of hospital the criteria for patient admission to the beds is also one of the factors that affect hospital or patient discharge from the the need for home nursing care. 1 hospital so that the provision of the The model of providing health care nursing care service can have obvious service at home is one of the advanced boundaries. 1 Moreover, there is a need to forms of care given once the patient has explore on how long the intensity of care been discharged from hospitalization. services provided at home, who involves However, it seems that this healthcare in the roles of providing nursing care service model is less than optimal. This services to patients in the home and how phenomenon occurs as a result of high the roles are performed. Therefore, this workload of nurses in hospitals who must study aims to explore the role of nurses provide advanced nursing services as an providing nursing care services to patients additional burden so that the nurses do not at home in improving the quality of follow up on the care service to the patient nursing care. in the patient's home. According Jester, there are two factors that underpin the METHODS development of nursing models at home, Study Design early discharging patients from the An appropriate research design was used hospital and prevention of patient entry to based on the purpose of the study, which the hospital. 1 was to explore individual experiences in Nursing services provided as a providing nursing care in order to improve home care to patients do not seem as the quality of nursing care. This was a simple as we can imagine. There are qualitative study with phenomenological several things that need to be considered: research design. Through a research the selection of patients or families; framework with a phenomenology design, patient self-defence strategy; home an understanding of the phenomenon of situation and certainly the patient's individual experience will be developed. 2 condition which is sometimes not supported by the patient's home situation. Sample 1 There are currently no standard The study was undertaken in 2014 in West regulations on the nursing service model Kalimantan, Indonesia, where the number at home although it is not uncommon for of home care nurses were limited and nurses in Indonesia providing healthcare home care was not popular at this time. service for patients at home. Little is Participants involved in this study were known about the experience of nurses selected by using purposive sampling providing home care services through a method. The inclusion criteria included in nursing home-care model especially in this study was nurses who have had Indonesian context. Nurses’ experiences experiences as a home care nurse for one in providing nursing care at home are year or more. The total number of

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 346 participants were three people. Creswell collecting and analysing data.6 After that, recognises that the number of participants several concepts were developed and in a phenomenology study vary from one classified so that the main consistent to 325.3-5 Moreover, a phenomenology concept was able to be determined. 7 The study is recommended to have between concepts obtained were as follows: the three and ten participants. 3 definition and the role of home care nurses; enablers in home care practice and Data Collection hindrances in home care practice; family These participants of this study have main involvement in home care practice and roles as either clinical nurses or nurse guidelines in the implementation of home academics with an additional role as a care. home care nurse. Data were collected through interviews by asking semi- structured questions and the interviews RESULTS were audio-recorded. Collecting data The process of data collection process was through the interviews was undertaken by undertaken over one month in 2014. either face to face or phone call. Before Interviews were conducted either by face the interviews were conducted, the to face or through a phone call as some of researcher had to ensure the research the participants did not live in the same ethical principles were employed by province (West Kalimantan, Indonesia) as ensuring the participants that the study the interviewer as the participants were participation is voluntary and thus the studying for their master degree in participants have rights to reject their Nursing. In this study, there were five participation during or before the data are themes generated from the interviews processed. The researcher also considered about the roles of home care nurses. The potential risks that will occur. Participants themes were definition and role of home in this study may experience a negligible care nurses, factors that enable home care risk from being participated in an practice, hindrances encountered during interview. the home care practice, family involvement and guidelines in home care Data Analysis practice. The collected data were then analysed by using content analysis. The recorded data Definition of home care and roles of home were verbatim transcribed into a written care nurse document. The transcripts were then From all of the three participants, the printed to facilitate the researcher definition of home care describes about a analysing the data by reading the form of care service provided and where transcript thoroughly. The researcher read the care service is performed. repeatedly the transcripts of the interviews to get an overview of the interviews to “... [Home care is] …. a service that is ensure the trustworthiness in the study. officially provided for health care at Data saturation was achieved during the home...” (Participant 1) process of data analysis. The concept of “...How we take care of patients at [their] data saturation is used when the incoming homes so that their needs can be information “produces little or no change” fulfilled...” (Participant 3) to the existing data during the process of

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Whereas, roles of home care nurse can be Nurses’ opinions being opposites with the acknowledged from the participants’ families’ opinions...” (Participant 2) statement as follows: “...Patient having lack of motivation because of a prolonged time in the “...Providing assistants, discussing, giving healing period. Cost effectiveness. feedbacks and resolving family’s problems Families being too busy. Lacking in family together...” (Participant 3) supports...” (Participant 1) “...Monitoring, providing wound care, facilitating outpatient care and delivering Family involvement basic nursing interventions...” (Participant Patient Family Involvement in Home 2) Patient Care can be seen from the “...Facilitating patients’ needs in which the following participant statements: patients and their families cannot accomplish the needs independently...” “...The family involves in controlling (Participant 1) diabetes such as eating pattern, [and] personal hygiene. The family will Enablers in home care practice. continue the care and patient controlling. This study also recognised factors The family fully involve [in the care] and is enabling the implementation of home care eager to learn for continuing the care...” practice. These factors were identified (Participant 1) from the participants’ statement below: “...Families help a lot. The healing [process] is quicker. However, the “... [The factors are] … the patients psychologic burden had by the families themselves... Full support from the make the families do not want to take families...” (Participant 1) care of the patients because the patients “...Short distance… the availability of put more trusts on the nurses than their time… proper supporting devices...” own families mainly when it is related to (Participant 2) the use of health technology. Family “...The government, in this case, the involvement is vital in identifying the Ministry of Health to make a regulation on patient’s problem earlier so that it will not home care for patients who need a longer be resolved very late...” (Participant 3) period of health care service...” (Participant 3) Guidelines in home care practice All the home care nurses in this study Hindrances in home care practice stated different point of views about the Meanwhile, factors that limit nurses guideline on the home care nursing providing home care practice can be practice. realised as follows: “...The guideline on home care is “...Lack of supports from the family. acquired from the Community Health Family having problem beside health Nursing book. However, there is also a problems. Nurses having lack of hospital foundation which make the knowledge. Excessive workload...” guideline on home care (Participant 3) implementation...” (Participant 2) “...Ignorance of families on the nurses’ “...The guideline was obtained when [I] [role of] boundaries. Family dependency. have been trained on home care training by the Ministry of Health. It can be

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acquired through the internet or the and his colleagues’ research study is that book of Community Nursing...” socioeconomic condition and family (Participant 3) decision influence the decision on the “...There is no specific guideline on the form of nursing care service for the application of home care practice in the patients, especially for elderly patients. 11 form of either procedures, interventions The role of the family supports is or nursing interventions...” (Participant 1) very important for the continuity of nursing care services provided at home. DISCUSSION Wilson, Davies and Nolan outlined that a In this study, it was identified that any good relationship between nurses and forms of nursing care services provided in families, who help taking care of patients, the patient's home is called as home care. is very accommodating and it is strongly These forms of care service vary from influenced by how nurses acknowledging, facilitating the needs of the patient, appreciating and responding on family’s performing basic nursing care and efforts in taking care of the patients. 12 monitoring vital signs. This service care is Therefore, Wilson and his colleagues also provided for both patients and families emphasize that the relationship can be who are unable to do the care developed very well between nurses, independently. Similar findings were patients and families when there is a found by two studies in which the role of mutual understanding and appreciation on home health care providers is conducted a daily routine at home.12 However, when in the form of identifying patients, the family relationship is well established, assessing their needs, conducting involving family in nursing care will be psychological and psychosocial much more challenging. 13 The same supportive care as well as providing analysis is stated by Silver and Wellman dietary or nutritional education. 8,9 that negative emotion will affect the Although this current study did not ability of the family on helping the mention the reasons why patients provision of patient care. 14 choosing a home care service, the reasons Gruber et al. also add that family for patients receiving home care services support is crucial not only to the recovery are disclosed by another study. One of the patients but also to the increase of reason is cost of institutional care (in this health and wellbeing as well as the case the hospitals) is high. Another reason development of positive roles. 13 Family is that elderly people expect to be treated involvement is also very important in at home by his relatives according to controlling patient activities such as eastern and western cultures. The last eating, taking medication and in reason is patients are able to choose how identifying patient problems at home so they continue to live and control their that is can be immediately reported to the daily conditions. 10 The same finding was nurse. identified by a study where three types of This study also identified that elderly patients who chose to have home family helps greatly in terms of care services were identified 11. They were performing follow-up care at home when the patients who were poor, dependent on the nurse is not available to the patient. family’s decision, free to decide the form Obviously, this role is applied when the of nursing care service for themselves. family have previously obtained guidance The significant meaning from Boggatz from the nurse. However, an important

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 349 thing needs to be considered is when the provision of nursing care service at home. form of care service requires high Results from this study identified several technology, then the patient will put more important things about home care nursing. trust on nurses who can provide the care One advantage of home care practice is than their own family. Therefore nurses the family involvement. Family need to be highly skilled and have involvement is very crucial because the sufficient knowledge in providing family can provide updated information interventions to patients who are highly about patients more quickly so that dependent on technology.14 complications can be prevented and thus Providing a well-established home the patients can be treated immediately. In care nursing service is supported by not addition, this form of home care services only nurses, patients and families, but also implies that the care for the patients a clear guideline and regulation. In this should be done in a sustainable manner. study, the home care nurses acquired Therefore, it needs an appropriate guides in providing the services through guideline for nurses in performing home various sources such as books, the care practice. Supports from the hospital or training. There have been no government and relevant stakeholders are rules and standards in the form of a crucial in supporting the continuity of guideline in performing home care patient care at home and issuing a uniform practice. Thus, it is important to have a guideline for the home care practice. home care practice that is provided in Further research is needed for examining accordance with the authority of the the impacts of the provision of home care nurses so that the provision of the care can service on patients’ health and wellbeing. support the quality of nursing care. If there is no clear regulation, the patient Declaration of Conflicting Interest may be treated at home in which they None declared should be treated in the hospital and thus new problem arisen and a fatality to the Funding patient may occur. Lakasing underlines This study was supported by School of Nursing, Faculty of Medicine, University of that there are several conditions where a Tanjungpura, West Kalimantan, Indonesia. home care service may not be suitable for 15 the patient. These conditions include Author Contribution patients who do not wish to be treated at This is the original work of the corresponding home, poor or inadequate care supports author. and the caregivers who cannot cope with the problems. Other reasons such as References untreatable distress symptoms, inadequate 1. Jester R. Rehabilitation settings. In: control of the symptoms at home and Jester R, ed. Advanced rehabilitation acute emergencies can also be nursing. Oxford: Blackwell inappropriate conditions for home care Publishing; 2007:29-41. 2. O'Brien L. Phenomenology. In: service.15 Schneider Z, Elliot D, LoBiondo- Wood G, Haber J, eds. Nursing CONCLUSION research: Method, critical appraisal Current form of nursing care service has and utilisation. 2nd ed. Sydney: developed. It does not only focus on Mosby; 2003:193-204. hospitalization but also develop on the

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3. Dukes S. Phenomenological 10. Toiviainen L. Home care for older methodology in the human sciences. people. Journal of the British Journal of Religion and Health. Menopause Society. 2005;11(2):57- 1984;23(3):197-203. 60. 4. Creswell JW. Qualitative inquiry and 11. Boggatz T, Farid T, Mohammedin A, research design: choosing among five Dassen T. Attitude of older Egyptians approaches. Thousand Oaks, towards nursing care at home: A California: SAGE Publications; 2013. qualitative study. Journal of Cross 5. Polkinghorne DE. Phenomenological Culture Gerontology. 2009;24:33-47. research methods. In: Valle RS, 12. Wilson CB, Davies S, Nolan M. Halling S, eds. Existantial- Developing personal relationships in phenomenological perspectives in care homes: Realising the psychology. New York: Plenum contributions of staff, residents and Press; 1989:41-60. family members. Aging and Society. 6. Guest G, Bunce A, Johnson L. How 2009;29:1041-1063. Many Interviews Are Enough?: An 13. Grubber KJ, Fleetwood TW, Herring Experiment with Data Saturation and MW. In-home continuing care Variability. Field Methods. services for substance-affected 2006;18(1):59-82. families: The bridges program. Social 7. Glasson J, Chang E, Chenoweth L, et Work. 2001;46(3):267-277. al. Evaluation of a model of nursing 14. Silver H, Wellman NS. Family care for older patients using caregiver training is needed to participatory action research in an improve outcomes for older adults acute medical ward. Journal of using home care technologies. Clinical Nursing. 2006;15:588-598. Journal of the American Dietetic 8. Marshall D, Howell D, Brazil K, Association. 2002;102(6):831-836. Howard M, Taniguchi A. Enhancing 15. Lakasing E. Providing good palliative family physician capacity to deliver care for patients at home. The quality palliative home care: An end- Practitioner. 2009;253(1717):28-31. of-life shared-care model. Canadian Family Physician. 2008;54(1703):1-7. Cite this article as: Ligita T. Home Care 9. Townson JK, Gregory JW, Cohen D, nurses’ roles in enhancing quality of et al. Delivering early care in diabetes nursing care for patients at home: A evaluation (DECIDE): A protocol for phenomenological study. Belitung a randomised controlled trial to assess Nursing Journal. 2017;3(4): 345-351. hospital versus home management at https://doi.org/10.33546/bnj.90 diagnosis in childhood diabetes. BMC Pediatrics. 2011;11(7):1-7.

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Yusuf N, et al. Belitung Nursing Journal. 2017 August;3(4):352-359 Received: 28 February 2017 | Accepted: 31 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

THE EFFECTIVENESS OF COMBINATION OF KANGAROO MOTHER CARE METHOD AND LULLABY MUSIC THERAPY ON VITAL SIGN CHANGE IN INFANTS WITH LOW BIRTH WEIGHT

Nuuva Yusuf1*, Suharyo Hadisaputro1, Runjati2, Ari Suwondo3, Imam D Mashoedi1, Supriyana1

1Magister Applied Midwifery, Health Ministry Polytechnic of Semarang, Central Java, Indonesia 2Midwifery Department, Health Ministry Polytechnic of Semarang, Central Java, Indonesia 3Department of Heath and Work Safety, Faculty of Public Health, Diponegoro University, Semarang, Central Java, Indonesia

*Corresponding author: Nuuva Yusuf.,S,ST Magister Applied Midwifery, Health Ministry Polytechnic of Semarang Jl. Tirto Agung, Pedalangan, Banyumanik, Kota Semarang, Jawa Tengah, Indonesia (50268) E-mail: [email protected]

ABSTRACT Background: Kangaroo mother care (KMC) and lullaby music methods have been considered as the alternative treatment for vital sign changes in low birth weight infants. However, little is known about the combination of the two methods. Objective: To identify effectiveness of combinations of Kangaroo mother care and Lullaby music methods on changes in vital signs in low birth weight infants. Methods: A quasi experiment with non-equivalent control group design. This study was conducted on October– December 2016 at the General Hospital of Ambarawa and General Hospital of Ungaran, Semarang, Indonesia. There were 36 samples selected using consecutive sampling divided into three groups, namely: 1) a group of low birth weight infants with the combination of KMC and lullaby music, 2) an low birth weight infant group with the lullaby music intervention, and 3) a control group given standard care in low birth weight infants by KMC method. Paired t-test and MANOVA test were used to analyzed the data. Results: Findings revealed that there were significant differences between the combination group, lullaby music group, and control group in temperature (p=0.003), pulse (p=0.001), respiration (p=0.001), and oxygen saturation (p=0.014) with significant value of <0.05, which indicated that there was a statistically significant difference in vital sign changes among the three groups. Conclusion: The combination of KMC method and lullaby music intervention was effective on vital sign changes (temperature, pulse, respiration, and oxygen saturation) compared with the lullaby music group alone and control group with KMC method in low birth weight infants. It is suggested that the combination of KMC and lullaby music methods can be used as an alternative to improve low birth weight care for mothers in the NICU and at home and to reach the stability of the baby's vital signs.

Keywords: kangaroo mother care, lullaby music, low birth weight, vital signs change

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Editor’s Note: This article has been updated on 11 July 2020 in terms of minor changes in the reference format. The update is based on BNJ policy on article correction. INTRODUCTION Low Birth Weight (LBW), especially in an alternative to substitute incubator with preterm birth, is due to the immaturity of efficient and effective treatment.4 the infant's organ system.1 Infant with low The Kangaroo Mother Care (KMC) birth weight has a tendency toward is considered as an alternative treatment, increased infection and susceptible to which has been performed in infants with complications. Infants with LBW are also low birth weight in hospitals to test the highly susceptible to hypothermia, due to effects of physiological parameters (heart the thinness of the fatty reserves under the rate, breathing, temperature and oxygen skin and the immature central heat saturation).5 Research on premature regulator in the brain.1 The problems often babies showed that the bradycardia occur in the infants with LBW are incidence is lower in the kangaroo care respiratory disorder, hypothermia, group who performed kangaroo hypoglycemia, hyperglycemia, brain treatments every hour compared to infants hemorrhage, and immunologic disorders.2 in the incubator (p = 0.048).6 In addition, LBW infant is also sensitive to new the number of infants with oxygen environments, which might cause them to desaturation is also lower in the kangaroo be susceptible to illness such as care group compared to the infants who developmental disorders, vision received standard care (p = 0.02). 6 (retinopathy), hearing, chronic lung In addition to KMC treatment, disease, increased morbidity and music therapy provided in the NICU is frequency of congenital abnormalities and considered able to reduce the room noise frequent hospitalization.3 levels. Music has measurable benefits on Conventional LBW treatment with physiological and psychological states in incubators is very expensive and requires infants and children and is recommended trained health personnel and adequate as part of NICU care in the room.7 Studies equipment facilities. In developing in Lithuanian involving 35 stable infants countries, income and human resources aged less than 32 postmenstrual weeks are limited in neonatal care, and usually showed that infant heart rate (HR) was have limited treatment rooms. In addition, decreased significantly in live lullaby the incidence of nosocomial infections in music group and recorder lullaby group, hospital is high, and infants in the NICU but not for control group (p = 0.02).8 In are exposed to the average noise levels of addition, the findings also showed that the 50-88 dB (reaching a peak level of more lullaby live group resulted in deeper sleep than 100 dB) from a variety of sources than the lullaby recorder group (p = 0.02) including ventilators, alarm monitors, and the control group (p = 0.006).8 incubators, conversations of NICU Lullaby music is included in classical officers, radios, telephones, water faucets, music that is easy to find in every human and cupboard doors,4 which can make culture, which can be used as baby LBW stability decrease. As a result, delivery music, so it is useful to regulate conditions such as hypoxemia and blood infant behavior (such as calming, focusing pressure instability may increase apnea on oneself) that accompanies to and bradycardia, alter cerebral blood flow communicate emotional information.9 and intraventricular hemorrhage. However, little is known about the Therefore, a practical method is needed as combination of the two interventions. Therefore, this study aims to determine

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 353 the effect of combination of KMC and second group was the group given the lullaby music on vital sign change in low lullaby music for 20 minutes in 7 days; birth weight infants. and the control group was given standard treatment of KMC method according to METHODS guideline in the hospitals. The steps of the Design intervention of the combination of KMC A quasi-experiment with non-equivalent Method and music lullaby as follows: 1) control group design. KMC method was done by the respondent's mother, 2) Baby was put in a Setting kangaroo position, using hats, nappies and This study was conducted on October – warmed socks, 3) Place the baby on the December 2016 at the General Hospital of mother's chest, in an upright position Ambarawa and General Hospital of directly to the mother's skin and make Ungaran, Semarang. sure the baby's head was fixed on the mother's chest. Position the baby with the Population and Sample elbow and leg flexed. The baby's head and The target population in this study was all chest resting on the mother's chest with low birth weight infants (LBW) who were slightly raised head, 4) After a good baby outside the incubator treated in the NICU position, kangaroo clothes were tied to of Ambarawa and Ungaran hospital support the baby. Furthermore, the baby's Semarang. There were 36 samples mother can do activity as usual while selected using consecutive sampling bringing the baby in a perpendicular divided into three groups, namely: 1) A position in the breast of the mother (skin group of LBW infants with the to skin contact) such as kangaroos, 5) combination of KMC and Lullaby music Perform the KMC method for 60 minutes (12 infants), 2) A LBW infant group with (less than 60 minutes are avoided because the Lullaby music intervention (12 too frequent changes will make the baby infants), 3) A control group given stress), 6) After 60 minutes performed standard care in LBW infants by KMC KMC method, continued with lullaby method (12 infants). The inclusion criteria music therapy provided with 60-75 dB of this study included: a) Mothers who using MP4 and speakers of the same had a LBW baby who was willing to be a brand to make sounds, and placed 30 cm research respondent; Infant weighing away from baby's ears or at baby's feet. 1500-2500 grams; b) Baby was able to To guide the sequencing, duration, and suck even if it was still weak; c) Baby was frequency of music interventions, no hard not dependent on oxygen; d) Baby did not and fast rules were applied. However, for get intravenous fluids; Baby with stable short-term sedatives or soothing effects, clinical conditions such as LBW had no music exposure was recorded most often use of respiratory aids; and e) no history around 20-30 minutes per session. of heart disease from parents. Instruments Intervention The instruments in this research included The intervention given to the first group observation sheets of combination was the combination of KMC method intervention, lullaby and control music, given for 1 hour and followed by lullaby observation sheet of temperature music for 20 minutes in 7 days; the measurement, pulse, respiration and

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 354 oxygen saturation; mp4 player with active Poltekkes-Smg / EC / 2016. Before the speaker, digital axillary thermometer, intervention was performed in infants, watch, pulse oximetry, KMC shirt for researchers conducted informed consent KMC implementation, and academic and provided information regarding calendar. In this study, temperature research objectives and procedures on measurements were carried out with a KMC methods and lullaby music to infant calibrated digital thermometer tool. It was mothers. After the mothers agreed to be a measured in axillary of the LBW infant research respondent, they signed the with a normal value of 36.5ºC-37.5ºC, if written informed consent. the LBW temperature was <36.5ºC then it was said to be hypodermic. While pulse Data analysis measurement and oxygen saturation were Paired t-test was performed to know the carried out with a calibrated pulse difference of vital sign change before and oximetry device. Normal pulse of LBW after given intervention in each group. infant was 120-160x / min and normal Levene test was used to test the oxygen saturation was >95%, the homogeneity and the results showed p- measurement was done on baby's toes. value >0.05, which indicated that the Respiratory measures were performed for temperature, pulse, respiration and oxygen one minute by looking at infant's saturation in all three groups had no breathing, with a normal value of 30-60x / significant difference or homogeneous. In min.10 addition, the normality test also showed p- value >0.05, which indicated that the data Ethical consideration were normally distributed. MANOVA This study has been approved by the was also used to determine the differences Health Research Ethics Committees of each variable after being given (K.E.P.K) of the Health Polytechnic of treatment when tested simultaneously. Semarang with number 175 / KEPK /

RESULTS

Table 1 Difference of temperature, pulse, respiration and oxygen saturation in the combination group, lullaby music group, and control group

Mean±SD Group Variable p-value Pre Post Combination of Temperature 36.6±0.1723 36.7±0.1371 0.039 KMC method and Pulse 133±8.415 137±8.317 0.018 Lullaby music Respiration 40±3.646 43±1.545 0.025 Oxygen Saturation 95±1.147 97±1.769 0.035 Lullaby Music Temperature 36.6±0.1815 36.5±0.2146 0.175 Pulse 131±5.959 128±4.079 0.038 Respiration 34±5.494 37±5.297 0.031 Oxygen Saturation 94±1.596 94±1.235 0.715 Control (KMC Temperature 36.6±0.1357 36.5±0.1084 0.044 method) Pulse 137±5.518 133±4.441 0.025 Respiration 41±4.830 36±3.742 0.000 Oxygen Saturation 93±1.303 92±1.215 0.358

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Paired t-test result as shown in the In the Lullaby musical group, only table 1 indicated that the mean pulse and respiration had p-value 0.038, temperature, pulse, respiration and oxygen 0.031 (<0.05) respectively, which saturation before and after intervention in indicated there was a significant the combination group obtained p-value difference in pulse and respiration before <0.05, which indicated that there was a and after intervention. While in the significant difference in temperature control group, there was a significant (p=0.039), pulse (p=0.018), respiration difference in temperature, pulse, (p=0.025), and oxygen saturation respiration before and after intervention (p=0.035) before and after given with p-value <0.05. There was no combination method (KMC method and difference in oxygen saturation with p- Lullaby music) on LBW infants. value 0.358 (>0.05).

Table 2 Difference of Vital Sign in the combination group, lullaby music group, and control group using MANOVA

95% confidence Variable Group Mean F Interval p value Lower Upper Bound Bound Temperature Combination 0.100 0.026 0.174

Lullaby music -0.042 -0.116 0.032 6.956 0.003 Control -0.083 -0.157 -0.009 Pulse Combination 4.00 1.074 6.926

Lullaby music -3.83 -6.760 -0.907 9.116 0.001 Control -3.17 -6.093 -0.240 0.000 Respiration Combination 2.50 0.283 4.717

Lullaby music 3.33 1.116 5.551 16.286 0.001 Control -4.67 -6.884 -2.449 Oxygen Combination 1.75 0.642 2.858 Saturation Lullaby music -0.25 -1.358 0.858 4.903 0.014 Control -0.42 -1.525 0.691

Table 2 shows that there were group had a higher value compared to the significant differences between the other two groups with a value of 0.100, combination group, lullaby music, and which means that the combination control group in temperature (p=0.003), intervention (KMC method and Lullaby pulse (p=0.001), respiration (p=0.001), music) is more effectively applied to the and oxygen saturation (p=0.014). While temperature change in LBW infants. the overall p-value was 0.000 (<0.05), Similar with the mean of pulse change and which indicated that there was a oxygen saturation in the combination statistically significant difference of vital group that had a higher value than the sign (temperature, pulse, respiratory, other two groups with a value of 4.00, oxygen saturation) between the three 1.75 respectively. This shows that the groups. combination (KMC method and Lullaby Based on the descriptive statistic music) is more effective to be applied to test, it was found that the mean of pulse and oxygen saturation changes in temperature change in the combination LBW infants. But, for the mean

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 356 respiratory changes, the lullaby music In addition, research showed that a group has a higher value than the lower incidence of bradycardia in LBW combination and control group with a infants in the KMC method group for an value of 3.33, which means that Lullaby hour than the LBW in incubator with music is more effectively applied to mean p=0.048. The KMC method also can respiratory changes in LBW infants. provide stimulus to the hypothalamus that can release corticotropin releasing factor DISCUSSION (CRF) and also endorphin so as to create a Findings in this study revealed that the sense of comfort and calm in the baby. combination (KMC method and Lullaby CRF to the anterior hippophage is music) intervention was effective on vital continued into the adrenal cortex resulting sign changes (temperature, pulse, in decreased cortisol hormone and then respiration, and oxygen saturation) decreased stress and an increase in compared with the lullaby music group immune system in the elevated infant, alone and control group with KMC characterized by a decreased fever.12 method in low birth weight infants. Research shows that the KMC method Lullaby music in this study only had an group for 5 minutes after delivery is effect on pulse and respiration, and significantly achieving pulse stability control group with KMC method had an (120-160 times / min) compared with the effect on temperature, pulse and KMC method group performed over 60 respiration. min after birth with a value of p = 0.001.13 The combination methods seems Another study revealed that the effective because there is a maternal occurrence of oxygen desaturation was neonatal thermal synchrony in the lower in LBW infants by KMC method kangaroo mother care method, which the compared with LBW infants in incubator mother's body temperature increases or with a significance value of 0.017,6 and decreases as needed to maintain the baby this study also showed lower oxygen within the neutral temperature range desaturation events in the group KMC (36.5ºC-37.5ºC).11 KMC is skin-to-skin compared with standard treatment with a contact between mother (or substitute) and significance value of 0.03.6 Thus, the infant starting from birth, prolonged, and KMC method can reduce the oxygen continuously, both in hospital and after desaturation of the baby in premature and return, with support for infection position, physiological stability. nutrition, prevention and management as On the other hand, lullaby music well as difficulty breathing in infants. reduces the impact of exposure to noise Literature also said that skin contact in the levels and will provide beneficial effects kangaroo method can decrease stress on physiological functions, slow pulse and characterized by low cortisol levels and heart rate, lower blood pressure, and increase inner bonds, decrease reduce stress hormone levels.14 Lullaby physiological pain responses, improve music is slow-moving music, reaching the cognitive development, and lower apnea limbic system that can directly affect incidence.1 While in terms of emotional reactions and human physical effectiveness, safety and hygiene of reactions such as heart rate, blood kangaroo method is the same as the most pressure and body temperature.15 This sophisticated type incubator, but in terms music therapy is particularly useful for of cost, it is much different. regulating hormones, slowing or

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 357 balancing the brain, affecting breathing, measurements before giving music heart rate, pulse and blood pressure and therapy. body temperature. However, in this study live lullabies music resulted in longer Declaration of Conflicting Interest sleep in infants compared with recorded None declared lullaby music group. It is line with the study revealed that maternal singing Funding during the KMC method lowers maternal This study was supported by Magister Applied Midwifery, Health Ministry anxiety and induces autonomic stability in 16 Polytechnic of Semarang, Central Java, preterm infants. Indonesia. Elements of music that cause relaxation are as follows: stable tempo; Author Contribution stability or gradual change in volume, All authors contributed equally in this study. rhythm, timbre, pitch, and harmony; consistent texture; predicted harmonic References modulation; appropriate kadens (melodic 1. Hockenberry MJ, Wilson D, Rodgers or harmonic configurations that give the CC. Wong's essentials of pediatric impression of equanimity and nursing. Philadelphia: Elsevier Health resolution).17 Research shows the result Sciences; 2016. 2. Ministry of Health of Indonesia. that music combined with the mother's Profil Kesehatan Indonesia 2014. voice can also be considered as a variation 7 Jakarta: Ministry of Health of received on music therapy. The study Indonesia; 2014. showed that there was a significant 3. Suradi R, Rohsiswatmo R, Dewi R, influence between the treatment of music Endyarni B, Rustina Y. Perawatan during the KMC method on the Bayi Berat Lahir Rendah (BBLR) respiratory rate decrease of 3.3 times / dengan metode kanguru [Low birth min.18 weight infants care using kangaroo method]. Jakarta: HTA Indonesia; CONCLUSION 2008. It can be concluded that the combination 4. Alipour Z, Eskandari N, Hossaini SKE, Sangi S. Effects of music on (KMC method and lullaby music) physiological and behavioral intervention is more effectively applied responses of premature infants: A for changes of temperature, pulse, randomized controlled trial. respiration, and oxygen saturation on Complementary Therapies in Clinical LBW infants with an average increase in Practice. 2013;19(3):128-132. temperature (0.1ºC), pulse (4 times/min), 5. Nirmala P, Rekha S, Washington M. respiration (3 times/min), oxygen Kangaroo mother care: Effect and saturation (2%). It is suggested that the perception of mothers and health combination of KMC and lullaby music personnel. Journal of Neonatal methods can be used as an alternative to Nursing. 2006;12(5):177-184. improve LBW care for mothers in the 6. Mitchell AJ, Yates C, Williams K, Hall RW. Effects of daily kangaroo NICU and at home and to reach the care on cardiorespiratory parameters stability of the baby's vital signs. Further in preterm infants. Journal of research is needed to control the noise Neonatal-Perinatal Medicine. level of the room by performing noise 2013;6(3):243-249.

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7. Stouffer JW, Shirk BJ, Polomano RC. Human Development. 2011;87(3): Practice guidelines for music 151-157. interventions with hospitalized 14. Salamon E, Kim M, Beaulieu J, pediatric patients. Journal of Stefano GB. Sound therapy induced Pediatric Nursing. 2007;22(6):448- relaxation: down regulating stress 456. processes and pathologies. Medical 8. Garunkstiene R, Buinauskiene J, Science Monitor. 2003;9(5):RA96- Uloziene I, Markuniene E. Controlled RA90. trial of live versus recorded lullabies 15. Campbell DG. Efek mozart. Jakarta: in preterm infants. Nordic Journal of Gramedia Pustaka Utama; 2001. Music Therapy. 2014;23(1):71-88. 16. Arnon S, Diamant C, Bauer S, Regev 9. Abromeit DH. The newborn R, Sirota G, Litmanovitz I. Maternal individualized developmental care singing during kangaroo care led to and assessment program (NIDCAP) autonomic stability in preterm infants as a model for clinical music therapy and reduced maternal anxiety. Acta interventions with premature infants. Paediatrica. 2014;103(10):1039- Music Therapy Perspectives. 1044. 2003;21(2):60-68. 17. Djohan. Terapi musik: Teori dan 10. Potter PA, Weilitz PB. Pocket guide aplikasi [Music therapy: Theory and to health assessment. Missouri: application]. Yogyakarta: Mosby Inc; 2002. Galangpress; 2006. 11. Anderson GC. Current knowledge 18. Kustio W. Pengaruh musik terhadap about skin-to-skin (kangaroo) care for respirasi bayi berat lahir rendah preterm infants. Journal of selama kangaroo mother care [Effect perinatology. 1991;11(3):216-226. of music on respiration of low birth 12. Putra HA. Efektifitas bunga rosella weight infants during kangaroo untuk penurunan tekanan darah pada mother care]. Jurnal Kebidanan dan pasien hipertensi di Desa Kedondong Keperawatan Aisyiyah. 2013;9(2): Kecamatan Kebonsari Kabupaten 175-182. Madiun [Effectiveness of roselle flower in lowering blood pressire in patients with hypertensin at Cite this article as: Yusuf N, Hadisaputro Kedondong Village Kebonsari S, Runjati, Suwondo A, Mashoedi ID, District Madiun regency]. Ponorogo, Supriyana. The effectiveness of Indonesia: Universitas combination of kangaroo mother care Muhammadiyah Ponorogo; 2013. method and lullaby music therapy on vital 13. Takahashi Y, Tamakoshi K, sign change in infants with low birth Matsushima M, Kawabe T. weight. Belitung Nursing Journal. Comparison of salivary cortisol, heart 2017;3(4): 352-359. https://doi.org/ rate, and oxygen saturation between 10.33546/bnj.161 early skin-to-skin contact with different initiation and duration times in healthy, full-term infants. Early

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Wiyatno ER, et al. Belitung Nursing Journal. 2017 August;3(4):360-369 Received: 17 May 2017 | Accepted: 31 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

EFFECT OF ACUPRESSURE ON QUALITY OF SLEEP AND PULSE RATE IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION

Eko Rustamaji Wiyatno*, Rr. Sri Endang Pujiastuti, Titin Suheri, Djenta Saha

Program Pascasarjana Magister Terapan Kesehatan Keperawatan, Politeknik Kesehatan Kementrian Kesehatan Semarang, Indonesia

*Corresponding author: Eko Rustamaji Wiyatno Program Pascasarjana Magister Terapan Kesehatan, Politeknik Kesehatan Kementrian Kesehatan Semarang Jl. Tirto Agung, Pedalangan, Banyumanik, Kota Semarang, Jawa Tengah, Indonesia (50268) E-mail: [email protected] ABSTRACT Background: Patients with acute myocardial infarction have a change in sleep pattern. Acupressure is identified as a therapy with the principle of healing to deal with sleep changes. Objective: To analyze the effect of acupressure on sleep quality and pulse rate in patients with acute myocardial infarction. Methods: This study employed a quasi-experiment study with non-randomized pretest-posttest with control group design. There were 50 respondents selected in this study, with 25 assigned in the intervention and control group using consecutive sampling. Quality Sleep Questionnaire and bedside monitor were used to measure sleep quality and pulse rate. Acupressure in combination of Neiguan point (PC 6), Shenmen (HT7), Sanyinjiao (SP6), Yintang (EX3) and Tay (EX5) was given as the nursing intervention in this study. Data were analyzed using paired t-test and independent t-test. Results: There was statistically a significant increase of quality of sleep and significant decrease of pulse rate in the intervention group with p-value 0.000 (<0.05). Conclusion: Acupressure has a significant effect on the increase of sleep quality and the decrease of pulse rate in patients with acute myocardial infarction. Thus, it is suggested that acupressure could be one of the nursing interventions for AMI patients to increase sleep quality and decrease of pulse rate.

Keywords: acupressure, acute myocardial infarction, sleep quality, pulse rate

INTRODUCTION Changes in lifestyle are major factors (WHO) data in 2012 showed that heart thought to influence susceptibility to disease was the leading cause of death in many diseases. Degenerative diseases are the world, causing 17.5 million deaths and often linked with the way people live their is expected to continue to increase to 22.2 life such as heart disease, stroke, and million by 2030.2 Acute myocardial obesity.1 World Health Organization infarction (AMI) disease is a type of

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Editor’s Note: This article has been updated on 12 July 2020 in terms of minor changes in the reference format. The update is based on BNJ policy on article correction. coronary heart disease that has high during hospitalization the number of morbidity and mortality rates. Data on the patients who had poor sleep quality was top ten causes of death in the world 45.6%, and after undergoing treatment showed that ischemic heart disease is the patients who had sleep quality was highest, which was 7.4 million deaths in decreased by 57.4%. 2012. The Center for Data and Sleep has an important role in Information Ministry of Health explained cardiovascular function, and sleep that the prevalence of coronary heart deprivation can lead to intensive anxiety, disease in 2013 based on medical irritability, and anger that increase heart diagnosis and symptoms was 1.5% or rate and myocardial oxygen need, which 2,650,340 people, while the number of may result in recurrence.7 Hemodynamic patients with coronary heart disease in manifestations in AMI patients may be East Java was 1.3% or 375,125 people.2 tachycardia or bradycardia.8 Heart rate The medical record data of ICCU in experienced tachycardia caused by acute the Hospital of Dr. Iskak Tulungangung pain and anxiety that increase the indicated that from January to August stimulation of the sympathetic nerve and 2016 AMI case was ranked first, with the adrenal hormones so that the pulse number of inpatients in ICCU room as increases.9 much as 43% with an average of 27 Decreased sleep quality needs to be patients per month.3 Based on the given serious attention in dealing with preliminary study with 8 patients AMI patients. Pharmacologic and non- diagnosed with myocardial infarction pharmacological methods can be used to stated that they have low quality of sleep. control sleep disorders. The Literature stated that critical patients pharmacological therapy used today is the admitted to intensive care have a tendency benzodiazepine drug class, however the to have sleep problems and circadian use of drugs has side effects such as patterns are impaired due to both hemodynamic decline, memory deficits, psychological and environmental factors.4 drug resistance and dependence when Patients with acute coronary have a used over a long period, whereas change in sleep patterns, with difficulty nonpharmacologic therapy is safer.7 Many starting and maintaining sleep, increasing non-pharmacologically independent reactive responses to stimuli, and nursing interventions can be given to decreased total sleep time, early stage of overcome sleep disorders as well as the deep sleep (Slow Wave Sleep) and REM negative impact felt by AMI patients such sleep. Sleep disorders in ICCU patients as dhikr,10 murotal,11 and acupressure.7,12 can be caused by interaction of patient Acupressure is a simple, cheap, easy care, disease severity, noise, mechanical to do, safe, and no side effects because it ventilation, pain, medication, or changes is not an invasive action.13 Acupressure is in circadian rhythm. very practical because it does not require The results of study of Schiza et al5 any equipment and enough with the hands indicated that revealed that approximately or fingers.14,15 Manual stimulation at the 56% of patients with sleep deprivation acupressure point is proven increasing and acute myocardial infarction on the serotonin and endorphin production and first day of hospitalization had low sleep contributing to increased serum cortisol quality in the first three days of regulation. Endorphin is a natural opiate hospitalization. Lei et al6 revealed that produced in the body, which triggers a

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 361 calming and stimulating response in the Shenmen (HT7), Sanyinjiao (SP6), body, has a positive effect on emotions, Yintang (EX3) and Tay (EX5) as the reduces anxiety, causes relaxation, nursing intervention in patients with improves sleep quality and normalizes decreased sleep quality and pulse body function,14 whereas serotonin has the elevation in AMI patients in ICCU. function of regulating mood and sleep.16 Therefore, this study aims to determine Empirical evidence of the effect of the effect of acupressure on quality of acupressure has been performed in several sleep and pulse rate in patients with acute studies. Masoumeh et al7 study revealed myocardial infarction. that that acupressure can have a therapeutic effect in improving sleep METHODS quality in ACS patients and has no side Design effects with p <0.001 and effect size 1.14. This study employed a quasi-experimental The intervention given in this study was study with non-randomized pretest- the acupressure at the point of Fengchi posttest with control group design, (GB 20), shenmen (HT7), yongquan conducted in the ICCU of Dr. Iskak (KL1), ying-tang (EX-3) with a duration Tulungagung hospital, East Java, of 18 minutes performed 1 times daily for Indonesia on January - February 2017. 3 days.7 Another study conducted by Shariati Population and sample et al15 indicated that acupressure in The target population in this study is all combining shenmen point (HT7), Hegu patients with acute myocardial infarction Li4) and Sanyinjiao (SP6) in 15 minutes (AMI) treated in the ICCU at Dr. Iskak for 3 times a week for 1 month showed Tulungagung hospital. Consecutive that there was a difference in sleep quality sampling was used to select the sample. between acupressure group and control There were 50 respondents selected in this group in hemodyalisis patients with p study, with 25 assigned in the intervention <0.001 and effect size 1.15. and control group. The inclusion criteria Based on the results of literature in this study were: 1) AMI patient aged ≥ review on acupressure therapy, it is 26 years, 2) able to communicate verbally, obtained that acupressure at 5 points with 3) had been treated at least 1 x 24 hours, combining the heart point of shen men and 4) did not take a sedative drug 4-5 (HT-7), the point of the neiguan heart hour before the intervention. The lining (PC-6), and the spleen point of san exclusion criteria were: 1) Patient in yin jiao (SP -6) has an effect on emergency/critical condition (shortness, improving the quality of sleep for those hypotension, shock, acute phase), 2) who have difficulty getting into sleep and unconscious, 3) patients with other sleep disturbances; and the special contraindications of acupressure: injured point of tay point (EX-5) and yintang skin, swelling and bone / fractures / (EX-3) gives a relaxed feeling.17 Selection fractures. of such intervention points is practical, easier to do, and the location of the Intervention selected point is easy to find and be Research was conducted by the researcher applied by the nurse. However, little is and an enumerator who have the known about the acupressure in competence to perform acupressure and combination of Neiguan point (PC 6), certified by the Association of

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Chiropractors and Akupresur Seluruh technique, which is a circular motion Indonesia (ACASI). Acupressure was opposite to the clock direction. The total performed at the point of Neiguan (PC 6), amount of massage time was ± 18 minutes Shenmen (HT7), Sanyinjiao (SP6), given 1 time a day before sleep at night Yintang (EX3) and tay (EX5) in the right between 20.00 to 22.00 pm for 2 days. and left body, so that the total number is 9 The control group in this study only acupressure points (See Figure 1). Each received treatment according to the point was performed for 2 minutes with standard of procedure of the ICCU in the the thumb of the right hand and sedation hospital.

Figure 1 Acupressure point for sleep quality improvement and pulse rate17

Instruments was detected. For the pulse rate, the Quality Sleep Questionnaire was used for bedside monitor was used, which was this study. This questionnaire is modified connected to the patients. The pulse value from the Pittsburgh Sleep Quality Index in the monitor represents the pulse (PSQI) and St.Mary's Hospital (SMH)18 frequency of the patient within a minute. sleep questionnaire adopted from Karota's study. Content validity of Quality Sleep Ethical consideration Questionnaire had been analyzed by 3 The study has met the ethical experts in Psychological Nursing, Sleep requirements of the Health Research and Medical & Gerontological Nursing Ethics Committee (K.EP.K) of Health from Prince of Songkla University, Polytechnic of Ministry of Health Thailand. Internal consistency of (Poltekkes) of Semarang with No. 284 / Cronbach's Alpha Coefficient of this KEPK / Poltekkes-Smg / EC / 2016. Prior questionnaire was 0.89.19 To distinguish to the research, respondents were given between good and poor sleep, researcher informed consent to provide information examined seven items of questions about the purpose, benefits and research including total hours of sleep at night, procedures. bedtime, frequency of awakened due to sleep disturbance, tired feeling of Data analysis drowsiness, wake up feeling fresh, sleep Data were processed and analyzed using depth and sleep satisfaction. A good or SPSS. Mean and frequency distribution bad score of sleep was identified by were described. Because data were in summing the score of items 1-7. If the normal distribution, paired t-test was score was ≤ 5, a good sleep quality was performed for paired group, and detected; if it was > 5, a poor sleep quality

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 363 independent t-test for unpaired group with them in the treatment and control group significant value <0.05. were males (88%; 84%), had elementary school background (52%; 60%), and RESULTS working in the private sectors (48%: Table 1 shows that the majority of the 40%). The homogeneity test showed p- respondents aged 41-59 years, which was value >0.05 in each variable, which means 60% in the treatment group with mean that there was no significant difference of 59.76 years old and 56% in the control respondents’ characteristics in the group with mean 59.88 years old. Most of intervention and control group.

Table 1 Homogeneity and distribution of respondents based on gender, age, education, and job and working status Intervention Control Variable p-value n % n % Age (years) 41-59 15 60.0 14 56.0 0.179 > 60 10 40.0 11 44.0 (Mean ± SD) (59.76 ± 10.647) (59.88± 8.880) Gender Male 22 88.0 21 84.0 0.425 Female 3 12.0 4 16.0 Educational level Elementary school 13 52.0 15 60.0 0.739 Junior high school 3 12.0 3 12.0 Senior high school 7 28.0 5 20.0 Graduate level 2 8.0 2 8.0 Job Not working 2 8.0 2 8.0 Farmer 8 32.0 12 48.0 0.563 Private 12 48.0 10 40 Civil servants, 3 12.0 1 4.0 Military/Police

Table 2 Frequency distribution of respondents based on the quality of sleep in patients with AMI Intervention Control Sleep Quality Pretest Posttest Pretest Posttest n % n % n % n % Good 0 0 18 72.0 0 0 0 0 Poor 25 100.0 7 28.0 25 100.0 25 100.0 (Mean±SD) 10.52±1.327 5.00±1.225 10.40±1.414 9.92±1.441

During pretest, both intervention of them had a good sleep quality and 28% and control groups had poor sleep quality had a poor quality. However, there was no (100%). But there was a sharply change of change of sleep quality in the control sleep quality during posttest in the group. intervention group. Of total patients, 72%

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Table 3 Frequency distribution of pulse rate in patients with AMI Group n Mean±SD Minimum Maximum Intervention group Pretest 25 89.68±11.142 70 108 Posttest 25 79.04±5.719 68 89 Control group Pretest 25 89.04±9.650 70 104 Posttest 25 86.60±6.916 70 96

As shown in the table 3, it can be pulse rate was 68 and the highest was 89. seen that the pulse rate before given While there was no change of the pulse intervention was 89.68 ± 11.142 with the rate during pretest and posttest in the lowest score was 70 and the highest was control group with the mean value of 108. There was a change in pulse rate posttest was 86.60±6.916, with the lowest after given intervention with a mean value value was 70 and the highest was 96. of 79.04 ± 5.719 with the lowest value of

Table 4 Quality of sleep in the intervention and control group using paired t-test Group Quality of n Mean SD t p-value Sleep Pretest 25 10.52 1.372 Intervention 22.461 0.000 Posttest 25 5.00 1.225 Pretest 25 10.40 1.414 Control 1.953 0.063 Posttest 25 9.92 1.441

Table 4 shows that there was no significant increase of the sleep quality statistically significant increase of quality in the control group with p-value 0.063 of sleep in the intervention group with p- (>0.05) value 0.000 (<0.05). However, there was

Table 5 Pulse rate in the intervention and control group using paired t-test Group Pulse rate n Mean SD t p-value Pretest 25 Intervention 89.68 11.142 6.725 0.000 Posttest 25 79.04 5.719 Pretest 25 89.04 9.650 Control 2.672 0.013 Posttest 25 86.60 6.916

Table 6 The difference in mean of sleep quality and pulse rate in posttest in the intervention and control group using independent t-test Posttest Variable n Mean ± SD t p-value Sleep quality Intervention group 25 5.00±1.225 13.008 0.000 Control group 25 9.92±1.441 Pulse rate Intervention group 25 79.04±5.719 4.212 0.000 Control group 25 86.60±6.916

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As shown in the Table 5, it is stimulus is sent to the center of the pons to indicated that there was statistically the midbrain (periaquedectus), then the significant decrease of pulse rate in the stimulus received by the periaquedectus intervention group and control group with conveyed to the hypothalamus, and from p-value 0.000, 0.013 (<0.05) respectively. this hypothalamus through the descending However, the decrease of the value of nerve pathway of the endorphin hormone pulse rate in the intervention group was secreted to blood vessels that provide (10.64) was higher than the pulse rate in a sense of calm, comfort and the control group (2.44). relaxation.14,20 Thus, this calm condition, Independent t-test as shown in the comfortable and relaxation will make table 6 shows p-value 0.000 (<0.05), respondents have the desire to sleep and which indicated that there were significant can achieve long and deep sleep duration differences in sleep quality and pulse rate (NREM 4th stage sleep).9 On the other between intervention and control group. hand, another effect of acupressure is to stimulate the release of serotonin hormone DISCUSSION that regulates mood, sleep, and muscle The results of this study revealed that contraction. Serotonin will act as a there was a significant effect of neurotransmitter that carries signals to the acupressure on the increase of the quality brain to activate the pineal gland of sleep in patients with acute myocardial producing the hormone melatonin, which infarction. This is consistent with the will affect the suprachiasmatic nucleus study in the increase of sleep quality in (SCN) in the anterior hypothalamus of the acute coronary syndrome patients (ACS) brain in circadian rhythm settings, after given acupressure intervention at resulting in decreased sleep latency, Fengchi point (GB 20), shenmen (HT7), nocturnal awakening, and an increase in yongquan (KL1), ying-tang (EX-3 ) with a total sleep time and sleep quality.16 duration of 18 minutes for 3 days.7 Acupressure is a therapy with the Similar results with the study conducted principle of healing touch that shows by Shariati et al15 indicated that there was more caring behavior on the respondents, an increase of sleep quality in 44 so as to provide feelings of calm, hemodialysis patients who were given comfortable, feelings that are more acupressure at combining shenmen point attention that can close the therapeutic (HT7), Hegu (Li4) and Sanyinjiao (SP6) relationship between researchers and for 15 minutes 3 times a week for a respondents. From the psychological month. In addition, literature stated that aspects, acupressure helps reducing the combination of the heart point of the anxiety of respondents.16 shen men (HT-7), the neiguan heart lining Additionally, acupressure as (PC-6), and the spleen point of san yin Chinese healing art and science is based jiao (SP-6) could decrease anxiety, and on the theory of equilibrium, which is a improve the sleep quality. While the other harmonious and proportional balance points of the tay (EX-5) and the yintang between the yin and yang elements. (EX-3) points provide a relaxed feeling.17 Acupressure interventions at the point of The increase of sleep quality in this cardiac, spleen and heart rest as well as study because the stimulation of sensory the intervention in this study will nerve cells at the acupressure point strengthen the energies of the spleen yin stimulates the nerve receptor in which the element and weaken the heart and heart

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 366 membrane elements. The occurrence of McFadden et al,23 acupressure yields the energy balance of the body will reduced heart rate greater (p = 0.043) and optimize the function and system of faster (p = 0.002) significantly more than organs so that there can be health placebo acupressure during treatment. improvements including sleep quality, prevention, healing and recovery from CONCLUSION illness.17 Based on the results of this study, it can Besides, findings of this study also be concluded that acupressure has a revealed there was a significant decrease significant effect on the increase of sleep of pulse rate after given acupressure quality and the decrease of pulse rate in intervention. In this regard, acupressure patients with acute myocardial infarction. can promote blood circulation and Qi, Thus, it is suggested that acupressure harmony of yin and yang, and the could be one of the nursing interventions secretion of neurotransmitters, thereby for AMI patients to increase sleep quality maintaining normal functioning of the and decrease of pulse rate. Further human body and providing comfort.15 research is needed to determine the Furthermore, manual stimulation of duration of effectiveness of acupressure in acupressure points has been shown to AMI patients. increase serotonin and endorphin production, which have a positive effect Declaration of Conflicting Interest on emotional stability, and lead to None declared. relaxation and normalization of body functions. As a result, vital signs such as Funding heart rate, breathing rhythm, and blood This study was supported by Program 14 Pascasarjana Magister Terapan Kesehatan pressure will be balanced. Keperawatan, Politeknik Kesehatan Kementrian In addition, the relaxation state due Kesehatan Semarang, Indonesia. to stimulation at the acupressure point is physiologically related to neural branches Author Contribution of sympathetic and autonomous or central All authors contributed equally in this study. nervous system. Relaxation will inhibit the increase of sympathetic nerves, so the References hormone that causes body dysregulation 1. Bild DE, McClelland R, Kaufman can be reduced. The parasympathetic JD, et al. Ten-year trends in nervous system that works against the coronary calcification in sympathetic nerve will slow or weaken individuals without clinical the body's internal workings.21 Thus, there cardiovascular disease in the is a decrease in vital signs such as heart multi-ethnic study of rate, breathing rhythm and blood pressure, atherosclerosis. PloS one. and muscle tension. However, the findings 2014;9(4):e94916. of this study is in line with the study of 2. Mendis S. Global status report on wang et al which states that there is a noncommunicable diseases 2014: decrease in pulse after acupressure at the Geneva: World health shenmen point (HT7) for 15 seconds 3 organization; 2014. times every 10 minutes with value (p 3. Ministry of Health. Situasi <0.05) in patients with chronic kesehatan jantung [Heart insomnia.22 Similarly, in the study of condition situation]. Jakarta: Pusat

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Data dan Informasi Kementerian 11. Setiawan FA. Pengaruh terapi Kesehatan Republik Indonesia; Murottal AlQuran terhadap 2014. kualitas tidur pasien di ICU RSUD 4. Chen J-H, Chao Y-H, Lu S-F, Panembahan Senopati Bantul Shiung T-F, Chao Y-F. The [Effect of Murottal AlQuran effectiveness of valerian therapy on sleep quality of patients acupressure on the sleep of ICU at ICU of Panembahan Senopati patients: A randomized clinical Hospital Bantul]. Yogyakarta: trial. International Journal of STIKES Jenderal A. Yani; 2015. Nursing Studies. 2012;49(8):913- 12. Widyatuti W. Terapi 920. komplementer dalam keperawatan 5. Schiza SE, Simantirakis E, [Complementary therapy in Bouloukaki I, et al. Sleep patterns nursing]. Jurnal Keperawatan in patients with acute coronary Indonesia. 2008;12(1):53-57. syndromes. Sleep Medicine. 13. Fengge A. Terapi akupresur: 2010;11(2):149-153. Manfaat dan teknik pengobatan 6. Lei Z, Qiongjing Y, Qiuli WU, [Acupressure therapy: Benefits Sabrina K, Xiaojing L, Changli W. and tratment technique]. Sleep quality and sleep disturbing Yogyakarta: Crop Circle Corp; factors of inpatients in a Chinese 2012. general hospital. Journal of 14. Hmwe NTT, Subramanian P, Tan Clinical Nursing. 2009;18(17): LP, Chong WK. The effects of 2521-2529. acupressure on depression, anxiety 7. Heydari Gorji MA, Rezaie S, and stress in patients with Pouresmail Z, Yazdani Chorati J. hemodialysis: A randomized The effect of acupressure on the controlled trial. International quality of sleep in patients with Journal of Nursing Studies. acute coronary syndrome in 2015;52(2):509-518. Cardiac Care Unit. Journal of 15. Shariati A, Jahani S, Hooshmand Critical Care Nursing. M, Khalili N. The effect of 2014;7(1):7-14. acupressure on sleep quality in 8. Aaronson PI, Ward JPT. At a hemodialysis patients. glance cardiovascular system. Complementary Therapies in Juwalita S, translator. Jakarta: Medicine. 2012;20(6):417-423. Erlangga; 2010.. 16. Majid YA, Fatimah S, Susanti RD. 9. Potter PA, Perry AG. Buku ajar Pengaruh akupresur terhadap fundamental keperawatan: kualitas tidur lansia di Balai Konsep, proses, dan praktik Perlindungan Sosial Tresna [Fundamental of nursing textbook: Werdha Ciparay [Effect of Concept, process, and practice]. acupressure on sleep quality of Jakarta: EGC; 2005. elderly in Balai Perlindungan 10. Sukarni S, Mardiyono M, Parwati Sosial Tresna Werdha Ciparay]. MDW. 4T Zikr in anxiety Bandung: Universitas Padjadjaran; reduction in acute coronary 2014. syndrome patients. Jurnal Riset 17. Sukanta PO. Pijat akupresur untuk Kesehatan. 2014;3(2):567-575. kesehatan [Acupressure massage

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for health]. Jakarta: Penebar Plus; Wolters Kluwer Health/Lippincott 2008. Williams & Wilkins.; 2008. 18. Buysse DJ, Reynolds CF, Monk 22. Wang L, Cheng W, Sun Z, et al. TH, Berman SR, Kupfer DJ. The Ear acupressure, heart rate, and Pittsburgh sleep quality index: a heart rate variability in patients new instrument for psychiatric with insomnia. Evidence-Based practice and research. Psychiatry Complementary and Alternative Research. 1989;28(2):193-213. Medicine. 2013;2013. 19. Bukit EK. Kualitas tidur dan 23. McFadden KL, Hernández TD. faktor-faktor gangguan tidur klien Cardiovascular benefits of lanjut usia yang dirawat inap di acupressure (Jin Shin) following ruang penyakit dalam rumah sakit, stroke. Complementary Therapies Medan 2003 [Sleep quality and in Medicine. 2010;18(1):42-48. sleep disorder factors in elderly clients in the medical ward of hospital, Medan 2003]. Jurnal Cite this article as: Wiyatno ER, Keperawatan Indonesia. Pujiastuti RSE, Suheri T, Saha D. 2005;9(2). Effect of acupressure on quality of 20. Stratton SA. Role of endorphins in sleep and pulse rate in patients with pain modulation. Journal of acute myocardial infarction. Belitung Orthopaedic & Sports Physical Nursing Journal. 2017;3(4): 360-369. Therapy. 1982;3(4):200-205. https://doi.org/10.33546/bnj.162 21. Corwin EJ. Handbook of pathophysiology. Philadelphia:

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Wulandhari A, et al. Belitung Nursing Journal. 2017 August;3(4):370-375 Received: 1 March 2017 | Accepted: 31 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

EFFECT OF FE-FORTIFIED TEMPE ON HEMATOLOGIC STATUS IN PREGNANT MOTHERS WITH ANEMIA

Anggraini Wulandhari*, Supriyana, Bahiyatun, Soeharyo Hadisaputro, Imam Djamaluddin Mashoedi

Magister Applied Midwifery, Poltekkes Kemenkes Semarang, Indonesia

*Corresponding author: Anggraini Wulandhari Magister Applied Midwifery, Poltekkes Kemenkes Semarang, Indonesia Jl. Tirto Agung, Pedalangan, Banyumanik, Kota Semarang, Jawa Tengah, Indonesia (50268) E-mail: [email protected]

ABSTRACT Background: The prevalence of anemia among pregnant mothers is still high in Indonesia. Fe-fortified tempe is a traditional soy product originating from Indonesia considered able to increase hematologic status. Objective: This study aims to determine the effect of Fe-fortified tempe on hemoglobin, hematocrit, and erythrocyte levels in pregnant women with anemia. Methods: This was a true-experimental study with randomized pretest and posttest control group design, conducted on November - December 2016 in Bandarharjo Health Center, Semarang, Indonesia. Sixty-eight respondents were selected using simple random sampling, with 34 respondents were randomly assigned to each group. Blood examination was performed in each respondent. Mean, percentage, and frequency distribution of respondents were described. Paired t test and independent t test with α = 0.05 were performed to analyze the data. Result: Findings showed that hemoglobin, hematocrit, and erythrocyte levels before and after intervention in the treatment group showed p-value 0.000 (< 0.05), which means there was a significant effect of Fe-fortified on the increase of hemoglobin, hematocrit, and erythrocyte levels. Conclusion: There was an increase in hemoglobin, hematocrit, and erythrocyte levels after given Fe-fortified tempe for 10 consecutive days. It is suggested that pregnant women can consume Fe-fortified tempe.

Keywords: Fe-fortified tempe, hemoglobin, hematocrit, erythrocyte, anemia

INTRODUCTION During pregnancy, anemia is defined as a approximately 37.1%, while in Central hemoglobin concentration (Hb) <110 g/L Java Province is 57.7%; and 18.36% in (< 11 g/dL), affects more than 56 million Semarang. The Community Health Center women globally, two thirds of them being of Bandarharjo reported 26.78% of the from Asia.1 The prevalence of anemia in prevalence of anemia. pregnant women in Indonesia is

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Editor’s Note: This article has been updated on 12 July 2020 in terms of minor changes in the reference format. The update is based on BNJ policy on article correction. Iron deficiency is a leading cause of to see the effect of Fe-fortified tempe for anemia in many parts of the world.2 Iron anemia. is an essential element in the production Sudargo revealed that tempe fortification of hemoglobin for the transport of oxygen can significantly increase hemoglobin to tissues and in the synthesis of enzymes levels in Wistar rats.7 The higher the that are required to use oxygen for the amount of fortified tempe given, the production of cellular energy.3 Iron greater the hemoglobin level in the blood deficiency anemia detected in early of the Wistar rat. Followed by Salmiah pregnancy is associated with a lower who modified tempe fortification into a energy and iron intake, resulting in an form of cake and proved to increase inadequate gestational weight gain over hemoglobin levels in children with iron the whole pregnancy, and a greater than deficiency anemia.8 two-fold increase in the risk of preterm delivery.1,4 METHODS In Indonesia, the management of Design iron-deficiency anemia cases is A true experiment with randomized pharmacologically performed by the pretest and posttest control group design. administration of 90 Fe tablets during pregnancy to raise the level of Setting hemoglobin 1 gr/dL per month.5 The The study was conducted on November - program has been well executed, as December 2016 in Bandarharjo Health evidenced by the relatively high Fe Center, Semarang. coverage. However, the incidence of anemia is still high, which may be caused Sample by the obedience of pregnant women in Sixty-eight respondents were selected consuming the Fe tablets. Besides, Fe using simple random sampling, which 34 tablets can cause side effects such as respondents were randomly assigned to discomfort in the pit of the stomach, each group. Pregnant mothers in trimester nausea, vomiting, diarrhea, colic, III were included to be respondents in this dizziness, and constipation, but not study. The exclusion criteria were: a) harmful.6 In other words, side effects pregnant women with complications such actually make them feel uncomfortable. as pre-eclampsia / eclampsia, placenta Therefore, alternative treatment might be previa, solution placenta, and others, b) needed. pregnant women who had hemoglobin The aim of the study was to provide formation disorders (e.g. thalassemic, alternative food, namely Fe-fortified hereditary hemolytic, and sickle cell tempe, to increase maternal hematologic anemia), c) pregnant women aged <20 status in pregnancy. Fe-fortified tempe is years and > 35 years old, d) pregnancy a traditional soy product originating from spaced <2 years, e) parity > 5, and f) mid- Indonesia that made by a natural culturing upper arm circumference <23.5 cm. and controlled Rhizopus sp. fermentation of soybean into a cake form, and added by Intervention Fe micronutrients. Tempe is very popular Blood tests were performed before the food in Indonesia. However, limited intervention (pretest), then the studies have been found in the literatures respondents were given the Fe-fortified tempe in the treatment group, and the Fe

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 371 tablet in the control group for 10 Ethical consideration consecutive days. After that a second Ethical consideration was obtained from blood test was performed again after the the Ethics Committee of Poltekkes treatment (posttest). Fe-fortified tempe in Kemenkes Semarang with number 269 / this study was given in the form of sari KEPK / Poltekkes-SMG / EC / 2016. tempe, which had been steamed, blended Researchers confirmed that all until smooth, and filtered to obtain the respondents have obtained an appropriate filtrate, then heated again to improve the informed consent. taste. Sari tempe was given as much as 200 ml per day for 10 consecutive days, Data analysis with the reason that the basic process of Mean, percentage, and frequency hemoglobin synthesis takes about 7-10 distribution of respondents were days until it becomes mature and ready to described. Paired t-test and independent t- be circulated to the whole body with red test with α = 0.05 were performed to blood cells. Provision of sari tempe was analyze the data. done by researchers and assisted by 5 enumerators. RESULTS Table 1 shows the frequency distribution Instrument of respondents based on maternal age, Blood examination was performed in parity, gestational age, education level, Clinical Pathology Laboratory of employment status, and nutritional status. Muhammadiyah University of Semarang The result of equality test shows that all using BC-2600 Auto Hematology variables had p-value > 0.05, which Analyzer to measure the levels of means that all variables did not influence hemoglobin, Hematocrit, and the relationship between treatment to the erythrocytes. levels of hemoglobin, hematocrit, and erythrocytes in the respondents, both in the treatment and control group.

Table 1 Frequency distribution of the characteristics of respondents Respondents Group p-value Characteristics Treatment Control Maternal Age (year) Mean ± SD 27.88±4.611 26.82±4.635 0.856 Parity Primipara 26.5% 41.2% 0.305 Multipara 73.5% 58.8% Gestational age (week) Mean ± SD 32.76±2.686 32.56±2.596 0.988 Educational level High 17.6% 11.8% 0.418 Middle 26.5% 41.2% Low 73.5% 47.1% Employment Status Employed 26.5% 35.3% 0.600 Unemployed 73.5% 64.7% Nutritional status According to diet 58.8% 67.6% 0.615 Not according to diet 41.2% 32.4%

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Table 2 Levels of hemoglobin, hematocrit, and erythrocytes in pregnant women with anemia before and after intervention in the treatment and control group Group Variable Mean±SD Treatment Control p-value (n=34) (n=34) Pretest 10.21±0.52 10.36±0.40 0.184 b Hemoglobin Posttest 10.73±0.49 10.84±0.46 0.402 b (g/dL) Mean difference 0.52±0.33 0.47±0.28 p-value 0.000a 0.000 a Pretest 31.08±1.93 30.52±1.52 0.191 b Posttest 32.97±1.72 32.30±1.60 0.102 b Hematocrit (%) Mean difference 1.89±0.83 1.78±0.88 p-value 0.000a 0.000 a Pretest 3.84±0.32 3.83±0.31 0.942 b Erythrocytes (x Posttest 4.13±0.35 4.04±0.32 0.258 b 106/uL) Mean difference 0.29±0.09 0.20±0.06 p-value 0.000a 0.000 a aPaired t test, bIndependent t-test

Based on the result of paired t-test, determined from 28 to 48 percent for hemoglobin, hematocrit, and erythrocyte pregnant women in the third semester.12 levels before and after intervention in the The results of this study revealed treatment and control group showed p- that there was a significant increase in value 0.000 (< 0.05), which means there hemoglobin (0.52 gr/dL), hematocrit was a significant effect of Fe-fortified on (1.89%), and erythrocytes (0.29x 106/uL) the increase of hemoglobin, hematocrit, after given Fe-fortified tempe for 10 and erythrocyte levels. However, consecutive days. The results of this study Independent t-test showed p-value >0.05, was in line with earlier findings of which indicated that there was no Salmiah who modified tempe fortification difference of hemoglobin, hematocrit, and into a form of cake and proved to increase erythrocyte count between the treatment hemoglobin levels in children with iron and control group after given intervention. deficiency anemia.8 Similar with the study of Martorell, et al13 who suggested that DISCUSSION iron fortified foods may decrease the Measuring hemoglobin and hematocrit is prevalence of anemia and increase common during pregnancy.9 Hemoglobin hemoglobin levels in women and children. (Hb) is the protein contained in red blood Iron in Fe-fortified tempe is an cells or erythrocytes that is responsible for essential micro mineral in the formation delivery of oxygen to the tissues.10 To of hemoglobin level. Hemoglobin is ensure adequate tissue oxygenation, a composed of four polypeptide chains of sufficient hemoglobin level must be globins that each of which contains heme maintained. When the hemoglobin level is molecules.14 There are various proteins low, the patient has anemia.10 Pregnant with important roles in cellular physiology women with hemoglobin levels less than that require iron to operate their 11.0 g/dl in the first and third trimesters functions.14 and less than 10.5 g/dl in the second However, although there was no trimester are considered anemic.11 While difference between the effect of Fe- normal values of hematocrit have been fortified tempe and Iron supplement

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 373 tablet, the result of this study indicated 2. Banhidy F, Acs N, Puho EH, Czeizel that tempe alone could improve the levels AE. Iron deficiency anemia: of hemoglobin, hematocrit, and pregnancy outcomes with or without erythrocytes. iron supplementation. Nutrition. Fe-fortified tempe remains 2011;27(1):65-72. 3. Bendich A. Preventive nutrition: the comparable with iron supplementation comprehensive guide for health although it almost universally professionals. Berlin, Germany: recommended during pregnancy to Springer Science & Business Media; 15,16 prevent iron deficiency. However, the 2013. absorption depends on the form of iron 4. Scholl TO, Hediger ML, Fischer RL, ingested and the composition of the diet Shearer JW. Anemia vs iron (tea and phytates inhibit absorption).17 deficiency: Increased risk of preterm Heme iron is more efficiently absorbed delivery in a prospective study. The than nonheme iron, but it is available only American Journal of Clinical from animal foods that generally are Nutrition. 1992;55(5):985-988. relatively expensive and therefore less 5. Ministry of Health of Indonesia. Pedoman operasional likely to be consumed by poor women in 15 penanggulangan anemia gizi di developing countries, including Indonesia [Operational guideline of Indonesia. Thus, the findings of this study anemia management in Indonesia]. provide an alternative treatment for those Jakarta: Direktorat Pembinaan who do not tolerate with oral iron Kesehatan Masyarakat. Ministry of supplement tablet. Health of Indonesia; 1998. 6. Rukiyah AY, Yulianti L. Asuhan CONCLUSION kebidanan IV (patologi kebidanan) There was an increase in hemoglobin, [Midwifery care IV (midwifery hematocrit, and erythrocyte levels after pathology)]. Jakarta: Trans Info given Fe-fortified tempe for 10 Media; 2010. 7. Sudargo T, Nisa FZ, Helmiyati S, consecutive days. It is suggested that Kusuma RJ, Arjuna T, Septiana RD. pregnant women can consume Fe-fortified Tempeh with iron fortification to tempe. overcome iron deficiency anemia. Pakistan Journal of Nutrition. Declaration of Conflicting Interest 2013;12(9):815-820. None declared. 8. Salmiah. Influence of consume cake base on tempe formula by fortified fe Funding for child under five years old anemia This study was supported by Magister of Fe. Makssar, Indonesia: Applied Midwifery, Poltekkes Kemenkes Universitas Hasanuddin; 2014. Semarang, Indonesia. 9. Khoigani MG, Goli S, HasanZadeh A. The relationship of hemoglobin Author Contribution and hematocrit in the first and second All authors contributed equally in this study. half of pregnancy with pregnancy outcome. Iranian Journal of Nursing References and Midwifery Research. 2012;17(2 1. Goonewardene M, Shehata M, Suppl1):S165. Hamad A. Anaemia in pregnancy. 10. Billett HH. Hemoglobin and Best Practice & Research Clinical hematocrit. In: Walker HK, Hall WD, Obstetrics & Gynaecology. Hurst JW, eds. Clinical methodsL The 2012;26(1):3-24. history, physical and laboratory

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examinations. 3rd ed. Boston: 14. Gropper SS, Smith JL. Advanced Butterworths; 1990. nutrition and human metabolism: 11. Tabrizi FM, Barjasteh S. Maternal Boston: Cengage Learning; 2012. hemoglobin levels during pregnancy 15. Sloan NL, Jordan E, Winikoff B. and their association with birth weight Effects of iron supplementation on of neonates. Iranian Journal of maternal hematologic status in Pediatric Hematology and Oncology. pregnancy. American Journal of 2015;5(4):211. Public Health. 2002;92(2):288-293. 12. Abbassi-Ghanavati M, Greer LG, 16. UNICEF/WHO. Preventing iron Cunningham FG. Pregnancy and deficiency in women and children: laboratory studies: A reference table technical consensus on key issues. for clinicians. Obstetrics & New York: UNICEF/WHO; 1998. Gynecology. 2009;114(6):1326-1331. 17. Rosso P. Nutrition and metabolism in 13. Martorell R, Ascencio M, Tacsan L, pregnancy: mother and fetus. Oxford: et al. Effectiveness evaluation of the Oxford University Press; 1990. food fortification program of Costa Rica: Impact on anemia prevalence Cite this article as: Wulandhari A, and hemoglobin concentrations in Supriyana, Bahiyatun, Hadisaputro S, women and children. The American Mashoedi ID. Effect of Fe-fortified tempe on Journal of Clinical Nutrition. hematologic status in pregnant mothers with 2015;101(1):210-217. anemia. Belitung Nursing Journal. 2017;3(4): 370-375. https://doi.org/10.33546/bnj.157

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Suminar IT, et al. Belitung Nursing Journal. 2017 August;3(4):376-382 Received: 12 June 2017 | Accepted: 3 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

RELATIONSHIP BETWEEN NURSE SUPPORTS AND FEARS OF HOSPITALIZED SCHOOL AGE CHILDREN IN PKU MUHAMMADIYAH HOSPITAL, YOGYAKARTA, INDONESIA

Istinengtiyas Tirta Suminar*, Indria Laksmi Gamayanti, Lely Lusmilasari

School of Nursing Faculty of Medicine, Universitas Gadjah Mada, Indonesia

*Corresponding author: Istinengtiyas Tirta Suminar School of Nursing Faculty of Medicine, Universitas Gadjah Mada, . Jl. Farmako, Senolowo, Sekip Utara, Kec. Depok, Kabupaten Sleman, Daerah Istimewa Yogyakarta 55281, Indonesia. E-mail: [email protected]

ABSTRACT Background: Being hospitalized is usually related to the fear, especially for children. Nurse supports should be able to help the children to deal with the fears related to nurse and medical services. Objective: This study aims to examine the relationship between nurse support and the fear of school-age children being treated in the PKU Muhammadiyah hospital, Yogyakarta. Methods: This study employed a cross sectional correlation design, which was conducted from October to December 2016 in PKU Muhammadiyah Hospital, Indonesia. The samples of the study were 49 mothers and school-aged children who were admitted to the children ward. A consecutive sampling was applied to determine sample size. The instruments used in this study were nurse support and CMFS-R (Child Medical Fear Survey- Revised) questionnaires. Chi square test was performed with significance level p = 0.05 and level of trust = 95% for data analysis. Results: Findings showed 42.9% of respondents had medical fear and 36.7% of them had medical fear related- behavior responses. The nurse support was in a high category (73.5%). Chi square test showed p-value 0.038 (>0.05), which indicated that there was statistically no significant relationship between nurse support and children fear. There was only age of the children had a significant relationship with fear with p-value 0.035 (<0.05). Conclusions: There was no significant association between nurse support and fear of school-age children.

Keywords: nurse support, fear, hospitalization

INTRODUCTION Hospitalization is admittance to the surgery; emergency medical treatment; hospital as a patient.1 Patients are admitted administration of medication; or to to the hospital for a variety of reasons, stabilize or monitor an existing condition.1 including scheduled tests, procedures, or Being hospitalized is not an easy or a

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Editor’s Note: This article has been updated on 13 July 2020 in terms of the completeness of correspondence address. The update is based on BNJ policy on article correction. regular occurrence, and may even be study with cross-sectional design. The terrifying, traumatic, to the child. subjects of this study were mothers and Hospitalization is a stressful event with school-aged children who were potential untoward consequences for hospitalized in the children's ward of PKU children and their families, which triggers Muhammadiyah Yogyakarta Hospital. the emergence of a fear reaction in children.2 Sample The fearful reaction that arises in There were 49 children selected using relation to this hospitalization process is a consecutive sampling. The inclusion normal response to the child. Child criteria of the samples were the children expresses his/her fear by crying, shouting, aged 6-12 years who have been saying verbally, mocking around, as well hospitalized at least 1x24 hours, full as expressing fears around him through a consciousness and able to communicate drawing object.3 verbally or non-verbally, their mothers Fear of school-aged children during were able to read and write Latin letters in the hospitalization process can be the Indonesian language, and agreed to let attributed to or influenced by several their children became respondents of the factors. Getting a shot/bodily injury is the study. most feared thing for school-aged children during hospitalization.4 This fear, if not Instruments observed, will have a negative impact on The instruments used in this study were a the child's perception, health care, and nursing support questionnaire modified health care workers. Some children from Suwanti (2010)10 based on Friedman reported physical symptoms (60%), (2008)11, a fear questionnaire to measure negative thoughts (81%), and avoidance fear of school-aged children modified from behavior (75%) when meeting with the Child Medical Fear Survey Revised most fear situation or stimulus.5 Thus, (CMFS-R), and observation sheet of support from health care teams, especially child's fear referring to Ramdaniati nurses, is one of the things that families (2011)12. Validity and reliability of nurse and children needed during the support and fear instruments were tested at hospitalization process. The nurse support 30 respondents prior to data collection. can help the child deal with the fear of The results showed good validity and separation associated with hospital care, reliability with correlation coefficients r = especially during painful procedures.6-9 0.39-0.70 and Cronbach alpha at intervals However, little is known about the of 0.832-0.901. study of children fear during hospitalization in Indonesia, especially in Data analysis Yogyakarta. Therefore, this study aimed to Data were analyzed using univariate and examine the relationship of nurse support bivariate analysis using SPSS. The chi- with the fear of school-aged children being square test was used to see the relationship hospitalized in the child's ward. between variables.

Ethical consideration METHODS Ethical approval was obtained from the Study design Ethics Committee of Faculty of Medicine, The study was conducted from 17 October Gadjah Mada University in September to 18 December 2016, using correlation 2016. Prior to the data collection, informed

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 377 consents were obtained from the respondents aged 6-9 years and 22.4% respondents aged 10-12 years. The ratio between boys and girls was not much difference, and RESULTS 49% of them have never been hospitalized Of 49 respondents included in this study, before. Most of them (71.4%) had a short as shown in the Table 1, 77.6% of duration of stay.

Table 1 Characteristic of the school age children (n=49) Frequency Characteristics n % 6-9 years 38 77.6 Age 10-12 years 11 22.4 Female 22 44.9 Gender Male 27 55.1 Hospitalization Yes 25 51.0 experience No 24 49.0 Short (≤2 days) 35 71.4 Length of stay Long (>2 days) 14 28.6

Table 2 Characteristic of parents (n=49) Frequency Characteristics n % Family income Under Regional Minimum Wage 10 20.4 Above Regional Minimum Wage 39 79.6 Mother’s Primary education (Elementary to 5 10.2 education junior high school) Secondary education (High 29 59.2 School) College education 15 30.6

Table 2 shows that the majority of parents (59.2%) had secondary background (79.6%) had family income above the education. regional minimum wage and half of them

Table 3 Distribution frequency of nurse support (n=49) Frequency Attributes n % Information and Moderate 16 32.7 Communication Support High 33 67.3 Emotional Support Moderate 5 10.2 High 44 89.8 Appraisal Support Moderate 15 30.6 High 34 69.4 Instrumental Support Low 2 4.1 High 47 95.9 Total Moderate 13 26.5 High 36 73.5

Table 3 shows that nurse supports in terms instrumental information (95.9%) were of communication (67.3%), emotional mostly in the high category. The total (89.8%), appraisal (69.4%), and percentage of nurse support was 73.5.

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Table 4 Distribution frequency of child medical fear scale (n=49) Frequency Characteristics n % Child Medical Fear No fear 28 57.1 Fear 21 42.9 Medical Fear related- No fear 31 63.3 behavior responses Fear 18 36.7

Table 5 Child medical fear scale items (n=49) Not at all A little A lot Specific Fears (%) (%) (%) Hurting myself 8 (16.3) 28 (57.1) 13 (26.5) Getting an injection 12 (24.5) 16 (32.7) 21 (42.9) Seeing blood come out of me 16 (32.7) 24 (49) 9 (18.4) Going to the hospital 25 (51) 14 (28.6) 10 (20.4) Having my finger stuck 13 (26.5) 15 (30.6) 21 (42.9) Missing school if I am sick 5 (10.2) 22 (44.9) 22 (44.9) Crying when I get hurt 10 (20.4) 24 (49.0) 15 (30.6) Having to stay a long time 11 (22.4) 16 (32.7) 22 (44.9) My friends/family will know if I am sick 30 (61.2) 16 (32.7) 3 (6.1) Being away from my family 5 (10.2) 20 (40.8) 24 (49) Doctors put a tongue blade in my mouth 4 (8.2) 21 (42.9) 24 (49) Talking to strangers at the hospital 33 (67.3) 12 (24.5) 4 (8.2) Doctors / nurses say not to shout or cry 23 (46.9) 24 (49) 2 (4.1)

Table 4 shows that children fear in both injection (42.9%), having a finger stuck medical fear and fear behavior responses (42.9%), missing school (44.9%), long- are mostly in the non-fear category. While term stay (44.9%), being away from family table 5 shows that the majority of sources (49%), being afraid of doctors’ tongue of fear of school-age children related to depressor (49%). medical services included fear of getting

Table 6 Relationship between characteristics of children and child medical fear (n=49) Medical fear related- Child medical fear Characteristics of children p value behavior responses p value No Fear Fear No Fear Fear n % n % n % n % 6-9 years 21 55.36 17 44.7 0.737 21 55.3 17 44.7 0.038* Age 10-12 years 7 3.6 4 36.4 10 90.9 1 9.1 Female 13 59.1 9 40.9 0.804 14 63.6 8 36.4 0.961 Gender Male 15 55.6 12 44.4 17 63 10 37

Hospitalization Yes 17 68 8 32 0.117 16 64 9 36 0.913 experience No 11 45.8 13 54.2 15 52.5 6 37.5 Length of Short (≤2 days) 21 60 14 40 0.523 21 60 14 40 0.453 stay Long (>2 days) 7 50 7 50 10 71.4 4 28.6 *significant if p value<0.05

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Table 7 Relationship between characteristics of family and child medical fear (n=49) Child medical fear Medical fear related- Characteristics of parent p value behavior responses p value No Fear Fear No Fear Fear n % n % n % n % Family Low 8 80 2 20 7 70 3 30 0.155 0.726 income High 20 51.3 19 48.7 24 61.5 15 38.5 Mother’s Primary and education secondary 3 60 2 40 1.000 2 40 3 60 0.342 education Collage 25 56.8 19 43.2 29 65.9 15 34.1 education

From children characteristics (age, gender, hospitalization experience, and length of stay), and parental characteristics (family income and mother’s education) as shown in Table 6 and 7, only age of the children had a significant relationship with fear with p-value 0.035 (<0.05).

Table 8 Relationship between nurse support and child medical fear (n=49) Nurse Support Child medical fear Medical fear related- (4 dimensions) p value behavior responses p value No Fear Fear No Fear Fear n % n % n % n % Moderate 6 46.2 7 53.8 0.350 8 61.5 5 38.5 1.000 High 22 61.1 14 38.9 23 63.9 13 36.1

Table 8 shows that there were no Findings of this study revealed that significant relationships between nurse the majority of sources of fear of school- supports (both moderate and high age children related to medical services supports) with child medical fear and included fear of getting injection, having a medical fear related-behavior responses finger stuck, missing school, long-term with p-value 0.350 and 1.000 (<0.05) stay, being away from family, being afraid of doctors’ tongue depressor. The fear of DISCUSSION separation from family or parents is the The experience of being hospitalized is highest score of fear in this study. usually a fear-provoking and even The fear of the highest score is the traumatic experience for children. In this fear of separation from parents, which in study, 42.9% of respondents had medical line with the previous study stated that fear and 36.7% of them had medical fear being away from parents a very difficult related-behavior responses. This is in line experience for the children.15,16 It might with Monteiro et al. found that a small be normal, but the strategies to avoid percentage of school-aged children have a persistent separation is necessity.16 With high degree of fear and almost all have the nurse supports during hospitalization, moderate fears during hospitalization.13 It children might be able to deal with the is also similar to Ginimol revealed that fear of nursing and medical interventions most of the school-aged children have a and have more confidence in their daily low fear and a small percentage of behavior in facing the situation/stressor in children have moderate fear during hospitalization. As Ratna stated that the hospitalization.14 support obtained by someone is able to improve the life and health of someone.17

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In contrast, the results of this study References revealed that nurse support was 1. Encyclopedia of Children's Health. significantly not related to children fears Hospitalization. 2016; http://www.health (p>0.05). But, based on the descriptive ofchildren.com/G-H/Hospitalization. results as shown in the Table 8, it could be html. Accessed 17 August, 2016. 2. Rokach A. Psychological, emotional and seen that the percentage of non-fear physical experiences of hospitalized condition is much higher in the children children. Clinical Case Reports and who received high support compared with Reviews. 2016;2(4):399-401. those who received moderate support. 3. Salmela M, Salanterä S, Aronen ET. Thus, it can be explained that the Coping with hospital‐related fears: meaningless relationship of nurse support experiences of pre‐school‐aged children. with fear and fear related- behavior of Journal of Advanced Nursing. children statistically occurred due to 2010;66(6):1222-1231. several things, such as lack of sample size, 4. Mahat G, Scoloveno MA, Cannella B. influence of intervening variables and Comparison of children's fears of outliers, and etc. medical experiences across two cultures. Journal of Pediatric Health Care.

2004;18(6):302-307. CONCLUSION 5. Muris P, Merckelbach H, Collaris R. It can be concluded that the fear of Common childhood fears and their children in this study was in the low origins. Behaviour Research and category, and the support from nurses Therapy. 1997;35(10):929-937. remains high. However, there was no 6. LeRoy S, Elixson EM, O’Brien P, Tong significant relationship between nurse E, Turpin S, Uzark K. Recommendations supports and the fear in school-age for preparing children and adolescents children in PKU Muhammadiyah for invasive cardiac procedures. Yogyakarta. Further research is needed to Circulation. 2003;108(20):2550-2564. examine other internal and external 7. Rennick JE, Morin I, Kim D, Johnston CC, Dougherty G, Platt R. Identifying factors related to the child medical fears children at high risk for psychological during hospitalization. sequelae after pediatric intensive care unit hospitalization. Pediatric Critical Acknowledgment Care Medicine. 2004;5(4):358-363. The authors acknowledge the pediatric nurses, 8. Jan MMS. Neurological examination of mothers and children who have been willing difficult and poorly cooperative children. to participate in this study. Journal of Child Neurology. 2007;22(10):1209-1213. Declaration of Conflicting Interest 9. Pinto JP, Barbosa VL. Maternal-infant None declared. bonding and the mother's participation during venipuncture: a psychoanalytic Author Contribution perspective. Revista Latino-Americana This is the original work of the corresponding De Enfermagem. 2007;15(1):150-155. author. 10. Sumanti I. Hubungan dukungan perawat dan keluarga dengan tingkat kecemasan Funding akibat menjalani perawatan pada anak School of Nursing Faculty of Medicine, usia pra sekolah [Relationship of nurse Universitas Gadjah Mada, Indonesia. and family support and anxiety due to undergoing treatment in pre-school age children]. Surakarta: Program Pasca Sarjana Universitas Sebelas Maret; 2010.

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11. Friedman MR. Family nursing: Theory and the anxiety level of mother in a & practic: Stamford, CT: Apleton & selected hospital of Udupi district. India: Lange; 2008. Manipal University; 1998. 12. Ramdaniati S. Analisis determinan 15. Hart D, Bossert E. Self-reported fears of kejadian takut pada anak pra sekolah hospitalized school-age children. Journal dan sekolah yang mengalami of Pediatric Nursing. 1994;9(2):83-90. hospitalisasi di Ruang Rawat Anak RSU 16. Lamtraktul S-a. Do not ignore separation BLUD dr. Slamet Garut [Analysis of anxiety in children. Belitung Nursing determinants of fear in pre-school and Journal. 2016;2(1):1-2. school age children who undergo 17. Ratna W. Sosiologi dan antropologi hospitalization in pediatric wards of RSU dalam perspektif ilmu keperawatan BLUD dr. Slamet Garut Hospital]. Tesis. [Sociology and anthropology in the Depok: Fakultas Ilmu Keperawatan nursing perspective]. Yogyakarta: Program Magister Keperawatan Pustaka Rihana; 2010. Universitas Indonesia; 2011. 13. Monteiro HM, Shetty AP, Bagali PV. Fears of school-age children and parental Cite this article as: Suminar IT, Gamayanti perceptions of nursing support during IL, Lusmilasari L. Relationship between hospitalization in a selected pediatric nurse supports and fears of hospitalized hospital, Mangalore. Muller Journal of school age children in PKU Muhammadiyah Medical Science and Research. Hospital, Yogyakarta, Indonesia. Belitung 2015;5(2):139-142. Nursing Journal. 2017;3(4): 376-382. 14. Ginimol A. A study of self reported fears https://doi.org/10.33546/bnj.111 of hospitalized school age children, and the association between the child’s fear

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Astuti A, et al. Belitung Nursing Journal. 2017 August;3(4):383-389 Received: 28 May 2017 | Accepted: 19 June 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

EFFECT OF PROGRESSIVE MUSCULAR RELAXATION ON ANXIETY LEVELS IN PATIENTS WITH CHRONIC KIDNEY DISEASE UNDERGOING HEMODIALYSIS IN THE GENERAL HOSPITAL OF TUGUREJO SEMARANG, INDONESIA

Ary Astuti1*, Anggorowati2, Andrew Johan2

1Master of Nursing, Faculty of Medicine, Diponegoro University, Semarang, Indonesia 2Faculty of Medicine, Diponegoro University, Semarang, Indonesia

*Corresponding author: Ary Astuti Faculty of Medicine, Diponegoro University. Jl. Prof. Soedarto, Tembalang, Kec. Tembalang, Kota Semarang, Jawa Tengah 50275, Indonesia. E-mail : [email protected] ABSTRACT Background: Patients with chronic kidney disease undergoing hemodialysis suffer changes in lifestyle, which cause physical and psychosocial problems, particularly anxiety. Progressive muscular relaxation is considered as an intervention to reduce anxiety. Objective: This study aims to examine the effect of progressive muscular relaxation in in reducing anxiety in patients with chronic kidney disease undergoing hemodialysis. Methods: This study used a quasi-experimental design involved 78 respondents, with 38 randomly assigned in the intervention and control group. The progressive muscular relaxation was performed on 14 muscle groups for 4-week period. Hamilton anxiety rating scale was used to measure anxiety. Univariate, bivariate and multivariate analyses were performed for data analyses. Results: The results showed a statistically significant difference in anxiety values between the intervention and control group with p-value 0.000 (<0.05). Conclusion: There was a significant effect of progressive muscular relaxation in reducing anxiety in patients with chronic kidney disease undergoing hemodialysis. The results of this study is expected to be one reference in making the progressive muscular relaxation as a nursing intervention in reducing anxiety in patients undergoing hemodialysis.

Keywords: anxiety, progressive muscular relaxation, hemodialysis, chronic kidney disease

INTRODUCTION Chronic Kidney Disease (CKD) is an minute / 1.73 m2, and needs to initiate abnormality of renal structure or function hemodialysis or renal transplant.1 Patients for more than 3 months progressive to undergoing hemodialysis experience terminal renal failure with Glomerular lifestyle changes in the family. The filtration rate (GFR) less than 15 ml / patients will experience a sense of loss

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Editor’s Note: This article has been updated on 13 July 2020 in terms of the completeness of correspondence address. The update is based on BNJ policy on article correction. because their normal lives are disrupted minimized by the role of nurses in by hemodialysis activity and this can lead overcoming anxiety. The role of the nurse to psychological problems in CKD is very important in the prevention of patients and unspecified anger will be anxiety and makes the patient not to feel projected into self and cause despair.2,3 anxious through comprehensive Chronic kidney disease was the 27th biological, psychological, social and leading cause of death in the world in spiritual nursing care.9 The anxiety 1990 and increased to18th in 2010. While symptoms of patients undergoing in Indonesia, the treatment of kidney hemodialysis are helpless, desperate, loss disease is the second rank of largest of interest in day-to-day, sleep changes, funding by BPJS health after cardiac energy loss, irritability and restlessness.2 disease, and data on the distribution of However, these symptoms can be reduced cases and cost of claims in Advanced by doing relaxation techniques. 9 Outpatient Ward of BPJS health are until Progressive Muscular Relaxation the third quarter of 2015.4 In addition, the (PMR) is a form of nursing intervention case of urinary system amounted to that can be administered to the patients 3,094,915, as the third highest rank with undergoing hemodialysis to reduce the cost is more than 3 trillion rupiah.4 anxiety.10 PMR is a relaxation technique The mortality rate of patients with focusing on slowly tensing and then chronic kidney disease was 27 (62.8%) of relaxing each muscle group, and focusing 43 patients, and other studies indicated on the difference between muscle tension that all of the patients with CKD reported and relaxation.11 Literature indicated that physiological and psychosocial stress.5 PMR is effective in reducing biological The prevalence of depression in patients stress levels.12 PMR results in a change in with hemodialysis was 20-30% until facial expression as an indicator of 47%,6 while those who have severe psycho-physiological tension, and this depression was approximately 1.1- 15% in technique is also recommended as one of men and 1.8-23% in women. Prevalence the relaxations for students in the end of of patients who had anxiety with the study.13 Therefore, this study aims to hemodialysis was 24 (35.82%).7 examine the effect of PMR in decreasing Despair will be felt by the patient anxiety in patients with chronic kidney with long-term hemodialysis. Patients disease undergoing hemodialysis. often feel worried about the condition of the illness due to unpredictable illness METHODS conditions whether to recover completely Study Design or not, thus causing problems in his life. This was a quasi-experimental study with Patients usually experience financial pretest-posttest with control group design. problems, difficulty in keeping jobs, disappearing sexual urges and even Setting impotence, depression caused by chronic This research was conducted on 13 April pain and fear of death. 2,8 to 13 May 2017 in the General Hospital of The impact of anxiety is related to Tugurejo Semarang, Indonesia. situational crisis, stress, changes in health status, death threats, self-concept changes, Population and Sample lack of knowledge and hospitalization. The population in this study were all The impact of such anxiety can be patients in hemodialysis ward of the

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General Hospital of Tugurejo amounted to more specific symptoms. Each symptom 234 people. There were 78 samples group was assigned a score of 0-4, which selected using simple random sampling, means that 0 means no symptoms, 1 mild with 39 assigned in the intervention and symptom, 2 moderate symptoms, 3 control group. The sample size was hemorrhagic symptoms, and 4 very severe calculated using the average formula of symptoms. Each score of the 14 symptom two independent populations,14 with drop groups is summed to know the degree of out anticipation 10%. The researchers anxiety of a person as a total score, determined that patients receiving consisting of: <14 no anxiety, 14-20 mild hemodialysis therapy in morning shift anxiety, 21-27 moderate anxiety, 28-41 were the treatment group, and the patients severe anxiety, and 42-56 very severe in the afternoon shift were the control anxiety. The instrument has been group. Respondents in both groups were translated in Indonesian language with the patients in the same hospital. The permission of the instrument developer. inclusion criteria of the sample were The HARS scale has been proven to have patients with hemodialysis therapy twice a validity and reliability to measure anxiety week, aged 18-65 years, able to read and with alpha Cronbach 0.93. write, patients with HARS> 14 score and full consciousness, good hearing function, Data Analysis able to read and write, no infection or Data were analyzed by univariate, inflammation, trauma, severe and acute bivariate and multivariate. In univariate heart disease, and with AV-shunt and analysis, data were presented in terms of double lumen access. mean, median, standard deviation, minimum, and maximum in the form of Intervention frequency distribution and percentage of Progressive Muscular Relaxation is a each variable. While bivariate analysis procedure to get relaxation on the muscles used t-test and multivariate analysis used in two steps: 1) to give a tension to a multiple linear regression test. muscle group, and 2) to stop the tension and focusing on how the muscles relax, Ethical Consideration and feeling the sensation. This This research was approved by the Health intervention was performed on 14 muscle Research Ethics Committee (KEPK) of groups in 8 times for 4-week period with a Faculty of Medicine, Diponegoro duration of 15 minutes per session. While University and the Hospital of Dr. Kariadi the control group received deep breathing Semarang with No.106 / EC / FK-RSDK / relaxation techniques as a Standard III / 2017. The researchers confirmed that Operational Procedure (SOP) at the each respondent has obtained an General Hospital of Tugurejo Semarang. appropriate informed consent.

Instrument Anxiety levels were measured using the RESULTS Hamilton Anxiety Rating Scale, adopted This study was conducted on 78 patients from previous study in Indonesian with chronic kidney disease who language.15 The scale consisted of 14 underwent hemodialysis, with 39 assigned symptom groups in which each group has in the intervention and control group.

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Table 1 Characteristics of the respondents Group Variable Intervention (n=39) Control (n=39) p-value ∑ % ∑ % Age (Year) Mean 48.64 50.07 0.752 Min-Max 22-65 27-64 Gender Male 25 64.1 26 66.7 0.528 Female 14 35.9 13 33.3 Education High 3 7.7 3 7.7 0.948 Low 36 92.3 36 92.3 Employment Unemployed 19 48.7 20 51.3 0.825 Employed 20 51.3 19 48.7 Marital status Single 5 12.8 6 15.4 0.209 Married 34 87.2 33 84.6 Income > Rp.1.909.000,- 17 43.6 16 41.0 0.532 < Rp.1.909.000,- 22 56.4 23 59.0 Length of hemodialysis treatment < 1 year 17 43.6 8 20.5 0.648 > 1 year 22 56.4 31 79.5 Anxiety Mean 21.58 21.07 0.294 Min-Max 17-27 16-29

The characteristics of the than 1.909.000 rupiah. It was 80.8% of respondents as shown in the Table 1 respondents had long-term hemodialysis indicated that the average age of treatment. Table 1 also shows the respondents in this study was 49.35 years, statistical results of the equality test with with 65.4% of them were males. Majority p-value > 0.05 in each variable, which of the respondents (92.3%) had low indicated that there were no significant education levels, and 50% of them had no differences of the characteristics of work. Most of them (55.9%) were married respondents in both groups or and the highest income (57.7%) was less homogeneous.

Table 2 Difference in anxiety before and after intervention (progressive muscular relaxation) in the intervention and control group Anxiety value Time of Intervention group Control group measurement Mean SD p-value Mean SD p-value Pretest 21.5897 2.74071 0.000 21.0769 3.04687 0.0463 Posttest 19.8718 2.34161 21.2051 2.80206

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Table 2 shows that there was a and in the control group with p-value significant difference in anxiety value in 0.0463 the intervention group with p-value 0.000

Table 3 Analysis of difference on anxiety after given progressive muscular relaxation in the intervention and control group Variable Group N Mean SD SE p-value Intervention 39 19.8718 2.37480 0.38027 0.000 Anxiety Control 39 21.2051 2.68323 0.42966

Table 3 shows the mean of anxiety there were statistically significant in the control group was greater than the differences in anxiety after PMR exercise mean of anxiety in the intervention group in the intervention group and control with p-value 0.000, which indicated that group.

Table 4 Factors contributing to anxiety Anxiety Characteristic B SE Beta p-value R R2 (Constant) 20.297 1.544 0.000 0.501 0.251 Length of hemodialysis -2.064 0.693 -0.298 0.004 treatment Group 2.152 0.547 0.394 0.000

Table 4 shows a multivariate psychosocial problem that often arises in analysis of the factors that contribute to patients undergoing hemodialysis. anxiety revealed that the length of Anxiety is a natural disorder of feeling hemodialysis treatment and the group had characterized by a feeling of deep or a significant association (p <0.05) with sustained fear or anxiety, with changes in anxiety, with the strong uninterrupted in judging reality and not correlation (r = 0.501). The magnitude of experiencing personality cracking.3 PMR odds for the change of anxiety was After the progressive muscular 25.1% (R = 0.251), which indicated that relaxation exercise in the treatment group, the decrease in anxiety was more the anxiety of patients with CKD influenced by PMR exercises than the undergoing hemodialysis decreased length of hemodialysis treatment. significantly with the mean change of 21.58 to 19.87, from medium level of DISCUSSION anxiety (55.26%) to low level of anxiety Findings showed that all patients with (31.58%). While in the control group, the chronic kidney disease undergoing mean of anxiety value of pretest was hemodialysis in this study experienced 21.07 and posttest 20.81. The anxiety anxiety. This is in accordance with level remains the same between pretest previous research revealed that the (50%) and posttest (47.37%). prevalence of patients with chronic kidney Progressive muscle relaxation is a disease undergoing hemodialysis in the method that helps relive muscle tension in General Hospital of Soedarso Pontianak a sequential manner.17 In this study, the experienced moderate anxiety for 24 PMR technique was performed for 15-30 people (35.82%).16 Anxiety becomes a minutes for 8 times in 4-weeks period.

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The time of the implementation of PMR is disease undergoing hemodialysis. Thus, different from previous studies that this intervention can be applied as one of performed in 45 minutes for 5 days,13 and nursing interventions in the hospital. also performed 2-3 times daily for 30 minutes in 10 weeks period.18 However, Declaration of Conflicting Interest the results were proven to be effective in None declared decreasing anxiety. The impact of PMR that can help an Funding individual feel relaxed is supported by This study was supported by Akper Pemkab Kotawaringin Timur Kalimantan Tengah, previous studies, revealed that progressive Indonesia. muscle relaxation was effective in 10 lowering biological stress levels ; and it Author Contribution is better compared with diaphragmatic All authors contributed equally in this study. breathing exercise.13 Nurses are very important to References provide support or counseling to decrease 1. Muttaqin A, Sari K. Asuhan keperawatan anxiety levels in patients, and they can gangguan sistem perkemihan [Nursing perform self-care interventions to care in urinary disorder system]. Jakarta, overcome anxiety experienced by patients. Salemba Medika; 2011. Interventions that can be implemented in 2. Alam S, Hadibroto I. Gagal ginjal patients with anxiety include [Kidney failure]. Jakarta: Gramedia environmental modification (according to Pustaka Utama; 2007. 3. Hawari D. Manajemen stress, cemas dan individual preferences), using relaxation, depresi [Management of stress, anxiety, building, coping with stress and anxiety, and depression]. Jakarta: Fakultas pharmacological interventions and Kedokteran Universitas Indonesia; 2001. additional strategies. This relaxation 4. Ministry of Health. Hari ginjal sedunia method aims to reduce muscle tension [World kidney day]. 2016. http://www. throughout the body and increase oxygen depkes.go.id/article/print/16031000001/h supply. In Nursing Intervention ari-ginjal-sedunia-2016 Classification (NIC),19 nursing 5. Wahyudi IED, Pujo JL. Angka kematian interventions conducted by nurses in pasien end stage renal disease di ICU overcoming anxiety is by instructing the dan HCU RSUP dr. Kariadi [mortality client's ability to use relaxation rate of patients with end stage renal disease at ICU dan HCU RSUP dr. techniques. On the other hand, the concept Kariadi]. Semarang: Fakultas of self-care theory initiated by Orem can Kedokteran, Universitas Diponegoro; be applied as an optimal effort in 2012. performing patient care independently to 6. Cheung YL, Molassiotis A, Chang AM. meet the needs of the body,20 especially to The effect of progressive muscle perform progressive muscular relaxation relaxation training on anxiety and quality in this study. of life after stoma surgery in colorectal cancer patients. Psycho‐Oncology. CONCLUSION 2003;12(3):254-266. Based on the results of this study, it can 7. Amalia F, Azmi SA. Gambaran tingkat be concluded that progressive muscle depresi pada pasien penyakit ginjal kronik yang menjalani hemodialisis di relaxation exercises significantly decrease RSUP DR. M. Djamil Padang anxiety in patients with chronic kidney [Depression level of patients with

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chronic kidney disease undergoing penderita penyakit ginjal kronik yang hemodyalisis at RSUP DR. M. Djamil menjalani hemodialisis di RS Universitas Padang. Jurnal Kesehatan Andalas. Kristen Indonesia [Anxiety in patients 2015;4(1). with chronic kidney disease undergoing 8. Baradero M, Dayrit MW, Siswadi Y. hemodyalisis at Universitas Kristen Klien gangguan ginjal: Seri asuhan Hospital Indonesia]. Media Medika keperawatan [Patients with kidney Indonesiana. 2012;46(3):151-156. failure: Nursing care series]. Jakarta: 16. Rustina. Gambaran tingkat depresi pada EGC; 2005. pasien gagal ginjal kronik yang 9. Setyoadi K. Terapi modalitas menjalani hemodialisis di RSUD Dr. keperawatan pada klien psikogeriatrik Soedarso Pontianak tahun 2012 [Nursing modality therapy in clients with [Depression level in patients with chronic psychogeriatric]. Jakarta: Salemba kidney failure undergoing hemodyalisis Medika; 2011. at RSUD Dr. Soedarso Pontianak in 10. Alfiyanti NE, Setyawan D, Kusuma 2012. Jurnal Mahasiswa PSPD FK MAB. Pengaruh relaksasi otot progresif Universitas Tanjungpura. 2013;1(1): 1- terhadap tingkat depresi pada pasien 15. gagal ginjal kronik yang menjalani 17. Jacobson E. Progressive relaxation. hemodialisis di Unit Hemodialisa RS 1938. Chicago: University of Chicago Telogorejo Semarang [Effect of Press. progressive muscle relaxation on 18. Kumar P, Nayak Rr, Devi SK. depression in patients with chronic Effectiveness Jacobson’s progressive kidney failure undergoing hemodyalisus muscle relaxation technique (PMRT) to at Hemodyalisis Unit at Telogorejo relieve anxiety among alcoholic patients Hospital Semarang]. Jurnal Ilmu MHI, SCB, Cuttack, Odisha. IOSR Keperawatan dan Kebidanan. 2016;2(4). Journal of Nursing and Health Science 11. Conrad A, Roth WT. Muscle relaxation 2015;4(4). therapy for anxiety disorders: It works 19. North American Nursing Diagnosis A. but how? Journal of Anxiety Disorders. NANDA nursing diagnoses. United 2007;21(3):243-264. States: North American Nursing 12. Blanaru M, Bloch B, Vadas L, et al. The Diagnosis Association; 1996. effects of music relaxation and muscle 20. Bağ E, Mollaoğlu M. The evaluation of relaxation techniques on sleep quality self‐care and self‐efficacy in patients and emotional measures among undergoing hemodialysis. Journal of individuals with posttraumatic stress Evaluation in Clinical Practice. disorder. Mental Illness. 2012;4(2). 2010;16(3):605-610. 13. Zargarzadeh M, Shirazi M. The effect of progressive muscle relaxation method on Cite this article as: Astuti A, Anggorowati, test anxiety in nursing students. Iranian Johan A. Effect of progressive muscular Journal of Nursing and Midwifery relaxation on anxiety levels in patients with Research. 2014;19(6):607. chronic kidney disease undergoing 14. Sastroasmoro S, Ismael S. Dasar-dasar hemodialysis in the General Hospital of metodologi penelitian klinis [Basic Tugurejo Semarang, Indonesia. Belitung clinical research methodology]. Jakarta: Nursing Journal. 2017;3(4): 383-389. Binarupa Aksara; 1995. https://doi.org/10.33546/bnj.88 15. Luana NA, Panggabean S, Lengkong JVM, Christine I. Kecemasan pada

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Fajriya II, et al. Belitung Nursing Journal. 2017 August;3(4):390-398 Received: 3 March 2017 | Accepted: 31 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

DEVELOPING A WEB-BASED INFORMATION SYSTEM IN DETECTION OF HIGH-RISK PREGNANCIES IN SEMARANG, INDONESIA: ADDIE MODEL

Ihsanti Indri Fajriya1*, Supriyana2, Bahiyatun2, Melyana Nurul Widyawati2

1Postgraduate Midwifery Program, Poltekkes Kemenkes Semarang, Indonesia 2Poltekkes Kemenkes Semarang, Indonesia

*Corresponding author: Ihsanti Indri Fajriya Postgraduate Midwifery Program, Politeknik Kesehatan Kementrian Kesehatan Semarang Jl. Tirto Agung, Pedalangan, Banyumanik, Kota Semarang, Jawa Tengah, Indonesia (50268) E-mail: [email protected]

ABSTRACT A web-based information system in this study was developed using ADDIE (Analysis, Design, Development, Implementation, and Evaluation) instruction model to facilitate the monitoring and reporting the existence of high-risk pregnancies in Semarang. The evaluation of the system revealed that web-based information system was very effective in terms of completeness, ease, timeliness, accuracy, and conformity with p-value <0.05. This innovation is expected to contribute positively to reduce maternal mortality rates in Indonesia, especially in Semarang.

Keywords: high-risk pregnancy, web-based system, Addie model

INTRODUCTION Health is one of the main components in Pregnancy is a normal phenomenon the Human Development Index (HDI),1 that occurs because of the meeting of which can support the creation of healthy sperm cells with egg in the fallopian tube, human resources to the success of health and then attached in the endometrium, development, as well as to create which will develop into a fetus, taking awareness, willingness, and ability to live 280 days or 40 weeks.2 High risk in healthy through maternal health efforts pregnancy is a state of pregnancy that is before pregnancy until childbirth.1 deviated from normal, which directly leads to maternal and infant morbidity and

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Editor’s Note: This article has been updated on 13 July 2020 in terms of minor changes in the reference format. The update is based on BNJ policy on article correction. death.3 Maternal Mortality Rate (MMR) is aims to propose the solution which will let used in maternal mortality monitoring, the health system be more useful and about six to eight percent of pregnant effective for health workers by developing women fall into the high-risk category web-based information system to facilitate during their pregnancy.4 Thus, women the monitoring, detecting and reporting of with pregnancies at greatest risk is a great the existence of high-risk pregnancy in concern for health workers, especially to Semarang city using Instructional systems manage their birth and health decision design (ISD). plans regarding reproductive care services.5 INSTRUCTIONAL SYSTEMS DEVE- According to WHO, the world’s LOPMENT (ISD) Maternal Mortality Rate (MMR) has The instructional systems design is a reached 289,000.6 While the rate of MMR systematic method of development of in Indonesia is also still high.1 In 2015 education and trainings programs for there were 35 cases of maternal deaths in improved student performance.9 The ISD Semarang City, Indonesia, with a total of process involves five steps: analysis, 77.3% high-risk pregnancies women.7 development, design, implementation, and Based on the Maternal Perinatal Audit, evaluation (ADDIE). The concept of ISD indicated that 55.7% of these death cases has been around since the early 1950s, could have been prevented.7 However, ADDIE first appeared in 1975. It was efforts that have been made by the Health created by the Center for Educational Office of Semarang City to suppress the Technology at Florida State University for MMR is by the establishment of Health the U.S. Army and then quickly adapted Surveillance Officers (GASURKES). 7 It by all the U.S. Armed Forces. The is expected that, as health surveillance military, having a large number of officers, they could do systematic instructional designers, greatly influenced collection, analysis, and interpretation of much of the corporate world to adapting health-related data needed for the the ISD or ADDIE model.10 planning, implementation, and evaluation of public health practice, as well as DEVELOPING WEB-BASED INFOR- document the impact of an intervention, or MATION SYSTEM USING ADDIE track progress towards specified goals, MODEL and allow priorities to be set and to inform This was a Research and Development public health policy and strategies.8 (R&D) study following the instructional However, the data collection and system design with analysis-design- analysis in the Health Surveillance development-implementation-evaluation Program is still in manual based using (ADDIE) model to develop web-based excel computer program, which may information system in detection high risk provide the risk of double input, error, and pregnancy. loss of data, as well as a delay in the report due to many entered-data more than Analysis one sheet. In this case, there is an absence This step is to analyze characteristics of of a system that can further facilitate the systems, the needs and limitations of midwives to coordinate the the system, and formulate health workers implementation and reporting of high-risk need.11 In this study, the analysis has pregnancy detection. Therefore, this study already been implemented by in-depth

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 391 interview with five health surveillance program could be operated directly on the officers in five community health centers computer. Besides, the research also in Semarang City, which its result developed an instrument to measure the indicated that there was a slow process of completeness, timeliness, accuracy, and detection of high risk pregnancies by conformity with Likert scale, namely excel format manually. They all agreed Strongly Agree (5), Agree (4), Simply that they need innovation using web-based Agree (3) Disagree (2), and Strongly system. Disagree (1). The instrument has been validated using expert judgment Design (Midwives) and been tested to 15 Where an outline and description of the respondents. The instrument showed good system and storyboard are created. validity result. Module, software program, instrument to assess the quality of system modules are Development designed and determined.12 In this study, In the development phase, instructional the development of web-based designers and developers create and information system (Indonesian version) assemble content assets blueprinted in the was the result of the analysis step, which design phase.11 In this phase, the aimed to help and facilitate the health designers create storyboards and graphics. personnel as the implementer of the The web-based system was described in program. The system was developed using the following figures: local web server (PHP), which this

Figure 1 Log In page

Figure 2 Main Menu Page

The main menu display as shown in Figure 2 presents maternity data menu, antenatal visit, maternal risk, visit data, maternal data management, and charts of risk pregnant women. This display menu is used as a tool for user menu

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entry tools.

Figure 3 Demographic data of pregant women

This includes the demographic data such as name, age, working status, education, address, contact, husband data, and the ownership of maternal book

Figure 4 Antenatal visit

This contains a history of maternal ANC visits during pregnancy, consisting of places where the mother performed ANC, who was the ANC service provider, and the number of checks during the first trimester until the third trimester.

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Figure 5 First page of high-risk pregnant women

This is a menu of the process of entering all types of pregnancy risk factors experienced by pregnant women. The outcomes were grouping of pregnancy risk based on Poedji Rochjati score that had been modified by the researcher.

Figure 6 Admin database

This contains a database of all pregnant women at high risk

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Figure 7 Admin database for data collection during visit and grouping of type of pregnancy

Figure 8 Map of the spread of pregnant women in Semarang

Implementation implemented to 10 respondents (5 The implementation phase includes the midwives and 5 health surveillance testing of prototypes to respondents.12 In officers) selected using purposive this study, the web-based system had been sampling.

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Evaluation with one group pretest-posttest. The web-based system has been evaluated Descriptive statistics and Wilcoxon test using Likert scale that has been developed were performed for data analysis. in the designed step. The evaluation was conducted using pre-experimental design

Table 1 Completeness value before and after using web-based system

Quality of web-based system Before After Completeness Data is complete and detailed 30 (25%) 40 (33.33%) Able to know the spread of pregnant women 20 (16.67%) 35 (29.17%) Able to know the number of pregnant women at risk 20 (16.67%) 34 (28.33%) through the graph Total 70 (58.33%) 89 (74.17) Ease Reporting can be easily set up from existing files 28 (14%) 30 (15%) Reporting available at the health center can be 20 (10%) 33 (27.5%) accessed easily by health officers in the office and the field Easily updated with database 20 (10%) 30 (15%) The existing reporting system facilitates coordination 27 (22.5%) 28 (23.3%) Existing systems can automate high-risk pregnancy 20 (10%) 36 (30%) detection Total 115 (57.50%) 157 (78.50%) Conformity Available data: 30 (37.5%) 34 (42.5%) Can produce an information appropriate to the needs of midwives and health officers in high-risk pregnancy detection Report: 30 (37.5%) 35 (43.75%) Information is generated according to the needs of midwives and health officers in high-risk pregnancy detection Total 60 (75%) 69 (86.25%) Accuracy There are no multiple entries for the same data 28 (17.50%) 35 (21.88%) Data processing can be done correctly 26 (16.25%) 30 (18.75%) Able accurately perform detection 20 (12.50%) 40 (25%) Information about pregnant women produced can be 20 30 trusted and free from the element of error (12.50%) (18.75%) Total 94 (58.75%) 135 (84.38%) Timeliness Presentation of report results can be made according 27 (33.75%) 35 (43.75%) to the scheduled date Diagnosis of pregnancy at risk can be done 26 (32.50%) 37 (46.25%) appropriately Total 53 (66.25%) 72 (90%) Time speed Time speed in diagnosis 42 minutes 31 minutes

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Table 1 shows better results of the timeline, and time speed after using the quality of web-based system in term of system in detection of high-risk completeness, ease, conformity, accuracy, pregnancies.

Table 2. Difference of quality of web-based system related to completeness, ease, conformity, accuracy, and timeliness using Wilcoxon test

Evaluation aspect Before After P-value Completeness Mean ±SD 4.20 ±0.422 3.10 ±0.876 0.018 Min-max 4-5 2-5 Ease Mean ±SD 10.80 ±0.632 15.90 ±0.738 0.005 Min-max 10-12 15-17 Conformity Mean ±SD 6.00 ±0.000 6.90 ±0.738 0.014 Min-max 6-6 6-8 Accuracy Mean ±SD 9.40 ±0.699 12.90 ±1.595 0.007 Min-max 8-10 10-14 Timeliness Mean ±SD 2.70±0.483 3.50 ±0.527 0.011 Min-max 2-3 3-4

Table 2 shows that there were CONCLUSION significant differences before and after It can be concluded that the web-based using the web-based system in terms of information system was very effective to completeness, ease, conformity, accuracy, be applied in detection of the pregnant and timeliness with p-value < 0.05. It was women at high risk. This innovation is proved that the web-based system is very expected to contribute positively to reduce effective to detect and monitor pregnant maternal mortality rates in Indonesia, women at high risk. The function of this especially in Semarang. web based information system is to reduce the error rate, reduce the time to fix errors, Declaration of Conflicting Interest speed up the timing of the provision of None declared reports, improve system security, and increase satisfaction.13 If the information Funding presented is qualified, then the decision This study was supported by Postgraduate Midwifery Program, Poltekkes Kemenkes making will not be misled.13 Semarang, Indonesia.

Author Contribution Limitation of the study All authors contributed equally in this study. The results of this study might not be generalized due to lack of respondents. References Further study is needed with bigger 1. MOH. Profil kesehatan Indonesia sample size to examine the effectiveness 2014. Jakarta: Menteri Kesehatan of the system. Republik Indonesia;2014. 2. Manuaba IAC. Ilmu kebidanan, penyakit kandungan, dan KB

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[Obstetric, gynecology, and family and Safety in Health Care. planning]. 2nd ed. Jakarta: Yayasan 2006;15(suppl 1):i25-i29. Bina Pustaka; 2010. 10. Hannum WH, Briggs LJ. How Does 3. Sriprasert I, Chaovisitsaree S, Instructional Systems Design Differ Sribanditmongkhol N, Sunthornlimsiri from Traditional Instruction? N, Kietpeerakool C. Unintended Educational Technology. 1982;22(1):9- pregnancy and associated risk factors 14. among young pregnant women. 11. Hadi SPI, Kuntjoro T, Sumarni S, International Journal of Gynecology & Anwar MC, Widyawati MN, Pujiastuti Obstetrics. 2015;128(3):228-231. RSE. The development of e-partograph 4. Miri K-P, Yaira H-R, Osnat L. The module as a learning platform for perceived risk of pregnancy as a midwifery students: The ADDIE mediator of the association between model. Belitung Nursing Journal. prenatal maternal self-efficacy and 2017;3(2):148-156. postnatal subjective well-being. 12. Kholifah LN, Supriyana S, Bahiyatun Psychiatry Research. 2016;244:62-64. B, Widyawati MN. Using ADDIE 5. Lee S, Holden D, Ayers S. How women model to design early detection system with high risk pregnancies use lay of child growth and development in the information when considering place of Community Health Center Of birth: A qualitative study. Women and Bendosari, Semarang Indonesia. Birth. 2016;29(1):e13-e17. Belitung Nursing Journal. 2017;3(3): 6. WHO. Fact Sheet: maternal mortality. 205-212. 2016; http://www.who.int/mediacentre/ 13. Zhang JK, Xu W. Web Service-based factsheets/fs348/en/. Accessed 25 Healthcare Information System March, 2017. (WSHIS): A case study for system 7. Department of Health of Semarang. interoperability concern in healthcare Profil kesehatan Kota Semarang. field. In Biomedical and Budayakan hidup bersih dan sehat Pharmaceutical Engineering, tahun 2008 [Health profile of Singapore, 2006. pp 588-594. Semarang city. Cultivating a clean and healthy life in 2008]. Semarang: Cite this article as: Fajriya II, Department of Health of Supriyana, Bahiyatun, Widyawati Semarang;2011. MN. Developing a web-based 8. Berkelman RL, Sullivan PS, Buehler information system in detection of JW. Public health surveillance. In high-risk pregnancies in Semarang, Oxford textbook of public health, 5th ed. Indonesia: ADDIE Model. Belitung Oxford University Press; 2009. pp 699- Nursing Journal. 2017;3(4):390-398. 715. https://doi.org/10.33546/bnj.160 9. Battles JB. Improving patient safety by instructional systems design. Quality

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Susanti D, et al. Belitung Nursing Journal. 2017 August;3(4):399-404 Received: 28 February 2017 | Accepted: 31 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

EFFECT OF CONSUMING TAMARIND AND TURMERIC DRINK ON THE LENGTH OF PERINEAL WOUND HEALING IN POSTPARTUM MOTHERS

Dewi Susanti1*, Onny Setiani2, Umaroh2, Kun Aristiati1, Imam Djamaluddin Mashoedi1, Mardiyono1

1Magister Applied Midwifery, Poltekkes Kemenkes Semarang, Indonesia 2Faculty of Public Health, Diponegoro University, Indonesia 3Midwifery Department, Poltekkes Kemenkes Semarang, Indonesia

*Corresponding author: Dewi Susanti Magister Applied Midwifery, Poltekkes Kemenkes Semarang Jl. Tirto Agung, Pedalangan, Banyumanik, Kota Semarang, Jawa Tengah, Indonesia (50268) E-mail: [email protected]

ABSTRACT Background: The incidence of perineal tear is still high in Indonesia. It is therefore the intervention to accelerate wound healing is needed. The use of turmeric and tamarind is considered as the alternative treatment for wound healing. However, little is known about the effect of the combination of turmeric and tamarind. Objective: To determine the effect of consuming turmeric and tamarind on the duration of perineal wound healing. Methods: The study was a quasi-experimental study with one group post-test only design conducted in the working area of the Community Health Center of Ngesrep and Srondol, Semarang City, Central Java, Indonesia in December 2016 until January 2017. There were 28 respondents recruited using consecutive sampling, with 14 randomly assigned in each group. The REEDA scoring system was used to measure the wound healing. Data were analyzed using Independent t-test. Results: The results revealed that the average duration of wound healing in the intervention group was 6.25 days, while in the control group was 8.57 days with p-value 0.000 (<0.05), which indicated that there was statistically significant effect of tamarind turmeric drink of the duration of perineal wound healing in postpartum mothers. Conclusion: There was a significant effect of turmeric tamarinds drink on the duration of perineal wound healing in postpartum mothers. It is therefore suggested to the health providers, especially midwives, to apply this intervention the accelerate healing of perineal wound in postpartum mothers.

Keywords: turmeric, tamarind, perineal wound, postpartum mothers

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Editor’s Note: This article has been updated on 13 July 2020 in terms of minor changes in the reference format. The update is based on BNJ policy on article correction. INTRODUCTION The incidence of perineum rupture is high, accelerate wound healing by increasing from a total of 1951 spontaneous vaginal wound contraction and accelerate births, there are 57% of mothers epithelial cell migration under wound.6 experienced perineal ruptures, which 28% However, little is known about the effect of them due to episiotomy, and 29% due of the combination of turmeric and to tear.1 The effect of perineal rupture on tamarind, especially in perineal wound the mothers include infections in the healing. Therefore, this study aimed to perineal rupture. Results of research determine the effects of turmeric and conducted by Sim Romi shows the tamarind on perineal wound healing in incidence of infections (7.1%) in postpartum mothers. postpartum mothers with episiotomy.2 Based on the preliminary study METHODS conducted at the Community Health Design Center of Ngesrep on July 20, 2015, of The study was a quasi-experiment with 140 mothers delivering in the working one group post-test only design conducted area of the health center, 97 of mothers in the working area of the Community suffered from perineum injuries and 1 Health Center of Ngesrep and Srondol, suffered from perineal wound infections. Semarang City, Central Java in December In the Community Health Center of 2016 until January 2017. Srondol, from 37 deliveries, 29 mothers (76.31%) suffered from perineal wound. Sample Mothers who have perineal ruptures Using consecutive sampling, the total certainly feel pain and discomfort, which sample in this study was 28 respondents, interfere with their activities, particularly which 14 randomly assigned in in caring their children.3,4 There is intervention and control group. The evidence of changes in the quality of life inclusion criteria included: a) a normal experienced by the mother during postpartum mother (the 1st day), b) had postpartum period, regularly a series of been willing to receive intervention and psychological and physical symptoms examination, c) a postpartum mother with such as physical limitations, fatigue and sutured second-degree perineal pain. Although this phenomenon is often lacerations, and d) willing to be regarded as temporary or non-permanent, respondent. The exclusion criteria it is strongly associated with an included a mother suffered from diseases assessment of the quality of life of that can inhibit wound healing, such as postpartum mothers.5 Thus, the effort to AIDS, kidney and hepatic disease). In this reduce the pain and discomfort in study, those who had less than 100% of postpartum mothers with episiotomy is intervention adherence were dropped out. needed. The use of turmeric and tamarind is Intervention considered as the alternative treatment for The treatment group was given wound healing. Turmeric and tamarind intervention in the form of consumption have been shown to be anti-inflammatory, of tamarind turmeric drink with a dose of antioxidant, anticarcinogenic, anti- turmeric (Curcuma Longa) was 165 mg / infection, analgesic, and anticoagulant.6,7 KgBB while the dosage of tamarind They also works at various stages to (Tamarindus Indiciae) was 1:3 of turmeric

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 400 weight. The amount of water used was was an observation sheet using the 150 ml. The drink was taken every REEDA scoring system (Redness, Edema, morning after breakfast until the wounds Ecchymosis, Discharge and Proximity) of the perineum healed. Perineal care was tool. The REEDA scale is a tool for also given to the treatment group. On the assessing perineal healing that was other hand, the control group received primarily developed by Davidson8 and standard treatment in the form of perineal later reviewed by Carey.9 It includes five care and oral antibiotics (10 amoxilin 500 items related to the healing process: mg tablets) taken 3 times daily. Perineal hyperemia, edema, ecchymosis, discharge care was done alone by the respondent, and coaptation of the wound edges i.e. by cleaning the perineum with clean (Redness, Edema, Ecchymosis, Discharge, water, then dried with a clean towel. Approximation - REEDA) (see Figure 1). The length of time and level of wound Instrument density were measured and observed one The research instrument used to measure day after treatment. the duration of perineal wound healing

Figure 1 REEDA Scale9

Data analysis adjusted to the standard informed consent Data were homogenous and in normal at the time of filling ethical clearance by distribution. Thus, independent t-test was first explaining the research (objective, used to analyze the data. benefits, risk, and duration). The participation of respondents was voluntary Ethical Consideration and the researcher ensured the Ethical clearance was obtained from confidentiality of the respondent's data. research ethics committees of Poltekkes Kemenkes Semarang with code of conduct: 271 / KEPK / Poltekkes-SMG / RESULTS EC / 2016. Research permit was obtained The characteristics of the respondents as from educational institution, National shown in the table 1 indicated that Unity Board of the Republic of Indonesia majority of the respondents in the in Semarang, and the Community Health intervention and control group aged 20-35 Center of Ngesrep and Srondil. Inform years, primipara, had spontaneous wound, consent given to the respondents had been normal nutritional status, enough sleep

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 401 pattern, normal stress level, and no characteristics of the respondents between infection. There was no difference in both groups.

Table 1 Characteristics of respondents Characteristics of Intervention group Control group Total respondents n % n % N % Age (Year) <20 years 3 37.5% 5 62.5% 8 28.5% 20-35 years 10 52.6% 9 47.4% 19 67.8% >35 years 1 100% 0 0% 1 3.7%

Parity Primipara 8 44.4% 10 55.6% 18 64.2% Multipara 6 60% 4 40% 10 35.8%

Type of wound Spontaneous 13 56.5% 10 43.5% 23 82.1% Episiotomy 1 20% 4 80% 5 17.9%

Nutritional Status Thin 1 100% 0 0% 1 3.6% Normal 5 29.4% 12 70.6% 17 60.7% Overweight 6 85.7% 1 14.3% 7 25% Obesity 2 66.7% 1 33.3% 3 10.7%

Sleep pattern Enough 8 40% 12 60% 20 71.4% Less 6 75% 2 25% 8 28.6%

Stress level Normal 5 33.3% 10 66.7% 15 53.6% Depression 9 69.2% 4 30.8% 13 46.4%

Infection Infection 0 0% 0 0% 0 0% No infection 14 50% 14 50% 28 100%

Table 2 Duration of perineal wound healing in postpartum mothers Minimum Maximum Standard of Group Mean value value deviation Intervention 5 8 6.25 1.06 Control 6 12 8.57 1.55

The results as shown in the table 2 12 days. The average duration of wound revealed that the minimum value of healing in the intervention group was 6.25 perineal wound healing in the treatment days, while in the control group was 8.57 group was 5 days, while perineal wound days. It tells that the tamarind turmeric healing in the control group was 6 days. juice could shorten the day of wound The maximum value in the intervention healing. group was 8 days while control group was

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Table 3 Effect of consuming tamarind turmeric on the duration of perineal wound healing in postpartum mothers Group N Mean P-value Intervention 14 6.29 0.000 Control 14 8.57 Total 28 100

Table 3 shows p-value 0.000 (<0.05), proproliferative signal transduction which indicated that there was statistically pathways.16 However, the medicinal value significant effect of tamarind turmeric of tamarind is mentioned in traditional drink of the duration of perineal wound Sanskrit literature. Tamarind fruits were healing in postpartum mothers. well known in Europe for their medicinal properties, having been introduced by DISCUSSION Arab traders from India. Tamarind This study aims to determine the effect of products, leaves, fruits, and seeds have turmeric and tamarind drink on the been extensively used in traditional Indian perineal wound healing in postpartum and African medicine.17 mothers. Findings of this study revealed This study provides the new insight that there is a significant effect of of the mixture tamarind turmeric juice tamarind turmeric juice on the duration of could reduce the duration of perineal perineal wound healing in postpartum wound healing compared to the perineal mothers. This result is in line with the care alone. However, the small sample previous studies, which reported that size might limit the generalization of the turmeric was applied and effective for findings. wound healing. It contains the antioxidant curcumin which may help reduce CONCLUSION inflammation and, in effect, may speed up There is a significant effect of turmeric the progress of the stages of wound tamarinds drink on the duration of healing.6 perineal wound healing in postpartum The wound healing potential of mothers. It is therefore suggested to the curcumin is attributed to its biochemical health providers, especially midwives, to effects such as its anti-inflammatory,10 apply this intervention the accelerate anti-infectious,11 and anti-oxidan,t12 healing of perineal wound. Further activities. Curcumin has also been found research is needed with bigger sample to enhance cutaneous wound healing size. through involvement in tissue remodeling, granulation tissue formation, and collagen Declaration of Conflicting Interest deposition.13 Various studies have shown None declared that curcumin's application on wound also enhances epithelial regeneration and Funding This study was supported by Magister Applied increases fibroblast proliferation and Midwifery, Poltekkes Kemenkes Semarang, 6,14 vascular density. Indonesia. On the other hand, tamarind extract enhances epidermal wound healing.15 It Author Contribution also promotes proliferation and migration All authors contributed equally in this study. of human skin cells through internalization via stimulation of

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References analogues. European Journal of 1. Boyle M. Wound healing. Jakarta: Medicinal Chemistry. 2009;44(2):915- EGC; 2009. 919. 2. Romi S. Kejadian infeksi luka 11. Mun S-H, Joung D-K, Kim Y-S, et al. episiotomi dan pola bakteri pada Synergistic antibacterial effect of persalinan normal di RSUP. H. Adam curcumin against methicillin-resistant Malik dan RSUD. Dr. Pirngadi Medan Staphylococcus aureus. Phytomedicine. [Episiotomy wound infection and 2013;20(8): 714-718. bacteria pattern in normal delivery at 12. Ak T, Gülçin İ. Antioxidant and radical H. Adam Malik Hospiyal and Dr. scavenging properties of curcumin. Pirngadi Hospital Medan. Medan: Chemico-Biological Interactions. Universitas Sumatera Utara; 2009. 2008;174(1):27-37. 3. Bagus MI. Ilmu kebidanan penyakit 13. Joe B, Vijaykumar M, Lokesh BR. kandungan dan keluarga berencana Biological properties of curcumin- [Obstetric, gynecology, and family cellular and molecular mechanisms of planning]. Jakarta: EGC; 2001. action. Critical Reviews in Food 4. Reeder SJ, Griffin K. Keperawatan Science and Nutrition. 2004;44(2):97- maternitas: Kesehatan wanita, bayi & 111. keluarga [Maternity nursing: Woman, 14. Sidhu GS, Singh AK, Thaloor D, et al. baby, and family health]. Jakarta: EGC; Enhancement of wound healing by 2011. curcumin in animals. Wound Repair 5. Wiknjosastro H. Ilmu kebidanan and Regeneration. 1998;6(2):167-177. [Obstetric]. Jakarta: Yayasan Bina 15. bin Mohamad MY, Akram HB, Bero Pustaka Sarwono Prawirohardjo. 2005. DN, Rahman MT. Tamarind seed 6. Akbik D, Ghadiri M, Chrzanowski W, extract enhances epidermal wound Rohanizadeh R. Curcumin as a wound healing. International Journal of healing agent. Life Sciences. Biology. 2011;4(1):81. 2014;116(1):1-7. 16. Nie W, Deters AM. Tamarind seed 7. Ferrara L. Antioxidant activity of xyloglucans promote proliferation and Tamarindus indica L. Ingredienti migration of human skin cells through Alimentari. Italy: Dipartimento di internalization via stimulation of Chimica Farmaceutica e Tossicologica; proproliferative signal transduction 2005. pathways. Dermatology Research and 8. Davidson N. REEDA: Evaluating Practice. 2013;2013:14. postpartum healing. Journal of Nurse- 17. El-Siddig K. Tamarind: Tamarindus Midwifery. 1974;19(2):6-8. Indica L. Vol 1. Malaysia: Crops for the 9. Alvarenga MB, Francisco AA, Oliveira Future; 2006. SMJVd, Silva FMBd, Shimoda GT, Damiani LP. Episiotomy healing Cite this article as: Susanti D, Setiani O, assessment: Redness, Oedema, Umaroh, Aristiati K, Mashoedi ID, Ecchymosis, Discharge, Approximation Mardiyono. Effect of consuming tamarind (REEDA) scale reliability. Revista and turmeric drink on the length of perineal latino-americana de enfermagem. wound healing in postpartum mothers. 2015;23(1):162-168. Belitung Nursing Journal. 2017;3(4):399- 10. Liang G, Yang S, Zhou H, et al. 404. https://doi.org/10.33546/bnj.155 Synthesis, crystal structure and anti- inflammatory properties of curcumin

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Suara E, et al. Belitung Nursing Journal. 2017 August;3(4):405-411 Received: 28 February 2017 | Revised: 27 April 2017 | Accepted: 31 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

RELATIONSHIP BETWEEN DEMOGRAPHIC CHARACTERISTICS AND SPIRITUAL WELLBEING AMONG CANCER SURVIVORS

Eviwindha Suara1*, Mardiyono2, Anggorowati3

1Program Magister Keperawatan, Universitas Diponegoro, Semarang, Indonesia 2Politeknik Kesehatan Kementrian Kesehatan Semarang, Indonesia 3Departemen Keperawatan, Universitas Diponegoro, Semarang, Indonesia

*Corresponding author: Eviwindha Suara Program Magister Keperawatan, Universitas Diponegoro, Jl. Prof. Soedarto, Tembalang, Kec. Tembalang, Kota Semarang, Jawa Tengah 50275, Indonesia. E-mail: [email protected]

ABSTRACT Background: Spiritual wellbeing (SWB) is an important quality-of-life dimension for cancer patients. Therefore, health professionals are demanded to improve SWB in these patients. A deeper understanding regarding the factors associated with SWB is needed. Objective: This study aims to examine the relationships of demographic characteristics of patients and spiritual wellbeing in patients with cancer. Methods: This was a cross-sectional correlational study with 60 respondents recruited using consecutive sampling. A spiritual wellbeing scale (SWBS) was used, and data were analyzed using Kendall's Tau and Spearman's rank. Results: Findings in this study showed that only age was statistically significant with spiritual wellbeing of cancer patients with p-value 0.003 (<0.05). There were no significant relationships of gender, education, occupation, long suffering, and type of cancers with spiritual wellbeing with p-value >0.05. Conclusion: There was a significant relationship between age and spiritual wellbeing in patients with cancer. This study provides the insight of knowledge regarding the factors affecting spiritual wellbeing in patients with cancer.

Keywords: demographic characteristics, spiritual wellbeing, cancer

INTRODUCTION Cancer is one of the main health problems worldwide.1 In Indonesia, cancer is the feared for its ferocity. According to the third largest contributor to death after International Agency for Research on heart disease. The prevalence of cancer Cancer (IARC), it is known that in 2012 patients in the population of all ages in there were 14,067,894 new cases of Indonesia is 1.4 % per thousand residents. cancer and 8,201,575 deaths from cancer The highest prevalence of cancer is in

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Editor’s Note: This article has been updated on 13 July 2020 in terms of the completeness of correspondence address. The update is based on BNJ policy on article correction. Yogyakarta Province, which is 4.1 % per a power greater than oneself.5 Spiritual thousand of the population, followed by well-being is positively associated with Central Java (2.1%) and Bali (2%).2 life purpose, social support, lower Cancer is a chronic disease that can distress, increased resistance to disease affect every aspect of human life. Any and effective in reducing physical and types of treatment against this disease, mental symptoms, pain, health problems, especially in advanced cancer, can cause anxiety and depression. However, various physical, psychological, social, spiritual well-being in each individual is and spiritual problems.3 However, this different because human is unique. Thus, study focuses only on the spiritual distress broader understanding regarding the of the patient. factors influencing spiritual well-being is Spiritual distress is a condition needed. when individuals or groups are Several factors identified in experiencing or at risk of impairment in literature, such as culture and beliefs or value systems that give it the environment, family, religion, life strength, hope and meaning of life, which experiences, characteristics and is characterized by the failure of the demographic factors.6-8 However, in this adaptation and non-fulfillment of spiritual study, only demographic factors and type needs.4 The other characteristics include of disease are examined with spiritual asking for spiritual help, revealing a doubt wellbeing in patients with cancer. in the belief system and in the sense of life, revealing more attention to death and after life, making decisions, rejecting METHODS ritual activities, and having signs such as Design crying, withdrawing, anxiety and anger, This was a cross-sectional correlational then followed by physical signs such as study to examine the relationship of impaired appetite, difficulty sleeping, and individual demographic factor (age, increased blood pressure.4 gender, working status, education, long Preliminary study at the General suffering), type of cancer, and spiritual hospital of Tugurejo Semarang was wellbeing in cancer patients. conducted with 4 cancer patients, indicated that they felt the disease is a Population and sample punishment in life, being wasted and The population of this study is patients unnoticed. Four of them said they were with cancer in stage 3 and 4 at the General reluctant to worship, desperate and Hospital of Tugurejo Semarang between physically exhausted. Some also April and May 2017. There were 60 expressed a desire to be cared by nurse. respondents selected using consecutive Therefore, health providers should pay sampling. The inclusion criteria of this attention with spiritual distress and study were: 1) patients with cancer stage improve the spiritual wellbeing in cancer III and IV who were hospitalized, 2) patients. compositional consciousness, 3) able to Spiritual wellbeing is a condition in communicate verbally, 4) over 18 years which a person have the ability to old, 5) had no cognitive and mental experience and integrate meaning and disorders, and 6) were not in the influence purpose in life through a person’s of antidepressant drugs. connectedness with self, others, nature, or

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Instruments has been granted permission for use in this Instruments in this study were divided study. into two parts, namely 1) demographic characteristics questionnaire that included Data analysis age, long suffering, education level, Mean and frequency distribution were occupation and the type of cancer; and 2) described. Kendall's Tau and Spearman's a spiritual wellbeing scale (SWBS) was rank were performed for data analysis. adopted from Ellison9 and Imam et al instrument.10 SWBS scale consists of 20 Ethical consideration items of measurement with 2 sub-scales, This study has been ethically approved by namely vertical dimension (religion the Ethical Committee of the Faculty of wellbeing (RWB)) and horizontal Medicine, Diponegoro University with dimension (existence wellbeing (EWB)). No. 89/EC/ FK-RSDK/III/2017. The RWB is to judge the relation of a person investigators have confirmed that each to God and EWB is to judge a person's respondent has an appropriate informed relationship with people and the consent. environment. Each sub-scale consists of 10 questions with Likert scale, ranging from 1(Strongly disagree) to 6 (Strongly RESULTS agree). This score is summed to yield Characteristic of respondents three value scales. SWB total scores can As shown in the Table 1, the average of range from 20 to 120. Based on the scores respondents aged 41 years, with 35% of obtained, the SWB scales are divided into males and 65% of females. Majority of 3 levels, namely low (20-40), moderate respondents were employed (68%) with (41-99) and high (100-120). The bachelor level background (15%). Forty- reliability and validity of this instrument two percent of respondents had breast has been done in the previous study with cancers, and the rest of them suffered valid and reliable result. This instrument from other cancers.

Table 1 Frequency distribution based on characteristics of respondents

Characteristics of Mean Min Max SD Frequency Percentage Respondents Age (Year) 48 26 75 11.9 - - Long suffering (Month) 29 2 120 24.1 - - Gender - - - - Male 21 35 Female 39 65 Employment - - - - Unemployed 19 32 Employed 41 68 Education - - - - Bachelor 9 15 Non-bachelor 51 85 Type of cancer - - - - Breast cancer 25 42 Other cancers 35 58

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Spiritual Wellbeing respondents in a good level of spiritual Table 2 shows that the majority of wellbeing. However, the mean of spiritual spiritual wellbeing of the respondents is in wellbeing was 81.88% with standard the moderate level (83.3 %). Only 15% of deviation 13.30.

Table 2 Spiritual wellbeing of the respondents

Spiritual wellbeing level Number of respondents Percentage (%) Bad 1 1.6 Moderate 50 83.3 Good 9 15 Mean: 81.88% Min: 38.00 Max: 109 SD: 13.30

Table 3 The relationship of spiritual wellbeing and its related factors using Spearman Rank and Kendall’s Tau test

Variables P-value

Long suffering 0.956 a Age 0.003*a Gender 0.739 b Type of cancer 0.466 b Educational level 0.548 b Employment 0.128b aSpearman Rank bKendall’s Tau test *< 0.05

Spearman rank test shows that age cancer and lung cancer. It was estimated has significant relationship with spiritual that in 2012 about 3.45 million new cases, wellbeing with p-value 0.003 (<0.05). and the first is breast cancer in women However, there were no significant (464,000 cases),15 followed by colorectal relationships of type of cancer, education, cancer, prostate cancer, and lung cancer. and employment with spiritual wellbeing But Ferlay said that new cases were found based on the result of Kendall’s tau test. more in men, which is about 1.4 million cases.15 Most of respondents suffered from DISCUSSION cancer less than 3 years. It is because the Majority of the respondents in this study patient comes at an advanced stage. Most aged 41 years, which is in line with the respondents did not know the symptoms previous study mentioned that there were of cancer, how to detect, seek treatment 45.8% of patients experienced cancer in and prevention. The high mortality of 1992-2006 at age 45-54 years,11 while cancer patients is due to a lack of Musarezaie et al12 also stated that the information about cancer, exposure to average age of cancer patients is 41.68 carcinogenic substances such as cigarettes years or in the old adulthood.13,14 and tobacco, and lifestyles that support the The most common gender was onset of cancer.15 On the other hand, women, with the most cancer types are most of the respondents had high school breast cancer followed by colorectal educational background (non-bachelor).

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Respondents with high levels of education differences in assessment tools, the will tend to be detected in the early stages number of samples, and the types of of cancer. The higher the education level cancer respondents. Therefore, it is of a person, the easier it is for the person necessary to further assess the factors that to absorb the information.16 cause differences from the spiritual Spiritual wellbeing (SWB) of most wellbeing of patients with cancer. research subjects in the study was at moderate levels (83.3%). The results of this study are in accordance with the CONCLUSION previous studies stated that SWB of most Based on the findings of this study, it is research subjects is at a moderate concluded that age statistically has level.6,17,18 However, this study revealed significant relationship with spiritual 1.6% of patients had bad level of spiritual wellbeing in patients with cancer. This wellbeing. study provides the insight of knowledge Findings of this research revealed regarding the factors affecting spiritual that there was a significant correlation wellbeing in patients with cancer. between age and spiritual wellbeing. This result is in line with Olver et al19 study Declaration of Conflicting Interest who indicated that there was a significant None declared relationship between age and SWB. The older the patients, the better the spiritual Funding wellbeing. But, this result is in contrast This study was supported by Program with the Kang et al20 study who found no Magister Keperawatan, Universitas significant relationship between age and Diponegoro, Semarang, Indonesia. SWB in patients with cancer. Similar with the relationship of type of cancer and Author Contribution SWB. The finding of this study was in All authors contributed equally in this line with the previous study,12 which the study. results showed no significant difference between SWB and cancer differences. References On the other hand, the other 1. Torre LA, Bray F, Siegel RL, demographic data such as gender, Ferlay J, Lortet‐Tieulent J, Jemal education and occupation in this study A. Global cancer statistics, 2012. were significantly unrelated to the CA: A cancer Journal for spiritual wellbeing level of the Clinicians. 2015;65(2):87-108. respondents. This is consistent with the 2. Ministry of Health of Indonesia. previous studies indicated that gender, Riset kesehatan dasar (Riskesdas) education and occupation did not affect 2013 [Basic health research the well-being of patients with cancer. 2013]. Jakarta: Ministry of Health 5,12,19 of Indonesia; 2013. It could be said that findings on the 3. Balboni T, Balboni M, Paulk ME, relationship between demographic et al. Support of cancer patients' characteristics and SWB in cancer patients spiritual needs and associations in this study have similarities and with medical care costs at the end differences with the other studies. This of life. Cancer. may be caused by several factors, namely 2011;117(23):5383-5391.

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4. Caldeira S, Carvalho ECd, Vieira of Behavioral Science (IJBS). M. Between spiritual wellbeing 2009;4(1): 59-69. and spiritual distress: Possible 11. Lindström LS, Li J, Lee M, et al. related factors in elderly patients Prognostic information of a with cancer. Revista Latino- previously diagnosed sister is an americana de Enfermagem. independent prognosticator for a 2014;22(1):28-34. newly diagnosed sister with breast 5. Elham H, Hazrati M, Momennasab cancer. Annals of Oncology. M, Sareh K. The effect of need- 2014;25(10):1966-1972. based spiritual/religious 12. Musarezaie A, Ghasemipoor M, intervention on spiritual well- Momeni-Ghaleghasemi T, being and anxiety of elderly Khodaee M, Taleghani F. A study people. Holistic Nursing Practice. on the efficacy of spirituality- 2015;29(3):136-143. based intervention on spiritual well 6. Musarezaie A, Naji-Esfahani H. being of patients with leukemia: A Investigation of the SWB and its randomized clinical trial. Middle relation with demographic East Journal of Cancer. parameters in patients with breast 2015;6(2):97-105. cancer referred to an oncology 13. Delgado-Guay MO, Hui D, hospital affiliated to the Isfahan Parsons HA, et al. Spirituality, university of medical sciences. religiosity, and spiritual pain in Journal of Education and Health advanced cancer patients. Journal Promotion. 2013;2: 42. of Pain and Symptom 7. Moodley T, Esterhuyse KGF, Management. 2011;41(6): 986- Beukes RBI. Factor analysis of the 994. spiritual well-being questionnaire 14. Faithfull S, Samuel C, Lemanska using a sample of South African A, Warnock C, Greenfield D. Self- adolescents. Religion and reported competence in long term Theology. 2012;19(1-2):122-151. care provision for adult cancer 8. Caldeira S, Carvalho EC, Vieira survivors: A cross sectional survey M. Spiritual distress—Proposing a of nursing and allied health care new definition and defining professionals. International characteristics. International Journal of Nursing Studies. Journal of Nursing Knowledge. 2016;53:85-94. 2013;24(2):77-84. 15. Ferlay J, Steliarova-Foucher E, 9. Ellison CW. Spiritual well-being: Lortet-Tieulent J, et al. Cancer Conceptualization and incidence and mortality patterns in measurement. Journal of Europe: estimates for 40 countries Psychology and Theology. 2006; in 2012. European Journal of 11:330-340. Cancer. 2013;49(6):1374-1403. 10. Imam SS, Karim NHA, Jusoh NR, 16. Soekidjo N. Promosi kesehatan Mamad NE. Malay version of dan perilaku kesehatan [Health spiritual well-being scale: Is Malay promotion and health behavior]. spiritual well-being scale a Jakarta. Rineka Cipta; 2012. psychometrically sound 17. Moeini M, Taleghani F, Mehrabi instrument? International Journal T, Musarezaie A. Effect of a

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spiritual care program on levels of Therapies in Health and Medicine. anxiety in patients with leukemia. 2012;18(5):18. Iranian Journal of Nursing and 20. Kang K, Im J, Kim H, Kim S, Midwifery Research. Song M, Sim S. The effect of 2014;19(1):88. logotherapy on the suffering, 18. Warner A, Hall K. Psychological finding meaning, and spiritual and spiritual well-being of women well-being of adolescents with with breast cancer participating in terminal cancer. Journal of the art of living program. In Hicks Current Directions in NL & Warren RE, Eds. Psychological Science. 2009;312. Psychology of Cancer. 2012. New York: Nova Science Publisher, Cite this article as: Suara E, Mardiyono, Inc. Anggorowati. Relationship between 19. Olver IN. A randomized, blinded demographic characteristics and spiritual study of the impact of intercessory wellbeing among cancer survivors. prayer on spiritual well-being in Belitung Nursing Journal. 2017;3(4):405- patients with cancer. Alternative 411. https://doi.org/10.33546/bnj.74

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Ulya FH, et al. Belitung Nursing Journal. 2017 August;3(4):412-419 Received: 1 March 2017 | Accepted: 31 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

COMPARISON OF EFFECTS OF MASSAGE THERAPY ALONE AND IN COMBINATION WITH GREEN COCONUT WATER THERAPY ON Β-ENDORPHIN LEVEL IN TEENAGE GIRLS WITH DYSMENORRHEA

Fitria Hikmatul Ulya¹*, Agus Suwandono¹, Ida Ariyanti¹, Ari Suwondo², Suryati Kumorowulan¹, Sri Endang Pujiastuti¹

1Magister Applied Midwifery, Poltekkes Kemenkes Semarang, Indonesia 2Fakultas Kesehatan Masyarakat, Universitas Diponegoro, Semarang, Indonesia

*Corresponding author: Fitria Hikmatul Ulya Magister Applied Midwifery, Poltekkes Kemenkes Semarang Jl. Tirto Agung, Pedalangan, Banyumanik, Kota Semarang, Jawa Tengah, Indonesia (50268) E-mail: [email protected]

ABSTRACT Background: Dysmenorrhea is pain during menstruation in lower abdomen, and is not due to other diseases. Effleurage massage and consuming green coconut water are considered able to reduce menstrual pain. However, little is known about the effect of the combination between the two interventions. Objective: To compare the effectiveness of effleurage massage and in combination with green coconut water on pain, anxiety, and ß-endorphin level in teenage girls with menstrual pain (dysmenorrhea). Design: A quasi-experiment with pretest-posttest approach design with control group. There were 36 samples recruited in this study by purposive sampling, which were divided into a massage therapy group, the combination therapy group, and a control group. Menstrual pain was measured using Numeric Rating Scale, while anxiety was measured using Zung Self rating Anxiety Scale (ZSAS), and endorphin level using ELISA (Enzyme-Linked Immunosorbent Assay). One-way ANOVA test and repeated ANOVA were performed as a bivariate analysis. MANCOVA and post hoc ANOVA were used for multivariate analysis. Result: The combination of massage and green coconut water was more effective in reducing pain (p 0.013) and anxiety levels (p 0.000), and in increasing β-endorphin (p 0.029) with significant value of <0.05 compared to the massage therapy alone. Conclusion: The combination of effleurage massage and green coconut water had significant effect in decreasing anxiety and pain levels, and increasing β-endorphin levels in teenage girls with painful periods (dysmenorrhea); and more effective than performing effleurage massage only. It is suggested that this combination therapy could be used as an alternative therapy for women with dysmenorrhea.

Keywords: massage, green coconut water, menstrual pain, β-endorphin levels, anxiety, dysmenorrhea

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Editor’s Note: This article has been updated on 13 July 2020 in terms of minor changes in the reference format. The update is based on BNJ policy on article correction. INTRODUCTION Prevalence rates of dysmenorrhea in the them cannot handle that because of the United States are 30-50 percent in women pain. Some are still able to work but with in reproductive age.1 Approximately 15% facial grimace of pain.7 However, this of them loose their job opportunities, and might affect mental and physical function. their schools and family life are In fact, the preliminary study revealed that damaged.1 The prevalence rate of most of the participants (100%) had dysmenorrhea in Thailand is as high as anxiety. Thus, the intervention to reduce 84.2% among female adolescents, which the pain is needed. cause low school attendance rates (21.1%) Most of women take pain relievers associated with severity of the symptoms.2 or prostaglandin inhibitors such as In Malaysia, the incidence of NSAIDs (non-steroids anti-inflammatory dysmenorrhea among students is 62.3%, drugs) in the form of ibuprofen, which had an effect on their study mefenamic acid, naproxen and aspirin are concentration (59.9%) and social widely used as initial therapy for interaction (58.6%).3 In Indonesia, the dysmenorrhe.8 However, these drugs have incidence of dysmenorrhea is 64.25%, side effects of gastrointestinal disorders consisting of 54.89% primary such as nausea, dyspepsia and vomiting.9 dysmenorrhea and 9.36% secondary The preliminary result showed that dysmenorrhea. The primary dysmenorrhea of the total number of the students, 70% is experienced by 60-75% of young of them took anti-pain medication, and women, with ¾ of them experiencing mild 30% of them only had some rests. By to moderate pain and ¼ experiencing seeing this phenomenon, this study aims severe pain.4 to propose the non-pharmacological The impact of dysmenorrhea cannot treatment to reduce menstrual pain by be ignored. Ten percent of high school giving massage or the combination of students cannot attend the class due to massage and green coconut water, which menstrual pain. 4 Research conducted by is safe, cheap, easy to do, and no side Dasuki concluded that the incidence of effects. Massage, such as effleurage dysmenorrhea in the area is around 97.6% massage, had a significant effect on pain and resulted in the disruption of daily in the previous study.10 Similar with green activities for 87.8 percent.5 coconut water had an effect on menstrual The preliminary study conducted by pain.11 researchers at SMK Duta Karya on 20 However, the effect of the students who had dysmenorrhea found combination between the two that 7 (35%) students experienced mild interventions is remarkable. It is assumed pain, 11 (55%) students had moderate that the combination will reduce pain pain, and 2 (10%) students with severe significantly, compared with one pain. intervention only. Dysmenorrhea, also known as Therefore, this study aims to painful periods, or menstrual cramps, is determine the effect of the combination of pain during menstruation in lower massage and green coconut water in abdomen, and is not due to other reducing menstrual pain, and compare diseases.6 It is often called as primary with the massage alone. dysmenorrhea. Although this condition is normal for every woman, but most of

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METHODS abdominal massage was given for 5 Design minutes was one of the massage A quasi experiment with pretest-posttest techniques by rubbing slowly and approach design with control group. circularly in the abdomen. The pure green coconut water was given as much as 250 Setting cc after given massage. In the control The study was conducted for 1.5 months group, the intervention such as giving at SMKN 1 Demak in November - pharmacological drugs or just taking some December 2016. rests were recommended.

Population and Sample Instrument There were 36 samples recruited in this Menstrual pain was measured using study by purposive sampling, which were Numeric Rating Scale with a pain score of divided into three groups, namely: 1) a 0-10, which 0: no pain, 1-3: mild pain, 4- group given massage therapy (12 6: moderate pain. Anxiety was measured respondents), 2) a group given the using Zung Self rating Anxiety Scale combination of massage and green (ZSAS) with score 20-40 refers to no coconut water (12 respondents), and 3) a anxiety, 40-60: mild anxiety, medium control group (12 respondents). The anxiety: 61-80, and severe anxiety: 81- inclusion criteria of this study included: a) 100. While β-endorphin level was the adolescent girls who were suffered measured using ELISA ((Enzyme-Linked from dysmenorrhea on the first day of Immunosorbent Assay), a biochemical menstruation for 3 consecutive months at technique primarily used in the field of least on the 1st – 3rd day, b) had been immunology to detect the presence of willing not to use any kind of therapies antibodies or antigens in a sample. other than therapy given by the researchers, c) was not afraid of syringes Ethical consideration when doing blood sampling, d) never Ethical clearance number for the study married and given birth, and e) had been was 021 / KEPK / Poltekkes-SMG / EC / willing to be a respondent and follow the 2017. Informed consent was given to the research procedure. The exclusion criteria respondents in the form of a written were: a) those who were diagnosed with statement of consent, which each certain gynecologic diseases, and b) respondent needs to approve and sign underwent pharmacologic treatment with without coercion (voluntary). painkillers. For those who did not follow the procedure, they were dropped out. Data analysis One-way ANOVA test and repeated Intervention ANOVA were performed as a bivariate For the massage group only, the analysis. MANCOVA and post hoc intervention was given 2 times per day for ANOVA were used for multivariate 3 days. While for the combination group, analysis. The MANCOVA test for testing the combined therapy was also given 2 the confounding factor whether the times per day for 3 days. The increase in beta-endorphin levels is interventions were performed by influenced by confounding or pure factors researchers and enumerators who were of the given intervention. Post hoc certified to give intervention. Effleurage

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ANOVA test was to see the effectiveness value 0.549. The average length of of the intervention. menstruation was 7 with p-value 0.956, RESULTS and the average of dysmenorrhea was 3 As shown in table 1, the result of with p-value 0.781. Thus, it can be descriptive analysis and homogeneity test concluded that the characteristics of the between group of massage, combination respondents were no different or group, and control group indicated that homogeneous (Sig.> 0.05). mean age of respondents was 16 with p-

Table 1 Respondent distribution in the group of massage, combination group (massage + green coconut water), and control group

Group Variable p-value Control Massage Combination Age (Year) Mean 15.67 16.25 15.92 0.549 Median 15.5 16 16 SD 0.985 0.754 0.996 Length of menstruation (day) Mean 6.58 6.58 6.92 0.956 Median 6.5 7 7 SD 0.9 0.992 1.084 Length of dysmenorrhea Mean 3.42 3.50 3.50 0.781 Median 3 3 3 SD 0.669 0.798 0.905

Table 2 Mean difference in anxiety level, pain, and endorphin levels before and after intervention among the three groups using One-way ANOVA

Group Variable p-value Control Massage Combination ß-Endorphin level Mean 241.42 221.96 203.50 0.294 Before SD 59.04 60.66 54.97 After Mean 244.33 283.74 282.72 0.046 SD 58.66 30.20 32.09 Anxiety level Mean 35.75 37.08 37.42 0.137 Before SD 2.491 1.975 1.782 After Mean 23.33 22.67 19.42 0.000 SD 2.741 2.015 2.109 Pain level Mean 5.50 5.58 5.17 0.569 Before SD 0.905 0.996 1.115 Mean 3.17 2.83 2.00 After 0.037 SD 0.937 1.267 1.044

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Table 2 shows that there was and pain level which showed the significant difference in β-endorphin level significant difference between the three after intervention among the combination, groups, with p-value of anxiety level was massage, and control groups with p-value 0.000 and pain level was 0.037. 0.046 (<0.05). Similar with the anxiety

Table 3 Mean difference in anxiety and pain level before and after intervention among the three groups using Repeated ANOVA

Variable Group Before After p-value Mean SD Mean SD Control group 35.75 2.491 23.33 2.741 0.000 Anxiety level Massage group 37.08 1.975 22.67 2.015 0.000 Combination group 37.42 1.782 19.42 2.109 0.000 Control group 5.50 0.905 3.17 0.937 0.000 Pain level Massage group 5.58 0.996 2.83 1.267 0.000 Combination group 5.17 1.115 2.00 1.044 0.000

Table 3 shows that there were anxiety and pain levels among the three statistically significant differences in groups with p-value < 0.05.

Table 4 Mean difference in β-endorphin level before and after intervention among the three groups using Friedman test

Variable Group Mean p-value Rank Control group 3.17 ß-Endorphin Massage group 4.83 0.000 level Combination group 5.00

Table 4 shows that the mean of β- value 0.000 (<0.05), indicated that there endorphin level in the combination group was statistically significant difference of was higher than β-endorphin level in the β-endorphin level among the three groups other two groups. Friedman test shows p-

Table 5 Confounding factors on anxiety level, pain, and β-endorphin levels using MANCOVA

p-value Variable Age Length of Length of menstruation dysmenorrhea Pain level 0.780 0.592 0.606 Anxiety level 0.711 0.631 0.846 β-endorphin level 0.217 0.489 0.272

MANCOVA test in Table 5 shows of menstruation, and length of that there were no significant relationships dysmenorrhea) with pain, anxiety, and between confounding factors (age, length endorphin level with p-value >0.05.

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Table 6 Comparison the effect of massage and combined massage-green coconut water on anxiety level, pain, and β-endorphin levels using Post Hoc ANOVA

Variable Group Mean p-value Difference Anxiety level Massage group 0.667 0.485 Combination 3.917 0.000 Pain level Massage group 0.333 0.460 Combination 1.167 0.013 ß-Endorphin level Massage group 38.39 0.030 Combination 39.41 0.029

Post-hoc ANOVA test shows that circulation, put pressure, warm the the combination of massage and green abdominal muscles, and increase physical coconut water was more effective in and mental relaxation.13 The mechanical reducing pain and anxiety levels with p- effect of effleurage technique is to help value <0.05 compared to the massage the vein work and cause body heat as only. But similar effect in increasing β- warming up. The physiological influence endorphin levels with p-value <0.05. of strong rubbing of the massage affects However, the combination group is a the circulation of blood in the deepest higher than massage group alone. tissues and in the muscles, which is a safe, easy, costless, no side effects, and can be DISCUSSION done alone or with the help of others. 13,14 Characteristics of respondents such as In addition, during massage, the age, length of menstruation and body secretes endorphin compound as a dysmenorrhea are often associated with natural body pain reliever and also create pain levels during menstruation. Age less a comfortable feeling. This was supported than 20 years is considered as a primary by previous study on the gate control risk factor for dysmenorrhea.12 It is theory of pain asserts that non-painful estimated that 50% of young women aged input closes the "gates" to painful input, between 15 and 24 experience pain during which prevents pain sensation from mestruation.12 However, findings of this traveling to the central nervous system.15 study revealed that there was no Therefore, stimulation by non-noxious significant relationship of age factor, input is able to suppress pain. Similarly, length of menstruation and duration of the massage that has a distraction effect dysmenorrhea with the level of anxiety, can also increase the formation of pain and β-endorphin. endorphins in the control system Findings of this study revealed that descendent. Massage can make patients both effleurage massage only and more comfortable due to muscle combined massage and green coconut relaxation. It is one non-pharmacological water had a significant effect on anxiety method that is considered effective in level, pain, and β-endorphin levels. reducing pain. 13,14 However, the combined intervention is On the other hand, green coconut much more effective compared with the water contains magnesium, which can effleurage massage only. overcome the pelvic flush due to muscle It is because effleurage massage relaxant effect during dysmenorrhea. technique aims to improve blood Magnesium also contributes to the

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 417 formation of serotonin neurotransmitter that performing effleurage massage and that can increase appetite, feelings of consuming green coconut water could be happiness and anti-depression.16 In used as an alternative therapy for women addition to serotonin, magnesium also with dysmenorrhea. Further research is plays a role in the formation of endorphin needed to explore the working mechanism and enkephalin neuropeptides that play a of some composition of green coconut role in the perception of pain received by water besides magnesium that can nerve endings.16 Magnesium has an decrease menstrual pain. important role in physiological processes of the body, particularly in the inhibition Declaration of Conflicting Interest of acetylcholine presinaps and N-Methyl- None declared. D-aspartic acid (NMDA) that inhibit Funding signal transduction, so that the pain and contraction are decreased.17 Another This study was supported by Magister Applied Midwifery, Poltekkes Kemenkes Semarang, function of magnesium is an inhibitor of Indonesia. neuromuscular junction and inositol triphosphate that play a role in the Author Contribution opening of calcium channel and inhibiting All authors contributed equally in this study. catecholamine secretion which implies in decreasing the strength of uterine References contractions and improvement of blood 1. French L. Dysmenorrhea. American supply, which decrease the pain Family Physician. 2005;71(2). sensation.16,17 2. Tangchai K, Titapant V, It can be said that magnesium Boriboonhirunsarn D. Dysmenorrhea contained in the green coconut water can in Thai adolescents: Prevalence, impact and knowledge of treatment. help relax the tension of the uterine Journal-Medical Association of muscle during menstruation, and working Thailand. 2004;87:S69-S73. together with the effect of massage 3. Liliwati I, Verna LKM, Khairani O. effleurage, thus making anxious and pain Dysmenorrhoea and its effects on levels decreased as well as lowering the school activities among adolescent prostaglandin hormone that affects the β- girls in a rural school in Selangor, endorphin hormone endorphin as a Malaysia. Medicine & Health. precursor of relaxation and calm and 2007;2(1):42-47. comfort. However, this study did not 4. Hendrik H. Problema haid: Tinjauan examine the levels of prostaglandins syariat Islam dan medis hormone. [Menstruation problem: Islamic and medical review]. Surakarta,

Indonesia: Tiga Serangkai; 2006. CONCLUSION 5. Dasuki D. Perilaku pencarian It is concluded that the combination of pengobatan keluhan dysmenorrhea effleurage massage and green coconut pada remaja di Kabupaten Purworejo water had significant effect in decreasing Propinsi Jawa Tengah [Treatment anxiety and pain levels, and increasing β- seeking behavior for dysmenorrhea in endorphin levels in teenage girls with adolescents of Purworejo Regency of painful periods (dysmenorrhea); and more Central Java Province]. Yogyakarta: effective than performing effleurage Universitas Gadjah Mada; 2006. massage only. Therefore, it is suggested 6. Osayande AS, Mehulic S. Diagnosis and initial management of

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dysmenorrhea. American Family 13. Alifa S. Efek teknik masase effleurage Physician. 2014;89(5):341-346. pada abdomen terhadap penurunan 7. Proverawati A, Misaroh S. Menarche intensitas nyeri pada disminore menstruasi pertama penuh makna primer mahasiswa [Effect of [Menarche: Meaningful first effleurage massage in the abdominal menstruation]. Yogyakarta: Nuha area on pain intensity of primary Medika; 2009. dysmenorrhea in students]. Malang: 8. Dawood MY. Primary dysmenorrhea: PSIK FKUB; 2012. Advances in pathogenesis and 14. Purwanti HS. Konsep penerapan ASI management. Obstetrics & eksklusif [Exclusive breastfeeding Gynecology. 2006;108(2):428-441. concept]. Jakarta: EGC; 2004. 9. Harel Z. Dysmenorrhea in adolescents 15. Kandel ER, Schwartz JH, Jessell TM, and young adults: etiology and Siegelbaum SA, Hudspeth AJ. management. Journal of Pediatric Principles of neural science. Vol 4: and Adolescent Gynecology. New York: McGraw-hill; 2000. 2006;19(6):363-371. 16. Guerrera MP, Volpe SL, Mao JJ. 10. Nurkhasanah SS, Fetrisia WW. Therapeutic uses of magnesium. Pengaruh masase effleurage terhadap American Family Physician. penurunan intensitas skala nyeri 2009;80(2). disminore pada siswi kelas IX MTsN 17. De Souza MC, Walker AF, Robinson 1 Bukittinggi tahun 2014 [Effect of PA, Bolland K. A synergistic effect of effleurage massage in lowering pain a daily supplement for 1 month of 200 intensity of dysmenorrhea in students mg magnesium plus 50 mg vitamin at class IX MTsN 1 Bukittinggi in B6 for the relief of anxiety-related 2014]. Jurnal Kesehatan STIKes premenstrual symptoms: A Prima Nusantara Bukittinggi. randomized, double-blind, crossover 2015;5(2). study. Journal of Women's Health & 11. Lestari F. Pengaruh pemberian air Gender-Based Medicine. 2000;9(2): kelapa hijau terhadap tingkat nyeri 131-139. haid pada mahasiswi Program Studi Ilmu Keperawatan STIKES 'Aisyiyah Cite this article as: Ulya FH, Suwandono Yogyakarta [Effect of coconut water A, Ariyanti I, Ari Suwondo A, on menstrual pain in nursing students Kumorowulan S, Pujiastuti SE. of STIKES 'Aisyiyah Yogyakarta]. Comparison of effects of massage therapy Yogyakarta: STIKES 'Aisyiyah; alone and in combination with green 2015. coconut water therapy on β-endorphin level 12. Bobak IM, Lowdermilk DL, Jensen in teenage girls with dysmenorrhea. MD. Buku ajar keperawatan Belitung Nursing Journal. 2017;3(4):412- maternitas [Maternity nursing 419. https://doi.org/10.33546/bnj.158 textbook]. Jakarta: EGC; 2005.

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Karo HYK, et al. Belitung Nursing Journal. 2017 August;3(4):420-425 Received: 3 March 2017 | Accepted: 31 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

LAVENDER (LAVANDULA ANGUSTIFOLIA) AROMATHERAPY AS AN ALTERNATIVE TREATMENT IN REDUCING PAIN IN PRIMIPAROUS MOTHERS IN THE ACTIVE FIRST STAGE OF LABOR

Hilda Yani Karo Karo*, Noor Pramono, Sri Wahyuni, Imam Djamaluddin Mashoedi, Leny Latifah

Postgraduate Midwifery Program, Poltekkes Kemenkes Semarang, Indonesia

*Corresponding author: Hilda Yani Karo Karo Postgraduate Midwifery Program, Poltekkes Kemenkes Semarang Jl. Tirto Agung, Pedalangan, Banyumanik, Kota Semarang, Jawa Tengah, Indonesia (50268) E-mail: [email protected]

ABSTRACT Background: Labor and childbirth is an extremely painful process. Aromatherapy is considered as one of the nonpharmacological methods to reduce labor pain. Objective: To determine the effect of lavender (Lavandula Angustifolia) aromatherapy on the level of pain in primipara in the first stage of labor. Methods: A quasi-experimental research with pretest and posttest design with control group conducted between October until November 2016. Forty respondents selected using consecutive sampling, which 20 assigned in each group. a Numerical Rating Scale (NRS) pain scale was used. Paired and independent t-test were used for data analyses. Results: The results showed that the p-value of labor pain after intervention was 0.000 (<0.05), which indicated that there was statistically mean difference of labor pain between intervention group (6.10) and control group (4.05) in primipara in the first active stage of labor. Conclusion: The women in the lavender aromatherapy group reported lower intensity of labor pain. The intervention study could be practiced in the community health centers for pregnant women in order for them to apply this healing method.

Keywords: labor pain, lavender aromatherapy, primipara

INTRODUCTION Despite being a natural process, labor and tension of smooth muscle and childbirth is an extremely painful vasoconstriction of blood vessels.2 This process.1 Many women are fearful and can decrease uterine contractions, blood anxious about the pain, which lead to flow, and oxygen to the uterus, and the excessive release of hormones such as onset of uterine ischemia that leads to catecholamines and steroids that can cause more pain. The long-term pain causes

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Editor’s Note: This article has been updated on 13 July 2020 in terms of minor changes in the reference format. The update is based on BNJ policy on article correction. hyperventilation with respiratory of linalool oil (51%) and linalyl acetate frequency 60-70 times per minute, (35%).6 Lavender is also the most popular decreases the maternal PaCO2 level, and and safest oil to use, which can increase increases the pH. If the mother's PaCO2 alpha waves in the brain and help to create levels are low then the fetal PaCO2 levels a relaxed state and reduce anxiety.7 will be low too, then resulting in Mothers who are undergoing birth, deceleration of the fetal heart rate. In soaking with lavender oil can reduce pain addition, pain causes uncoordinated in the perineal area and reduce anxiety.7 uterine activity and leads to prolonged Research on the effect of labor that can ultimately threaten fetal and aromatherapy using lavender had been maternal life, and leads to increased studied in Kediri Indonesia, and it is systole blood pressure resulting in the proven effective in reducing pain in potential for cardiogenic shock.3 mothers during the first stage of labor.8 Intensity of labor pain in primiparas However, it is assumed that the is often more severe than labor pain in aromatherapy might not affect all mothers multiparas. It is because multipara in Indonesia, due to different taste in mothers experience cervical thinning using lavender for treatment. Besides, coinciding with cervical dilatation, while bigger sample size is presented in this in primipara the cervical thinning process study. Therefore, the study aimed to occurs earlier than cervical dilatation.4 determine the effect of lavender as This process causes the intensity of the aromatherapy in reducing pain in mother primiparous contraction to be more severe during the first stage of labor in Deli than multiparous, especially in the first Serdang, North Sumatera, Indonesia. stage of labor. Preliminary survey during October - December 2015 in the working area of the Community Health Center of METHODS Delitua showed that there were 42.55% of Design primigravida had normal duration of the A quasi experimental research with pretest first stage of labor (10-14 hours), 27.65% and posttest design with control group. of primigravida had more than 14 - 20 hours duration, and 10.63% of Setting primigravida had more than 20-24 hours The research was conducted for 2 months duration of the first stage of labor. between October until November 2016 in Therefore, the intervention to reduce pain the Labor Clinic in the working area of that leads to long-term duration of the the Community Health Center of Delitua stage of labor in primipara is needed. in Deli Serdang Regency. Aromatherapy is one of the interventions considered as an alternative Sample therapy to reduce the pain in primipara. Forty respondents selected using Aromatherapy is a therapy that uses consecutive sampling, which 20 assigned essential oils to help improve or maintain in each group. The inclusion criteria health, encourages, refreshes and awakens included the primigravida in the first body spirit.5 Lavender (Lavandula active phase of labor (cervix is dilated angustifolia) is one of the essential oil- from 4-10 cm), the height of fundus uteri producing flowers, which can be used for was 32 cm - 38 cm above the symphysis, aromatherapy with the main components

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 421 presentation of the back of the head, and the influence of lavender aromatherapy on willing to be respondent. the level of pain in primigravida. Chi square test was also performed for testing Instruments confounding factors. A research instrument to measure pain used a Numerical Rating Scale (NRS) Ethical consideration pain scale in the range of 0-10, which The study permission was obtained from indicates that 0 refers to no pain, 1-3 Department of Health of Deli Serdang and refers to mild pain, 4-6 moderate pain, and the Community Health Center of Delitua. 7-10 refers to severe pain.9 Pain was The study has been approved by the measured before and after intervention. Ethical Research Committee with No. 278/KEPK/Poltekkes-Smg/EC/2016. The Intervention researchers have confirmed that each Lavender essential oil was used as respondent have obtained an appropriate aromatherapy in 10 ml of each pack. The informed consent. lavender aromatherapy has been applied in the electric aromatherapy diffuser, which was turned on for 5 minutes in an RESULTS intervention room. When the room was Table 1 shows that the average of age of ready, then the researcher invited the respondents in the intervention and respondents to the room for 30 minutes. control group was 23 years old, and the cervix dilation was 6. There were no Data analysis effects of age and cervix dilation on labor There was no difference in characteristics pain as the result of chi square with p of the respondents and labor pain with p- 0.855 for age, and p 0.314 for cervix value <0.05. Paired and independent t-test dilation (<0.05). were used for data analysis to determine

Table 1 Age and cervix dilation of the respondents and its influence on labor pain

Group N Mean SD Min. Max. Median P-value (Chi Square) Age (Year) Intervention 20 23.55 2.16 20 27 24 0.855 Group 20 23.70 2.92 20 29 24 Cervix Dilation Intervention 20 6.10 1.210 4 8 6 0.314 Group 20 5.65 1.599 4 8 5

Table 2 Anxiety level in the primigravida mothers and its influence on labor pain using chi-square test

Group N Mild Moderate P-value N % N % (Chi Square) Intervention 20 8 40 12 60 0.114 Group 20 7 35 13 65

Table 2 shows that 40% of mild anxiety and 60% had moderate respondents in the intervention group had anxiety, while 35% respondents in the

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 422 control group had mild anxiety and 65% labor pain with p-value of chi square of them had moderate anxiety. There was result 0.114 (<0.05). no significant influence of anxiety on

Table 3 Fatigue in the primigravida mothers and its influence on labor pain using chi-square test

Group N Yes No P-value N % N % (Chi Square) Intervention 20 12 60 8 40 0.527 Group 20 10 50 10 50

As shown in the Table 3, 60% of There was no significant influence of respondents in the intervention group and fatigue on labor pain with p-value of chi 50% in the control group had fatigue. square result 0.527(<0.05).

Table 4 Distribution of Labor Pain in the in the intervention and control group using independent t-test

Pain Group Mean Mean t P-value Difference Pre-test Control 6.55 -0.30 -0.88 0.381 Intervention 6.85 Post-test Control 6.10 2.05 5.72 0.000 Intervention 4.05

Table 4 shows that the mean of pain which indicated that there was statistically during pre-test between intervention and mean difference of labor pain between control group had no difference with p- intervention (6.10) and control group value 0.381 (p <0.05), while p-value of (4.05). pain after intervention was 0.000 (<0.05),

Table 5 Effect of lavender aromatherapy on labor pain in the intervention and control group using paired t-test

Pain Mean SD t P-value Control (Pre-Post) 0.450 0.945 2.13 0.046 Intervention (Pre-Post) 2.800 1.196 10.46 0.000

Table 5 shows that the mean of pain group compared to the decrease of pain in before and after intervention in the control the control group. group was 0.450 with t count 2.13 and p- value 0.046 (<0.05), while the mean of pain before and after intervention in the DISCUSSION intervention group was 2.800 with t count Age factor, cervical dilation, anxiety 10.46 and p-value 0.000 (<0.05), which level, and maternal fatigue are often indicated that there was a significant associated with pain before childbirth.10,11 effect of aromatherapy in the intervention Therefore, suitable planning and group and standard treatment in control performing midwifery interventions to group on labor pain. However, the higher control the pain during delivery seem to decrease of pain was in the intervention be necessity. However, the result of the present study showed that these factors

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 423 have not been associated with labor pain. the primiparous women in the North of The results of this study revealed Sumatera Indonesia and has proven that there was a significant difference of effective in reducing labor pain. labor pain before and after lavender aromatherapy. This finding supports the finding of the previous study that shows a CONCLUSION significant influence of lavender According to the results of this study, the aromatherapy to reduce maternal pain women in the lavender aromatherapy during the first stage of labor.12 A semi- group reported lower intensity of labor experimental clinical trial found that pain. This intervention study could be women who were treated with lavender practiced in the community health centers aromatherapy during labor reported a for pregnant women in order for them to lower intensity of pain than women in a apply this healing method. control group.1 Similar with study of Kaviani revealed that The mean of pain Declaration of Conflicting Interest intensity perception in the aroma group None declared. was lower than that of the control group at Funding 30 and 60 minutes after the aromatherapy 13 This study was supported by Postgraduate intervention (p< 0.001). However, the Midwifery Program, Poltekkes Kemenkes result of this study was in contrast with Semarang, Indonesia. the Burns et al study who reported that aromatherapy scent had little effect on the Author Contribution pain realization of the primiparous All authors contributed equally in this study. women.14 Similar with Yazdkhast References revealed that there was no difference in 1. Lakhan SE, Sheafer H, Tepper D. The mean duration of the active phase of effectiveness of aromatherapy in reducing 15 labor. pain: A systematic review and meta- Aromatherapy affects the body in analysis. Pain Research and Treatment. three ways: pharmacological effects of the 2016:8158693. hormones and enzymes that can cause 2. Rukiyah AY. Asuhan Kebidanan II chemical changes in the body; (Persalinan) [Midwifery care II (Labor)]. psychological effects, including relaxation Jakarta: Yayasan Bina Pustaka; 2009. 3. Astuti R. Pengaruh aromaterapi terhadap and sedative effects on the body; and nyeri persalinan kala I di Bidan Praktik physiological effects resulting from the Swasta Kecamatan Polokarto [Effect of brain’s response to inhaling aromas.13,16 aromatherapy on pain of labor stage I at The studies conducted on the issue have Bidan Praktik Swasta Kecamatan shown that lavender aroma might suppress Polokarto]. Central Java: Universitas the activity of the sympathetic nervous Jenderal Soedirman; 2009. 4. Winkjosastro GH. Fisiologi janin dalam system.13,17 Volatile compounds may enter Ilmu kebidanan [Fetal physiology in the bloodstream through the nasal or lung obstetrics]. Jakarta: PT Bina Pustaka mucosa, or directly diffuse into the Sarwono Prawirohardjo; 2008. olfactory nerve and pass up to the limbic 5. Bagharpoosh M, Goodarzi GSM. Effect of system which can influence the progressive muscle relaxation technique on sympathetic nervous system.18 pain relief during labor. Acta Medica The results of this study indicated Iranica. 2006;44(3):187-190. that the lavender aromatherapy fits with 6. Yanti S, Keb M. Buku ajar asuhan kebidanan persalinan [Textbook on

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midwifery care in delivery]. Yogyakarta: intensitas nyeri persalinan fisiologis pada Pustaka; 2010. primipara inpartu kala satu fase aktif di 7. Cunningham F, Leveno K, Bloom S, BPM “Fetty Fathiyah” Kota Mataram Spong CY, Dashe J. Williams Obstetrics. [Effect of inhalation of lavender 24th ed. New York: McGraw-Hill; 2014. aromatherapy on physiology labor pain in 8. Kumalasari EP. Studi tentang manfaat primipara at sstage I active phase at BPM aromaterapi (aroma lavender) terhadap “Fetty Fathiyah” Kota Mataram]. Majalah penurunan tingkat nyeri ibu pada Kesehatan FKUB. 2016;2(2):108-119. persalinan kala I fase aktif di Bidan 13. Kaviani M, Azima S, Alavi N, Tabaei MH. Praktek Swasta Wilayah Kerja Puskesmas The effect of lavender aromatherapy on Ngletih Kecamatan Pesantren Kota Kediri pain perception and intrapartum outcome [Study on benefits of lavender in primiparous women. British Journal of aromatherapy in lowering pain in mothers Midwifery. 2014;22(2). during develivery stage I active phase at 14. Burns E, Zobbi V, Panzeri D, Oskrochi R, Bidan Praktek Swasta Wilayah Kerja Regalia A. Aromatherapy in childbirth: a Puskesmas Ngletih Kecamatan Pesantren pilot randomised controlled trial. BJOG: Kota Kediri]. Kediri, Indonesia: Sekolah An International Journal of Obstetrics & Tinggi Ilmu Kesehatan Surya Mitra Gynaecology. 2007;114(7):838-844. Husada. 2012. 15. Yazdkhasti M, Pirak A. The effect of 9. Judha M. Teori pengukuran nyeri dan aromatherapy with lavender essence on nyeri persalinan [Theory of measurement severity of labor pain and duration of labor of pain and labor pain]. Yogjakarta: Muha in primiparous women. Complementary Medika; 2012. Therapies in Clinical Practice. 10. Sinambela M. Pengaruh tingkat kecemasan 2016;25:81-86. dan mekanisme koping ibu primigravida 16. Trevelyan JE, Booth B. Complementary terhadap lamanya kala I persalinan medicine for nurses, midwives and health spontan di Klinik Bersalin Swasta Wilayah visitors. New York: Macmillan; 1994. Kerja Puskesmas Deli Tua Kabupaten Deli 17. Heuberger E, Redhammer S, Buchbauer G. Serdang tahun 2013 [Effect of anxiety and Transdermal absorption of (-)-linalool coping mechanism of primigravida mothers induces autonomic deactivation but has no on the duration of stage I of spontneous impact on ratings of well-being in humans. delivery at Klinik Bersalin Swasta Wilayah Neuropsychopharmacology. Kerja Puskesmas Deli Tua Kabupaten Deli 2004;29(10):1925. Serdang in 2013]. Medan, Indonesia: 18. Toda M, Morimoto K. Effect of lavender Universitas Sumatera Utara. aroma on salivary endocrinological stress 11. Sulistyowati DID. Efektifitas terapi aroma markers. Archives of Oral Biology. lavender terhadap tingkat nyeri dan 2008;53(10):964-968. kecemasan persalinan primipara kala I di Rumah Sakit dan Klinik Bersalin Cite this article as: Karo HYK, Pramono Purwokerto [Effect of lavender N, Wahyuni S, Mashoedi ID, Latifah L. aromatherapy on pain and anxiety of Lavender (Lavandula Angustifolia) delivery in primipara at stage I at hospital aromatherapy as an alternative treatment and delivery clinic of Purwokerto]. Jakarta: in reducing pain in primiparous mothers in Universitas Indonesia. Fakultas Ilmu the active first stage of labor. Belitung Keperawatan; 2009. Nursing Journal. 2017;3(4):420-425. 12. Karlina SD, Reksohusodo S, Widayati A. https://doi.org/10.33546/bnj.159 Pengaruh pemberian aromaterapi lavender secara inhalasi terhadap penurunan

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Mardiyah A, et al. Belitung Nursing Journal. 2017 August;3(4):426-431 Received: 725 May 2017 | Revised: 19 June 2017 | Accepted: 31 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

FUNCTIONAL STATUS IN PATIENTS WITH CHRONIC KIDNEY DISEASE BEING TREATED WITH HEMODIALYSIS IN PKU MUHAMMADIYAH HOSPITAL, YOGYAKARTA, INDONESIA

Adiyati Mardiyah1*, Anggorowati1 , Andrew Johan2

1Master of Nursing, Faculty of Medicine, Diponegoro University, Semarang, Indonesia 2Faculty of Medicine, Diponegoro University, Semarang, Indonesia

*Corresponding author: Adiyati Mardiyah Master of Nursing, Faculty of Medicine, Diponegoro University, Jl. Prof. Soedarto, Tembalang, Kec. Tembalang, Kota Semarang, Jawa Tengah 50275, Indonesia. E-mail: [email protected] ABSTRACT Background: Hemodialysis process is useful for patients with end-stage renal disease. However, this is a situation of abject dependence on a machine, a procedure and a group of qualified medical professionals for the rest of their lives that may influence their functional status. Objective: This study aims to describe the functional status of patients with chronic kidney disease undergoing hemodialysis. Method: This was a descriptive study with cross-sectional design, which conducted in the PKU Muhammadiyah Hospital Yogyakarta Indonesia on March 2017. There were 78 patients selected using purposive sampling. Functional status was measured using SF-36 questionnaire. Descriptive statistic was performed for data analysis Result: The total average of functional status level was 42.92, with Physical Component Scale (PCS) of 42.31 and Mental Component Scale (MCS) of 45.78. Conclusion: There were functional deficiencies in both physical and mental status in patients with chronic kidney disease undergoing hemodialysis. Thus, it is suggested that pharmacological management of these patients need stringent monitoring on part of the psychiatrist to deal with mental health problems, and the interdisciplinary team need to do great efforts to improve functional status and quality of life of patients with chronic kidney disease.

Keywords: hemodialysis, functional status, chronic kidney disease

INTRODUCTION Chronic kidney disease is a general term partly to cause and pathology, severity, for heterogeneous disorders affecting the and rate of progression. The definition of structure and function of the kidney.1 The chronic kidney disease is based on the variation in disease expression is related presence of kidney damage (i.e.,

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Editor’s Note: This article has been updated on 13 July 2020 in terms of the completeness of correspondence address. The update is based on BNJ policy on article correction. albuminuria) or decreased kidney function Based on theoretical analysis, (i.e., glomerular filtration rate [GFR] <60 functional status is seen as mL/min per 1·73 m²) for 3 months or multidimensional consisting of behavior more, irrespective of clinical diagnosis. 1,2 (daily performance or activity), Chronic kidney disease consists of various psychological (mood), cognitive stages, where the final stage of chronic (attention, concentration), and social kidney disease is called end-stage renal (activities related to roles according to disease (ESRD). stage of development).7 Functional status Based on the data from United is an ability of individuals to use their Stated Renal Data System (USRDS),3 it is physical capacity to fulfill their life known that there were 678,383 prevalent obligations to carry out physical activity, cases of ESRD; the unadjusted prevalence self-care, maintenance, and obligation to (crude proportion) was 2,067 per million interact with others, so as to improve the in the U.S. population in 2014. This health of individuals. 7 increased rate also occurs in Indonesia Complications that occur in patients which the data show that patients with who undergo hemodialysis include chronic kidney disease continues to rise.3 discomfort, increased stress, and low According to PT. ASKES, the number of quality of life.6 Preliminary result showed chronic kidney diseases cases was 17,507 that patients undergoing hemodialysis people in 2010, which continues to rise by experience decreased muscle strengths about 23,261 cases in 2011, and 24,141 and fatigue. Most of the patients felt bored cases in 2012. While based on Riskesdas,4 with the treatment, which might trigger the number of patients with chronic distress and lead to psychological kidney disease in Indonesia reached problem. Therefore, the purpose of this 504.248 persons, and in 2011 study was to describe the functional status approximately 12,500 patients had end- of patients with chronic kidney disease stage renal disease who needed routine undergoing hemodialysis. hemodialysis, with 4,445 patients from West java, followed by Yogyakarta (1,914 METHODS patients), Bali (1,847 patients), and Study Design Central Java (725 patients). 4 This was a descriptive study with cross- Hemodialysis process is very useful sectional design, which conducted in the for patients with end-stage renal disease. PKU Muhammadiyah Hospital However, complication may occur to the Yogyakarta on March 2017. patients who undergo hemodialysis, which will influence functional status of Population and Sample patients.5 Functional status is an ability to The target population in this study was perform daily activities, including in patients with chronic kidney disease who doing a job, self-care, and taking care of underwent routine hemodialysis at PKU family or social roles, as well as personal Muhammadiyah Hospital, Yogyakarta. function in various fields, like physical There were 78 patients selected using health, the quality of self-care and role purposive sampling. The inclusion criteria activity, intellectual status, social to select sample were: 1) patients who activities, attitudes toward the world and received a regular hemodialysis twice a against self, and emotional status.6 week, 2) long-term treatment at least 1

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 427 year or more, 3) no interference with Data Analysis musculoskeletal and nervous system. Descriptive statistic was performed for data analysis to describe frequency Instruments distribution and the mean and standard Functional status was measured using SF- deviation. 36 questionnaire, which adopted from Safarudin (2012)8 in Indonesian version. Ethical Consideration The SF-36 questionnaire consists of: 1) This study has been ethically approved by Physical component scale dimension the Health Research Ethics of Faculty of (PCS) consisting of Physical function Medicine of Diponegoro University and (PF), Role Physical (RP), Bodily Pain Dr. Kariadi Hospital Semarang with No. (BP), General Health (GH), Vitality (VT), 81/EC/FK.RSDK/III/2017. The Social Function (SF), and 2) Role and researchers have confirmed that all dimension of Mental component scale respondents have obtained appropriate (MCS) consisting of Role Emotional (RE) informed consents. and Mental Health (MH) aspects which have been used extensively by the RESULTS hemodialysis population. There are 8 Table 1 shows that the number of the dimensions with 36 items. If the score < respondents was 78 with 61.5% of males 60, means low functional status; and if the and 38.5% of females. The majority of the score 100, means very good functional respondents aged 41-50 years (69.2%), status. The instrument has been validated with senior high school level background with the result of coefficient correlation (74.4%), and unemployed (75.64%). Most was 0.3, and Cronbach alpha was 0.898. of respondents had a hemodialysis treatment for 2-4 years (78.2%).

Table 1 Frequency distribution of the characteristics of the respondents based on age, gender, education, employment status, and length of hemodialysis treatment (n=78)

Characteristic of respondents Frequency % Gender Men 48 61.5 Women 30 38.5 Education Junior High School 12 15.4 Senior High School 58 74.4 University 8 10.2 Age (year) 31-40 19 28.4 41-50 54 69.2 >50 5 6.4 Employment status Employed 19 24.35 Unemployed 59 75.64 Length of hemodialysis treatment 2-4 years 61 78.2 4-6 years 14 17.9 >6 years 3 3.84

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Table 2 The level of functional status (n= 78)

Functional Status SF-36 Dimensions Mean SD Physical Function (PF) 50.13 7.68 Role Physical (RP) 29.49 9.65 Bodily Pain (BP) 47.95 5.97 General Health (GH) 36.21 8.72 Vitality (VT) 39.23 7.93 Social Function (SF) 49.67 6.03 Role Emotional (RE) 35.89 8.94 Mental Health (MH) 49.07 8.88 Physical component scale (PCS) 42.31 4.70 Mental component scale (MCS) 45.78 8.69 Total SF-36 42.92 4.39

Table 2 shows that the total score of Functional status in this study was SF-36 dimension was 42.92, with physical measured in terms of physical and mental component scale was 42.31 and mental component scale. Physical component component scale was 45.78. This score aspect is related to the ability or limitation indicates that the functional status of in doing daily activity, such as walking, patients undergoing hemodialysis was walking up the stairs, and any other low. Of 8 dimensions, the role physical activities. This self-limited condition is dimension was the lowest. associated with muscle weakness, as the complication of hemodialysis. In addition, DISCUSSION Physical inactivity is associated with This study aims to describe the functional higher levels of fatigue in ESRD status of patients with chronic kidney patients.11I Fatigue is one of the most disease undergoing hemodialysis with SF- frequent complaints of dialysis patients 36 dimensions. The majority of the and is associated with impaired health- respondents aged 41-50 years (69.2%). It related quality of life (HRQOL).12 The is in contrast with previous studies which prevalence of fatigue ranges from 60% to stated that Chronic kidney disease (CKD) as high as 97% in patients on long-term is common in the elderly,9 and the renal replacement therapy.13 Fatigue is a predicting a further increase in prevalence subjective sense of weakness, lack of is occurring among those aged 65 years energy, and tiredness.14 and older.2 On the other hand, patients with Findings of this study revealed that chronic kidney disease undergoing the functional status patients with chronic hemodialysis cause psychiatric symptoms kidney disease undergoing hemodialysis and it is worth noting the same to avoid the PKU Muhammadiyah Hospital confusion. The most common psychiatric Yogyakarta remains low. This is in line complication occurring as a result of renal with previous study indicated that patients failure is depression in the patient and with terminal renal failure who undergo anxiety in the associated partner.15 Most hemodialysis have decreased vitality, dialysis patients who are employed may physical and psychological functioning, seldom return to full time work activity. It resulting in a decline in their quality of can be seen that 75.64% of patients in this life.10 study were unemployed. Work in addition

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 429 to a source of income is often associated 2. Stevens LA, Levey AS. Current status with a sense of accomplishment, self- and future perspectives for CKD testing. esteem and identity in most patients. 16 In American Journal of Kidney Diseases. addition, Extreme anxiety and anxiety 2009;53(3):S17-S26. somatic symptoms such as breathlessness, 3. United States Renal Data System. 2016; http://www.usrds.org/2016/view/v2_01.a palpitations, chest pain, sweating and fear spx. Accessed 25 August, 2016. of dying may occur in renal failure cases. 4. Minsitry of Health of Indonesia. Riset It is also noteworthy that when depressed, kesehatan dasar (Riskesdas) 2013 [Basic the dialysis patient has at his disposal a health research 2013]. Jakarta: Minsitry very effective method of escape i.e. of Health of Indonesia. 2013. suicide.16 5. Nitta K, Okada K, Yanai M, Takahashi This study provided the information S. Aging and chronic kidney disease. regarding the functional deficiencies in Kidney and Blood Pressure Research. patients with chronic kidney disease 2013;38(1):109-120. undergoing hemodialysis. There is a 6. Sathvik BS, Parthasarathi G, Narahari multifaceted problem having both MG, Gurudev KC. An assessment of the quality of life in hemodialysis patients physical and psychological connotations using the WHOQOL-BREF for the patient. questionnaire. Indian Journal of Nephrology. 2008;18(4):141. CONCLUSION 7. Doran D. Nursing outcomes: The state of The results of this study revealed the science. Burlington: Jones & Bartlett that there was a low functional status in Publishers; 2010. both physical and mental status in patients 8. Safarudin S. Hubungan pola terapi, nilai with CKD undergoing hemodialysis. ureum kreatinin plasma dan hemoglobin Thus, it is suggested that pharmacological dengan kualitas hidup pasien management of these patients need hemodialisis di RSUD Dr Soedarso stringent monitoring on part of the Pontianak [Relationship of therapy pattern, creatinin ureum plasma, psychiatrist to deal with mental health hemoglobin, and quality of life of problems, and the interdisciplinary team patients with hemodyalisis at Dr need to do great efforts to improve quality Soedarso Pontianak Hsopital]. Jakarta: of life of patients with CKD. Universitas Indonesia; 2012. 9. Garg AX, Papaioannou A, Ferko N, Declaration of Conflicting Interest Campbell G, Clarke J-A, Ray JG. None declared Estimating the prevalence of renal insufficiency in seniors requiring long- Funding term care. Kidney International. This study was supported by Master of 2004;65(2):649-653. Nursing, Faculty of Medicine, Diponegoro 10. Cleary J, Drennan J. Quality of life of University, Semarang, Indonesia. patients on haemodialysis for end‐stage renal disease. Journal of Advanced Author Contribution Nursing. 2005;51(6):577-586. All authors contributed equally in this study. 11. Brunier GM, Graydon J. The influence of physical activity on fatigue in patients References with ESRD on hemodialysis. Anna 1. Levey AS, Coresh J. Chronic kidney Journal. 1993;20(4):457-461. disease. The Lancet. 2012;379(9811): 12. Jhamb M, Weisbord SD, Steel JL, Unruh 165-180. M. Fatigue in patients receiving maintenance dialysis: A review of

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definitions, measures, and contributing 16. De Sousa A. Psychiatric issues in renal factors. American Journal of Kidney failure and dialysis. Indian Journal of Diseases. 2008;52(2):353-365. Nephrology. 2008;18(2):47. 13. Murtagh FEM, Addington-Hall J, Higginson IJ. The prevalence of Cite this article as: Mardiyah A, symptoms in end-stage renal disease: A Anggorowati, Johan A. Functional systematic review. Advances in Chronic status in patients with chronic kidney Kidney Disease. 2007;14(1):82-99. disease being treated with hemodialysis 14. Stone P, Richards M, Hardy J. Fatigue in in PKU Muhammadiyah Hospital, patients with cancer. European Journal Yogyakarta, Indonesia. Belitung of Cancer. 1998;34(11):1670-1676. Nursing Journal 2017;3(4): 426-431. 15. Chen YS, Wu SC, Wang SY, Jaw BS. https://doi.org/10.33546/bnj.87 Depression in chronic haemodialysed patients. Nephrology. 2003;8(3):121-126.

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Muliani RH, et al. Belitung Nursing Journal. 2017 August;3(4):432-437 Received: 4 March 2017 | Accepted: 31 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

EFFECT OF CONSUMING RED SPINACH (AMARANTHUS TRICOLOR L) EXTRACT ON HEMOGLOBIN LEVEL IN POSTPARTUM MOTHERS

Resty Himma Muliani*, Ariawan Soejoenoes, Titi Suherni, Soeharyo Hadisaputro, Imam Djamaluddin Mashoedi

Magister Applied Midwifery, Politeknik Kesehatan Kementerian Kesehatan Semarang, Indonesia

*Corresponding author: Resty Himma Muliani Magister Applied Midwifery, Politeknik Kesehatan Kementerian Kesehatan Semarang Jl. Tirto Agung, Pedalangan, Banyumanik, Kota Semarang, Jawa Tengah, Indonesia (50268) E-mail: [email protected]

ABSTRACT Background: Postpartum mothers are susceptible to anemia, due to loss of blood count during labor. Postpartum anemia causes uterine subinvolution which causes postpartum hemorrhage, facilitates puerperium infection, decreases breastfeeding and causes mamae infection. One alternative to prevent anemia in postpartum is to consume vegetables with high iron one red spinach. Red spinach is one of the non-heme iron sources needed to synthesize hemoglobin. Objective: To determine the effect of red spinach in increasing the levels of hemoglobin in postpartum mothers. Methods: This was a quasi-experiment with pretest posttest with control group design in October-December 2017 at the Community Health Center of PONED Tarub, Tegal regency, Indonesia. Thirty postpartum mothers were included using purposive sampling, which 15 assigned in each group. Blood sampling and examination were performed in each respondent. Paired and Independent t-test were done for data analysis. Results: The results of the 14-day intervention of given red spinach extract showed that there was a significant increase of hemoglobin level (1.25 g / dL) with p-value 0.047. Conclusion: There is a significant effect of consuming red spinach extract (Amaranthus tricolor L.) on the increase of hemoglobin level in postpartum mother. It is recommended that midwives could apply this intervention and cooperate with agriculture and food processing in order to produce red spinach extract that increases hemoglobin, hematocrit and erythrocytes levels.

Keywords: red spinach, Amaranthus tricolor l, hemoglobin level, postpartum mothers

INTRODUCTION Anemia is one of the causes of maternal countries and 51% in developing death.1 The prevalence rate of anemia is countries.1 According to WHO (World still high, which is 14% in developed Health Organization), the higher

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Editor’s Note: This article has been updated on 13 July 2020 in terms of the completeness of correspondence address. The update is based on BNJ policy on article correction. prevalence of anemia is among pregnant substances with antioxidant properties. women group,2 supported by Taner et al3 The main type of carotenoids in spinach is who said that the prevalence of anemia in beta carotene, while the other active women is 41.6%. substance is chlorophyll. While the types In Indonesia, the maternal mortality of flavonoids contained in spinach are rate is 220 per 100,000 live births, which lutein and quercetin. Quercetin is a is 30% due to anemia.1 While maternal powerful antioxidant, which is able to mortality rate in Tegal district has capture superoxide free radicals and increased significantly from 146.6 in 2013 inhibit oxidation of LDL cholesterol. In to 173 per 100,000 live births in 2014.4 addition, there are two types of spinach, Anemia has been the third rank of the i.e. green spinach and red spinach. Both indirect causes of the maternal mortality.4 are rich in vitamin C, but green spinach is Therefore the effort the decrease mortality richer in vitamin A while red spinach rate is necessity. contains more iron.6 However, although The government of Indonesia has red spinach has more iron and usually been implementing interventions to consumed in the society. Little is known reduce the number of maternal mortality, about the effect of red spinach in such as Basic Emergency Neonatal increasing iron, particularly in postpartum Obstetric Services (PONED), which is mothers. Most of the studies were applied in the community health center in conducted in mice. Tegal district.4 Fajria et al states that red spinach Anemia does not only occur during extract increase iron and hemoglobin pregnancy, but also during puerperium. levels in the blood of mice equal to 17.5% Postpartum anemia leads to uterine compared with iron supplement.7 Aryani subinvolution, hemorrhage, and et al8 showed that the dose of water infection.5 Thus to prevent anemia among extract of red spinach leaves affect the postpartum mothers is needed. One of the amount of erythrocytes and hemoglobin preventive efforts is by consuming red levels in white mice. The most influential spinach or Amaranthus Tricolor L as dose was the treatment with a dose of 1 proposed in this study. gram / Kg weight. Gideon mentioned that Red spinach has been widely there was an increase in Fe serum in cultivated throughout Indonesia, Wistar strain female rats, with a mean of especially in the mountain areas. It is also total serum of Fe value was 106.7 μg / dL easily found both in traditional and to 113.5 μg / dL after given an infusion of modern markets, even some people plant red spinach leaf with dose 10% given as spinach. Spinach contains protein, fat, much as 3 cc per day.9 Therefore, the carbohydrates, potassium, iron, amarantin, objective of this study was to determine routine, purines, and vitamins A, B and the effect of red spinach in increasing the C.6 Society believe that red spinach can levels of hemoglobin in postpartum improve kidney function, and digestion mothers. because of high fiber content. It is also good for diabetics, high cholesterol, hypertension, anemia, and for maintaining METHODS balance of body weight and cleansing of Design puerperal blood.6 Spinach also contains This was a quasi-experiment with pretest carotenoids and flavonoids that are active posttest with control group design.

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Setting takes approximately 7-10 days until it The study was conducted in October- becomes mature and ready to be December 2017 at the Community Health circulated throughout the body with red Center of PONED Tarub, Tegal regency. blood cells.10,11

Population and Sample Instrument In this study, there were 30 postpartum Blood sampling and examination were mothers included using purposive performed before and after intervention sampling. Fifteen respondents were (the day 15). All blood examination was assigned in each group. The inclusion examination on the lab. criteria were: 1) postpartum mothers ( the 1st - 21st day), 2) Mothers with mid-upper Data analysis arm circumference ≥ 23.5 cm, 3) Mothers Comparative test of mean difference of who did not consume herbs, 4) Willing to hemoglobin level between treatment and be a respondent. The exclusion criteria control group was analyzed using were: 1) Sick postpartum mothers and 2) independent t-test because the data were postpartum mothers with complication normally distributed. Paired t-test was (infection.) also performed to see the effect of intervention. Intervention In this study, mothers in the intervention and control group received Fe capsules in RESULTS the same dose for 14 days. However, in Table 1 shows that the majority of the the intervention group, mothers also respondents in the intervention and received red spinach extract in the form of control group aged 25-27 years, had tablet, which was consumed three times normal BMI, 26 MUAC, 40% appropriate per day or 1400 mg per day. The intake, and not working. Analysis showed provision of Fe capsule and red spinach p-value > 0.05 in all variables, which extract was given in stages, namely stage I indicated that there was no significant only for 3 days at the beginning of difference of the characteristics of the administration after the pretest. Then the respondents between intervention and researcher was assisted by two control group. enumerators (midwives) to do a home Independent t-test as shown in the visit as a stage II to give Fe capsule and table 2 indicated that there is no difference red spinach extract for the next 3 days, of hemoglobin level in the intervention and continued until 5 stages and ended at and control group with p- value 0.743. the day 14. These steps were done in order However, there is statistically significant that the researcher could monitor and difference of hemoglobin after ensure that the Fe capsule and red spinach intervention with p-value 0.023 in the extract were properly consumed regularly intervention and control group. up to 14 days intervention in both control While paired t-test showed there is a and intervention groups. Provision of Fe significant effect of red spinach in the capsules and red spinach extract capsules intervention group and standard was done for 14 days because the intervention in the control group on erythropoiesis process occurs in 7 days, hemoglobin in postpartum mothers with and formation or synthesis of hemoglobin p-value <0.05. However, the mean

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 434 difference of hemoglobin level in the than hemoglobin in the control group intervention group (1.253) was higher (0.307).

Table 1 Characteristic of Postpartum mothers in the intervention and control group

Characteristics of Group p-value respondents Intervention Control Age (Year) Mean ± SD 25.60±4.120 27.80±5.031 0.426 Median 24.00 27.00 Min±max 20±32 20±30 Body Mass Index Thin 0.00 % 0.00 % 0.916 Normal 60,0% 73.3% Overweight 40.0% 26.7% Mid Upper Arm Circumference (Cm) Mean ± SD 25.93±1.486 26.20±1.568 0.897 Median 26.00 26.00 Min±max 24±28 24±29 Nutrition intake Appropriate 40.0% 46.7% 0.139 Inappropriate 60.0% 53.3% Educational level

Low 73.3% 60.0% 0.150 Middle 26.7% 40.0% High 0.00 % 0.00% Working status Working 40.0% 53.3% 0.134 Not working 60.0% 46.7%

Table 2 Difference of hemoglobin levels in the intervention and control group

Group Hemoglobin (g/dL) Intervention Control p-value

Pretest Mean ± SD 11.57±1.37 11.71±1.04 0.7431 Min±max 9.60±13.70 9.60±13.20 Posttest Mean ± SD 12.91±0.97 12.02±1.06 0.0231 Min±max 11.40±14.30 9.90±13.80 Mean difference of pretest-posttest p-value 0.0002 0.0012 Difference of mean of hemoglobin level 0.0002 Mean±SD 1.253±0.49 0.307±0.27 Min±max 0.2±1.9 0.00±1.00 1Independent t-test 2Paired t-test

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DISCUSSION While Vitamin C in red spinach is also The aim of this study was to determine the very helpful for the absorption of non- effect of red spinach on hemoglobin level. heme iron by changing the shape of ferries Findings of this study revealed that red to ferrous so as to facilitate the body in the spinach or Amaranthus Tricolor L has a iron absorption process. High iron and significant effect on the increase of vitamin C content in red spinach causes hemoglobin levels. This indicates that red iron more easily absorbed by the body spinach increases the hemoglobin not only four times faster than without vitamin C.13 in rats, but also in human, particularly in However, the result of this study is postpartum women. in line with Astuti et al who mentioned The increase of hemoglobin in this that the hemoglobin level in pregnant study because of red spinach contains women was increased 0.93 gr/dL after more iron, which is easy to be absorbed in given red spinach extract in two weeks. the duodenum and upper intestine This study provides evidence that red (proximal jejunum).12 Non-hem iron in spinach could increase the level of food and inorganic iron salts or other hemoglobin (1.25 gr/dL) in postpartum complexes must first be converted to women who received iron supplement ferrous free iron before being absorbed by capsules. intestinal mucosal cells.10,12 The iron will soon join in the blood plasma with beta globulin, i.e., apotransferin, to form CONCLUSION transferrin, which is then transported in According to the results of this study, it plasma. This iron loosely binds to the can be concluded that there is a significant transferrin and consequently can be effect of consuming red spinach extract released into every cell of tissue in each (Amaranthus tricolor L.) on the increase part in the body. In the cell cytoplasm, of hemoglobin level in postpartum this iron joins primarily with a protein, mother. It is recommended that midwives i.e., apoferritin to form ferritin.10 could apply this intervention and Apoferritin has a molecular weight of cooperate with agriculture and food about 460,000, and various amounts of processing in order to produce red spinach iron can join in the form of a group of iron extract that increases hemoglobin, radicals with this large molecule. Ferritin hematocrit and erythrocytes. Further may contain only a small amount of iron research is needed to investigate about the or even a large amount of iron. The iron other substances contained in red spinach stored as ferritin is called a spare iron.10 extract that can increase hemoglobin, In addition to the high iron content, hematocrit and erythrocyte levels; and there are other substances in the content of also, research related to side effects of red red spinach that plays a role in the spinach extract is needed. formation of hemoglobin and erythrocytes.11 Folic acid and vitamin B12 are the main ingredients in the formation Declaration of Conflicting Interest of cell nuclei. Vitamin B6 and amino None declared acids and glycine in red spinach in the Funding initial reaction of heme formation. This study was supported by Magister Applied Vitamin B6 and B12 are needed in the Midwifery, Politeknik Kesehatan Kementerian process of formation of globin sitesis.11 Kesehatan Semarang, Indonesia.

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of red spinach leaves (amaranthus tricolor Author Contribution l.) on the number of erythrocytes and All authors contributed equally in this study. hemoglobin levels in white rats (rattus norvegicus): As a source of biology References learning for high school students in class 1. National Population and Family Panning XI on learning material in the circulation Board. Indonesian health and system in humans]. Jurnal Bioedukatika. demographic survey 2012. Jakarta: 2013;1(1). National Population and Family Panning 9. Hadwinata G, Jasaputra DK, Suhendra A. Board; 2013. The effect of red amaranth (amaranthus 2. Benoist Bd, McLean E, Egll I, Cogswell gangeticus l.) on the level of fe serum in M. Worldwide prevalence of anaemia wistar female rats. Bandung, Indoensia: 1993-2005: WHO global database on Faculty of Medicine, Maranatha Christian anaemia. Geneva: WHO; 2008. University; 2015. 3. Taner CE, Ekin A, Solmaz U, et al. 10. Guyton AC. Human physiology and Prevalence and risk factors of anemia mechanisms of disease. Philadelphia: WB among pregnant women attending a high- Saunders Co; 1992. volume tertiary care center for delivery. 11. Bakta IM. Hematologi klinik ringkas [Brief Journal of the Turkish German clinical hematology]. Jakarta: EGC; 2006. Gynecological Association. 2015;16(4): 12. Astuti KH, Widyastuti AH. Pengaruh 231. konsumsi jus bayam merah terhadap 4. Department of Health of Tegal Regency. peningkatan kadar Hb pada ibu hamil di Health profile of Tegal Regency. Tegal, Kecamatan Tawangmangu [Effect of red Indonesia: Department of Health of Tegal spinach juice on the increase of Hb level in Regency;2014. pregnant mothers at Tawangmangu 5. Prawirohardjo S. Obstetrics. 4th ed. Jakarta: district]. Jurnal Bidan Prada. 2015;6(1). Tridasa Printe; 2010. 13. Muwakhidah M. efek suplementasi Fe, 6. Handayani T. Apotek hidup. Yogyakarta: asam folat dan vitamin b12 terhadap CV. Ilmu Padi Infra Pustaka Makmur; peningkatan kadar hemoglobin (Hb) pada 2013. pekerja wanita di Kabupaten Sukoharjo 7. Fajria MA, Wuyung PE, Handayani S, [Effect of Fe supplementation, folat acid Freisleben SKU, Freisleben H-J. Effect of and vitamin b12 on the increase of red spinach amaranthus gangeticus vs hemoglobin level at working women at commercial iron tablets to increase blood Sukoharjo district]. Semarang: Program levels of iron & hemoglobin in iron- Pascasarjana Universitas Diponegoro; adequate mice. Asian Journal of 2009. Biochemical and Pharmaceutical Research. 2015;5(3):136-142. Cite this article as: Muliani RH, 8. Aryani RP, Widyaningrum T. Pengaruh Soejoenoes A, Suherni T, Hadisaputro S, dosis ekstrak air daun bayam merah Mashoedi ID. Effect of consuming red (amaranthus tricolor l.) terhadap jumlah spinach (Amaranthus Tricolor L) extract on eritrosit dan kadar hemoglobin pada tikus hemoglobin level in postpartum mothers. putih (rattus norvegicus): Sebagai sumber Belitung Nursing Journal. 2017;3(4):432- belajar biologi siswa sma kelas XI pada 437. https://doi.org/10.33546/bnj.156 materi pembelajaran sistem sirkulasi pada manusia [Effect of a dose of water extract

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Melati AR, et al. Belitung Nursing Journal. 2017 August;3(4):438-442 Received: 4 March 2017 | Accepted: 31 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

EFFECT OF SOLUS PER AQUA (SPA) ON INFANT WEIGHT

Agrystina Ryma Melati*, C Tjahjono Kuntjoro, Sri Sumarni, Kamilah Hidayati, Rr. Sri Endang Pujiastuti

Postgraduate Midwifery Program, Politeknik Kesehatan Kementrian Kesehatan Semarang, Indonesia

*Corresponding author: Agrystina Ryma Melati Postgraduate Midwifery Program, Politeknik Kesehatan Kementrian Kesehatan Semarang Jl. Tirto Agung, Pedalangan, Banyumanik, Kota Semarang, Jawa Tengah, Indonesia (50268) E-mail: [email protected] ABSTRACT Background: The prevalence of skinny infants in Indonesia is still high. Baby's spa is considered to be able increase infant’s weight. Objective: To determine the effect of baby spa in infant weight in in Bebengan Village, Boja Sub District, Kendal Regency, Central Java, Indonesia. Methods: This study was a quasi-experimental study with non-equivalent control group design. There were 38 infants were selected using purposive sampling, divided into three groups, namely: 1) a group received spa two times per week (12 infants), 2) a group received spa three times per week (13 infants), and 3) a control group. Baby digital scale of ARN-EBSD-04 was used to measure infant weight. Data were analyzed using paired t- test and ANOVA. Results: There was statistically significant effect of intervention in each group on the infant’s weight. However, the data showed that the intervention that had a better effect on infant weight was the intervention of spa in two times per week with mean difference before and after intervention of 603 g. Conclusions: Doing spa two times per week could significantly increase infant weight effectively. Therefore, it is recommended for midwife to apply this intervention to increase the weight gain of babies and to reduce the number of skinny infants in Indonesia.

Keywords: solus per aqua, baby weight, spa

INTRODUCTION Solus Per Aqua (Spa) is derived from the therapy, including a food service, healthy Latin phrase ‘Solus per aqua’ which drinks and physical activity.2 means ‘health from water’.1 Spa means a Spa in infants has 2 components, traditional health effort with a holistic namely swimming and massage. approach, in the form of comprehensive Swimming, one type of exercises that can treatment using a combination of improve health, is a sport without the hydrotherapy skills, massage, aroma- force of gravity of the earth (non-weight

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Editor’s Note: This article has been updated on 13 July 2020 in terms of minor changes in the reference format. The update is based on BNJ policy on article correction. barring) with the risk of minor injury that Kendal regency. The exclusion criteria because when swimming all the weight is were babies with congenital defects. held by water. The benefits of swimming in infant are to make baby relax, stimulate Intervention appetite, and increase diet and sleep Implementation of Spa was done for 30 patterns.3 Spa given to infants aged 2 - 18 minutes consisting of 15 minutes for baby months with a minimum weight of 5 Kg.4 swimming and 15 minutes for baby Spa in this study is an intervention massage. The Spa was provided at the to reduce the prevalence of skinny infants "Agrys Baby SPA" facility, conducted by in Indonesia, which is 12.1% in 2015 a certified health worker and an consisting of 6.8% in thin category and enumerator. Baby spas were given on a 5.3% in very thin category.5 While in the regular schedule and at the same time province of Central Java, the prevalence each week. In group 1, the baby's Spa was of skinny infants is 11.1% and 16% in the given 2 times per week on Monday and Kendal regency, which is considered as Wednesday at the same time (regular critical condition.6 Spa is considered able schedule). Group 2 was given Baby Spa 3 to help baby’s immune system and times a week on Tuesday, Thursday, and alleviate digestive issues, which may Sunday at the same time (regular increase baby’s weight.7 Therefore, this schedule), and group 3 for the control study aimed to determine the effect of spa group was given infant massage on on infant’s weight. Friday.

METHODS Instrument Design Baby weight was measured using ARN- A quasi-experimental study with non- EBSD-04 baby digital scale, which has equivalent control group design. already been calibrated. All data collection of infant weight used the same Setting measuring instrument by recording the The study was conducted in Bebengan display results on the scales, without village, Boja district, Kendal regency, classifying the size of the weight because Central Java, Indonesia, on December 12, the data taken in the form of data ratio. 2016 until January 8, 2017. Data collection of infant weight in all three groups was first weighed before Sample intervention as pretest, during By using purposive sampling, 38 infants intervention, and at the end of intervention were selected and divided into 3 groups, as posttest. namely: 1) a group received Spa 2 times per week (12 infants), 2) a group received Ethical consideration spa 3 times per week (13 infants), and 3) a The ethical requirements have been met control group. The inclusion criteria to by the researcher by applying Ethical select sample were: infants aged 3-6 Clearance to the Health Research Ethics months, exclusive breastfeeding, normal Commission (KEPK) of Poltekkes birth weight, baby’s mother had been Kemenkes Semarang, and Ethical willing to be a respondent, and domiciled Clearance Certificate has been issued with in the village of Bebengan, Boja district, ethical code: 248 / KEPK / Poltekkes-Smg / EC / 2016 on December 8, 2016.

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Data analysis RESULTS Dependent t-test was used to determine Table 1 shows that there were no the mean differences before and after the significant differences in age and gender intervention in each group. ANOVA was among the three groups with p-value used to test the effectiveness of Solus per >0.05. Similar with the results of aqua on infant weight among the three normality data test of infant weight before groups. and after intervention showed that data on infant weight variable was in a normal data distribution among three groups with p-value 0.95 (p> 0,05).

Table 1 Frequency distribution of age and gender in infants aged 3-6 months in Bebengan village, Boja district, Kendal regency Age (Month) Gender Group Male Female Mean p-value p-value f (%) f (%) Intervention 1 4.50 0.078a 6 (50) 6 (50) Intervention 2 4.54 0.073a 6 (46.2) 7 (53.8) 0.926b Control 4.46 0.073a 7 (53.8) 6 (46.2) Total 19 (50) 19 (50) aTest of Normality with Shapiro-Wilk bChi-Square Test

Table 2 Infant weight before and after intervention in the Intervention group 1, 2 and control group using Paired t-test Infant weight variable Mean Std. Deviation Min Max p-value N Intervention group 1 Pretest (gram) 6647.08 888.319 5230 7920 0.0001 12 Posttest (gram) 7250.08 887.723 5780 8430 Intervention group 2 Pretest (gram) 6458.46 840.866 5130 7995 0.0001 13 Posttest (gram) 6964.62 879.748 5585 8460 Control group Pretest (gram) 6617.69 920.429 5130 8250 0.0001 13 Posttest (gram) 7008.85 913.173 5490 8560

The result of Paired t-test as shown infant weight between pretest and posttest in the table 2 indicated that there were in each group with p-value 0.0001 statistically significant differences of (<0.05).

Table 3 Difference effect of Spa on infant weight in the intervention group 1, 2 and control group using ANOVA Group Mean ± SD Min – Max Mean Square F p-value Intervention 1 603 ± 124.096 505 – 910 Intervention 2 506.15 ± 139.585 430 – 965 140779.847 11.634 0.0001 Control 391.15 ± 41.138 310 – 445

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ANOVA test shows that the mean This stimulation activates the square of infant’s weight among the three parasympathetic autonomic nervous group was 140779.847 with F value system in the area of the raphe nuclei and 11.634, and p-value was 0.0001 (<0.05), nucleus solitarius, which are the sensory which mean that there was statistically region of the medulla and the pound that significant effect of intervention in each enter the brain through the vagus nerves group on the infant’s weight. However, and glosovaringeus. The raphe nuclei also the data showed that the intervention that projects into the hypothalamus, causing had a better effect on infant weight was the secretion of Corticotropin Releasing the intervention 1 (two times spa per Factor (CFR). Furthermore, CFR week) with mean difference before and stimulates the pituitary gland to increase after intervention of 603 g, which was the production of Proopiomelanocortin higher compared to the intervention 2 and (POMC) and endorphin.10 β-endorphin is control group. a polypeptide that plays a role in increasing intake of food (orexigenic), so DISCUSSION that infants will consume more breastmilk The aim of this study was to determine the to meet increased food intake effect of spa on infant weight. According requirements. 9 to the findings of this study, there was a Stimulated activity of the autonomic significant effect of spa on infant weight. nervous system causes the response of the There was an increase on weight before pancreas (Langerhans Island) to the and after intervention among the group of cholinergic impulse response to an given Spa two times per week, Spa three increased secretion of insulin and time per week, and control group. glucagon, which serves to increase the However, the group who received Spa two absorption of food.11 Mechanism also times a week had a higher increase of occurs in the gastrointestinal organs and baby’s weight, 603 grams compared to the sphincters in the nonandrogenic impulse other groups. response that stimulates appetite. The fact of the increase of baby's The finding of this study is also in weight in this study because during the line with the Cohen’s criteria, infants who intervention process the mothers said that were given baby spa for 2 times a week the baby felt so much hungry and suckled can have a tremendous effect on infant strongly. This however corresponds to the weight gain with an effectiveness value of theory of the body's mechanism of 56.8%, and for infants given spa for 3 massage and swimming, that the pressure times a week can have a profound effect received by the sensory nerve fibers Aβ on infant weight gain with an distributes the impulse from the touch effectiveness of 23.9%. This is also receptors to the central nervous system similar with research conducted in NICU having a diameter of 5-12 μm and a LLRM Medical College in India in conduction velocity of 30-70 m/s.8 Some October 2009 - September 2010, revealed impulse are delivered through the afferent that premature infants who were given fibers C for warm temperature receptors, massage for 28 days had an increase in which are closely related to sense of infant weight gain of 476.7 grams in the touch, furthermore it sends messages to intervention group and 334.9 grams in the the brain through the neural network control group, so that the effectiveness located in the spinal cord.9 value was 11.9%.12

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4. Suhardjo. Pemberian makanan pada bayi CONCLUSION dan anak [Giving food for baby and According to the results of this study, it children]. Yogyakarta: Kanisius; 1992. can be concluded that Spa in 2 times per 5. Minsitry of Health of Indonesia. Health week could significantly increase infant profile of Indonesia in 2013. Jakarta: Minsitry of Health of Indonesia; 2014. weight effectively. Therefore, it is 6. Minsitry of Health of Indonesia. Basic recommended for midwife to apply this health research. Jakarta: Minsitry of intervention to increase the weight gain of Health of Indonesia; 2013. babies and to reduce the number of skinny 7. Khorsandi J. Water Babies: A Texas spa infants in Indonesia. is serving up a bucketful of relaxation for the tiniest of patrons. Declaration of Conflicting Interest http://dujour.com/lifestyle/float-baby- None declared hydrotherapy-infant-massage-water- therapy/. Accessed 1 March 2013. Funding 8. Guyton AC, Hall JE. Sensasi somatik: This study was supported by Postgraduate Buku ajar fisiologi kedokteran [Somatic Midwifery Program, Politeknik Kesehatan sensation: Medicice physiology Kementrian Kesehatan Semarang, Indonesia. textbook]. 11th ed. Jakarta: EGC; 2012. 9. Ganong WF. Buku ajar fisiologi Author Contribution kedokteran [Medicice physiology All authors contributed equally in this study. textbook]. 20th ed. Jakarta: EGC; 2002. 10. Guyton AC. Human physiology and References mechanisms of disease. Philadelphia: 1. Scott J, Harrison A. Spa: The official WB Saunders Co; 1992. guide to spa therapy at levels 2 & 3. 11. Roesli U. Pedoman pijat bayi prematur Boston: Cengage Learning; 2006. & bayi usia 0-3 bulan [[Guideline of 2. Ministry of Health of Indonesia. massage for pemature baby and baby Pedoman persyaratan kesehatan aged 0-3 months]. Jakarta: Trubus pelayanan sehat pakai air (SPA). Agriwidya; 2001. Peraturan Meteri Kesehatan Republik 12. Kumar J, Upadhyay A, Dwivedi AK, Indonesia Nomor 1205/ Menkes/ Per/ x/ Gothwal S, Jaiswal V, Aggarwal S. 2004 [Guideline for health requirements Effect of oil massage on growth in for healthy services using water. preterm neonates less than 1800 g: A Regulation of Ministry of Health of randomized control trial. The Indian Indonesia No 1205 1205/ Menkes/ Per/ x/ Journal of Pediatrics. 2013;80(6):465- 2004]. Jakarta: Ministry of Health of 469. Indonesia; 2004. 3. Roesli U. Pedoman pijat bayi prematur Cite this article as: Melati AR, Kuntjoro CT, dan bayi usia 0-3 bulan [Guideline of Sumarni S, Hidayati K, Pujiastuti RSE. Effect massage for pemature baby and baby of Solus Per Aqua (SPA) on infant weight. aged 0-3 months]. Jakarta. Trubus Agro Belitung Nursing Journal. 2017;3(4):438-442. Wijaya; 2007. https://doi.org/10.33546/bnj.154

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Kurniati FD, et al. Belitung Nursing Journal. 2017 August;3(4):443-449 Received: 8 June 2017 | Accepted: 3 August 2017 http://belitungraya.org/BRP/index.php/bnj/

ORIGINAL RESEARCH ISSN: 2477-4073

PATIENT SATISFACTION AND ITS RELATIONSHIP WITH THE QUALITY OF COMPREHENSIVE EMERGENCY OBSTETRIC AND NEONATAL CARE (CEmONC) IN THE GENERAL HOSPITAL OF PANEMBAHAN SENOPATI BANTUL

Fitri Dian Kurniati1*, Lely Lusmilasari1, Sri Mulatsih2

1Master of Nursing, Faculty of Medicine, Universitas Gadjah Mada, Indonesia 2Department of Child Health, Faculty of Medicine, Universitas Gadjah Mada/Sardjito Hospital, Indonesia

*Corresponding author: Fitri Dian Kurniati Master of Nursing, Faculty of Medicine, Universitas Gadjah Mada, Jl. Farmako, Senolowo, Sekip Utara, Kec. Depok, Kabupaten Sleman, Daerah Istimewa Yogyakarta 55281, Indonesia. E-mail : [email protected] ABSTRACT Background: Patient satisfaction has emerged as an increasingly important health outcome and is currently used to evaluate the quality of care. Objective: To describe the level of satisfaction of mothers after caesarean section and examine its relationship with the quality of Comprehensive Emergency Obstetric and Neonatal Care (CEmONC). Methods: This was an analytic descriptive study using cross-sectional design. The study was conducted in Alamanda ward in the General Hospital (RSUD) of Panembahan Senopati Bantul Indonesia during September until November 2016. There were 55 respondents selected using purposive sampling. The instruments included The Scale for Measuring Maternal Satisfaction (SMMS) – caesarean birth and the Quality of CEmONC questionnaires. Spearman’s rho and logistic regression were performed for data analysis. Result: Results showed that 47.3% respondents rated the quality of CEmONC in high category and 56.4% were satisfied. The correlation value between quality of CEmONC and patient satisfaction was 0.285 (p = 0.035; OR = 1.96). Conclusion: Level of satisfaction of mothers after caesarean section was associated with the quality of CEmONC in the General Hospital of Panembahan Senopati Bantul Indonesia.

Keywords : services quality, CEmONC, patient satisfaction

INTRODUCTION Patient satisfaction is defined as a equal or more than patient’s expectation. subjective measurement from patient after Patient satisfaction is one of important health treatment by comparing patient’s outcomes to indicate good achievement of expectation and perceived services.1 health services. Patient will be satisfied when services

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Editor’s Note: This article has been updated on 13 July 2020 in terms of the completeness of correspondence address. The update is based on BNJ policy on article correction. Low level of patients satisfaction quality of CEmONC in the General towards health care quality have been Hospital of Panembahan Senopati Bantul. identified,2,3 especially in patients after caesarean delivery (17.8%). The low METHODS achievement of patient satisfaction is due This was an analytic descriptive study with to poor communication between patient cross-sectional design. The study was and health workers, as well as less conducted in Alamanda ward in RSUD responsive of health workers towards Panembahan Senopati Bantul during conditions and the needs of patient.4 September until November 2016. There However, high level of patient satisfaction were 55 respondents selected using towards health services will encourage purposive sampling. The Scale for patient to obey health advices, medication Measuring Maternal Satisfaction (SMMS) planning, and further medication.5 In – caesarean birth was used in this study, addition, satisfaction level of mother after modified from Gungor and Beji11. Patient caesarean section is dependent on the satisfaction refers to an expression of the accuracy on medical examination, feeling of mothers post-caesarean delivery characteristics of health workers, patient towards quality of service in terms of ten privacy, and cleanliness of the room.4 dimensions, namely : 1) perceptions of According to literature, factors health care workers, 2) preparation for c- affecting postpartum maternal satisfaction section, 3) comfort, 4) the provision of include physical environment, hygiene, information and involvement in decision complete facilities,6 interpersonal behavior making, 5) stickiness with baby, 6) of officers, health status of mother and treatment of postpartum, 7) ward baby,7 ease of access to health facilities condition, 8) hospitals facilities, 9) location, cost, experience and maternal privacy, and 10) meeting expectations of demographics,8 and hospital accreditation.1 patients. Comprehensive emergency obstetric Another instrument used was and neonatal care (CEmONC) questionnaire of the Quality of CEmONC implementation in hospitals is one of the based on the standard of Ministry of target groups assessments in hospital Health about for implementation of accreditation standards 2012 version.9 One CEmONC. Quality of CEmONC in this of the things that affect patients in study is defined as an assessment of post- deciding to use the CEmONC facilities is caesarean mothers towards the the quality of services provided, especially implementation of CEmONC, in terms of in post-partum mothers.10 aspects of the structure and processes in The General Hospital of accordance with defined service standards. Panembahan Senopati Bantul is one of Aspects of the structure include the hospitals that is able to implement completeness of human resource routine CEmONC in 24 hours in the area of checks, equipment, and medicines; while Yogyakarta. The results of CEmONC aspects of process include the interaction evaluation at this hospital revealed a between health care workers with patient, number of indications that the quality of namely on the ability of officers to serve service does not meet standards, as well as patients and adequate interpersonal skills. in the case of fulfillment of human The validity and reliability of the resources and interpersonal treatment are instruments were performed in 30 post- not optimal. Therefore, this study aimed to caesarean section mothers, and the results analyze patient’s satisfaction toward showed valid and reliable instruments.

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Univariate data analysis was Faculty of Medicine, Universitas Gadjah conducted to determine the frequency Mada in September 2016. Informed distribution of each variable. While consent has been done before data bivariate analysis was used to determine collection. the relationship between patient satisfaction with quality of CEmONC. RESULTS Logistic regression was also implied for The characteristics of the respondents as this study. Quality of CEmONC was shown in the Table 1 indicated that categorized into low quality, medium, and majority of respondents (85.5%) aged 20- high. Low quality if x < µ - 1,0 SD, 35 years. Of those all respondents, 61.8% whereas if µ - 1,0 SD ≤ x ≤ + 1,0 SD, and had senior high school background, and high if x > µ + 1,0 SD.12 While patient 74.5% were not working or being satisfaction was categorized into satisfied housewives. The respondent’s incomes and dissatisfied based on the cutoff point. were more than regional minimum wage, The statistical test used in this study was and the majority of them were multipara the correlation of Spearman's rho. (65.5%), and 72.7% had never been Approval of this study was hospitalized. obtained from the Ethics Committee of

Table 1 Characteristics of the respondents (n=55) Characteristics Frequency Percentage (%) Age (year) 20-35 47 85.5 35-49 8 14.5 Education Level Basic 16 29.1 Medium 34 61.8 High 5 9.1 Working status Not working 41 74.5 Working 14 25.5 Income level Under minimum wage 14 25.5 Above minimum wage 41 74.5 Parity Primipara 19 34.5 Multipara 36 65.5 Experience of being hospitalized No 40 72.7 Yes 15 27.3

Of eleven items of structural aspects process aspect, the majority of the as shown in the Table 2, there were two respondents got services in accordance points that have not been optimized, with the standards, except 1.8% of them namely the availability of like air did not get an examination for the stomach conditioner (fan or air conditioning) and bleeding, and suggestion for (54.5%) and towels / tissues in hand mobilization after surgery. washing facilities (70.9%). While in the

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Table 2 Frequency distribution of the Quality of CEmONC (n=55) Never Sometimes Always Question n (%) n (%) n (%) Structure: There are obstetricians routinely conduct examination 0 (0) 12 (21.8) 43 (78.2) There is pediatrician routinely conduct examination 2 (3.6) 12 (21.8) 41 (74.6) Receiving assistance from nursing care 0 (0) 4 (7.3) 51 (92.7) There is an anesthetist who is briefing prior to surgery 3 (5.5) 12 (21.8) 40 (72.7) Completeness of medicine 0 (0) 8 (14.5) 47 (85.5) Completeness of kind of examinations 3 (5.5) 12 (21.8) 40 (72.7) Getting services immediately without having to pay first 0 (0) 5 (9.1) 50 (90.9) Cleanliness of room conditions 0 (0) 10 (18.2) 45 (81.8) Available of air conditioner (fan, AC) 30 (54.5) 14 (25.5) 11 (20) Available of soap / disinfectants for washing hands 1 (1.8) 14 (25.5) 40 (72.7) Available of towels / tissues in hand washing facilities 39 (70.9) 12 (21.8) 4 (7.3) Process: Officers are polite and friendly 0 (0) 13 (23.6) 42 (76.4) Officers take action with full skill and deftly 0 (0) 8 (14.5) 47 (85.5) Officers provide a time for consultation 0 (0) 17 (30.9) 38 (69.1) Officers provide information that is easily understood 0 (0) 7 (12.7) 48 (87.3) Having and explanation of any actions to be performed 0 (0) 7 (12.7) 48 (87.3) Having an examination of blood pressure and pulse 0 (0) 9 (16.4) 46 (83.6) Having an examination of abdominal and bleeding 1 (1.8) 23 (41.8) 31 (56.4) Being suggested for mobilization after surgery 1 (1.8) 7 (12.7) 47 (85.5) Having a monitoring of nutritional intake 0 (0) 8 (14.5) 47 (85.5)

Table 3 Quality of CEmONC (n=55) Category Frequency Percentage (%) Basic 10 18.2 Medium 19 34.5 High 26 47.3 Total 55 100

Table 4 Satisfaction levels of mothers post caesarean section (n = 55) Satisfaction levels Frequency Percentage (%) Unsatisfied 24 43.6 Satisfied 31 56.4 Total 55 100

Table 3 shows that nearly half of all improved. While Table 4 shows that respondents (47.3%) rated the quality of 56.4% of the respondents were satisfied CEmONC in high category, which and unsatisfied (43.6%) with the quality of indicated that the quality of CEmONC in CEmONC. RSUD Panembahan Senopati must be

Table 5 Bivariate analysis of the relationship between patient satisfaction levels post SC emergency with quality of CEmONC using Spearman's rho test (n=55) Variable Patient satisfaction Quality of CEmONC r 0.285 P 0.035* * significant p<0.05

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Bivariate analysis using Spearman's rho each aspect can still be optimized to test showed correlation value 0.285 (p = increase patient satisfaction, especially in 0.035), indicating that there was a the timeliness of the operating schedule. significant positive correlation between The longer the patient waiting time to get patient satisfaction post C-section service, then the level of patient emergency and the quality of CEmONC. satisfaction will be even lower.17 It means that the higher quality of Allowing the patient to wait without a CEmONC, the higher patient satisfaction. clear reason can lead to negative The values of coefficient correlation (r) perceptions of service quality so that it was 0.285, indicating the low correlation. can affect the level of satisfaction. The result of logistic regression analysis Another thing that should be raised shows that the quality of CEmONC is about communication. Communication becomes the main factor affecting patient is an important pillar in providing services satisfaction. to patients.18 Inadequate communication can lead to gaps and less satisfaction.7 DISCUSSION The bivariate analysis in this study A quality is multidimension based on the shows there was a significant relationship criteria and measurement. Quality of between patient satisfaction with the CEmONC was measured in terms of quality of CEmONC. High and low level structure and process of services of patient satisfaction is influenced by the according to standard of services. level of service quality, 18 and the better Generally, result showed that patients quality of CEmONC increases patient have got standardized comprehensive satisfaction.19 However, some efforts emergency obstetric and neonatal care, should be made to improve the quality of both structural and process aspects. CEmONC, namely by training of health However, human resources were key workers, improving interpersonal component on comprehensive emergency communication and counseling, ensuring obstetric and neonatal care in hospital.13 the availability of medicines and supplies, Most respondents stated that equipment and improving the service management and medicines are fully available in the system. hospital. To reduce maternal and neonatal Quality of service can be used as mortality in developing countries, one factor for patients to select a hospital. equipment and medicines should be in Patients as consumers should be given a sufficient quantities.14 The availability of satisfactory service. Dissatisfaction will facilities at the hospital is one of the make them find other health facilities.5,20 dimensions for assessing the quality of However, the success of health services service.15 Building infrastructure, medical can be seen from the level of patient and non-medical equipment, medicines, satisfaction. and money are material resources that should be owned by a CEmONC CONCLUSION hospital.16 The level of patient satisfaction after Generally, most of the respondents caesarean section was associated with the in this study were satisfied with the quality of CEmONC in the General service. This indicates that the services in Hospital of Panembahan Senopati Bantul. the General Hospital of Panembahan Health workers are expected to improve Senopati is good. However, the services in quality of care to improve patient

Belitung Nursing Journal , Volume 3, Issue 4, July-August 2017 447 satisfaction. CEmONC must be monitored International Journal for Quality in by hospital manager or director according Health Care. 2011;23(3):278-283. to the standard. Further research is needed 6. Susmaneli H, Triana A. Dimensi to identify other variables affecting patient mutu pelayanan kebidanan terhadap satisfaction and the quality of CEmONC. kepuasan pasien program Jampersal [Dimension of midwifery care quality

on satisfaction of patients of Declaration of Conflicting Interest Jampersal program]. Kesmas: None declared National Public Health Journal.

2014;8(8):418-422. Funding 7. Schoenfelder T, Klewer J, Kugler J. This study was supported by Master of Determinants of patient satisfaction: Nursing, Faculty of Medicine, Universitas A study among 39 hospitals in an in- Gadjah Mada, Indonesia. patient setting in Germany.

International Journal for Quality in Author Contribution Health Care. 2011;23(5):503-509. All authors contributed equally in this study. 8. Srivastava A, Avan BI, Rajbangshi P,

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