Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11909 The effect of Qur'anic Healing on reducing the frequency of Auditory Hallucination Rating Scale (AHRS) in schizophrenia Muhammad Rosyidul Ibad, Febry Syaren Alfianti, Muhammad Ari Arfianto, Tutu April Ariani, Zahid Fikri Nursing Study Program, Faculty of Health Sciences, Universitas Muhammadiyah Malang, Indonesia Abstract Auditory hallucinations have led to decreased productivity, impaired interaction, and diminished well-being in individuals with schizophrenia. However, the challenge lies in enabling patients to independently manage their hallucinations, and one potential approach is through psycho-religious methods utilizing the Qur’an. This study aimed to assess the impact of Qur’anic heal- ing on reducing the frequency of auditory hallucinations in individ- uals with schizophrenia. Employing a quasi-experimental design with a one-group pre-post-test, this study included 35 respondents selected through purposive sampling. Inclusion criteria stipulated that participants must have a diagnosis of schizophrenia accompa- nied by auditory hallucinations, coherent thinking, a cooperative attitude, and adherence to the Muslim faith. The Auditory Hallucination Rating Scale (AHRS) served as the instrument for data collection, with analysis conducted using the Wilcoxon test. The findings revealed a significant effect of Qur’anic healing on reducing the frequency of auditory hallucinations, indicated by a p- value of 0.000 (p<0.05). Qur’anic healing demonstrated effective- ness in alleviating auditory hallucinations among individuals with schizophrenia. We recommend incorporating Qur’anic healing as an additional supportive therapy for schizophrenia patients. Moreover, it is anticipated that listening to Qur’anic healing will enhance the patient’s adaptive coping mechanisms. Introduction Hallucinations are considered characteristic symptoms of psy- chosis and are part of the ‘psychosis superspectrum’ within the Hierarchical Taxonomy Of Psychopathology (HiTOP) initiative.1 They manifest as signs and symptoms of mental disorders in the form of sensory responses (hearing, sight, taste, smell, and touch) to stimuli that are not real.2,3 If not handled properly, hallucina- tions can pose a risk, leading the sufferer to potentially injure themselves or others, and even harm the surrounding environ- ment. This occurs because the patient is influenced by their hallu- cinations, leading them to engage in actions beyond their control.4 Unfortunately, it is not uncommon to observe mentally ill patients committing acts of violence as a result of the hallucinations they experience.5,6 Individuals experiencing auditory hallucinations may pose a danger to themselves, others, and their environment. Moreover, hallucinations impair overall functioning and con- tribute to biological, social, and spiritual problems.7–9 In such cases, positive behavior is influenced by an individual’s positive perception of society and prevailing norms.10. The severity of the problem is exacerbated by the content of auditory hallucinations, which can range from direct violence towards others to suicide attempts.11–13 Schizophrenia is a major mental disorder, particularly preva- lent in countries where it ranks at the top among all existing men- tal disorders.14,15 It affects the brain, leading to disturbances in per- ceptions, emotions, movement, and behavior.16 In Indonesia, it is estimated that 6.7 per 1,000 households suffer from schizophrenia, and 14.0% of Indonesian households have practiced pasung, which involves the restraining and confinement of individuals with mental health problems (Kemenkes, 2018).17 Patients experi- encing hallucinations can be treated through both pharmacological Correspondence: Muhammad Rosyidul Ibad, Nursing Study Program, Faculty of Health Sciences, Universitas Muhammadiyah Malang, Indonesia. E-mail: ibad@umm.ac.id Key words: auditory hallucinations; schizophrenia; Qur'anic Healing; Surah Ar-Rahman. Contributions: MRI, conceptualization, data curation, formal analysis, methodology, validation, writing - original draft, review and editing; FSA, conceptualization, investigation, methodology, validation, and writing - original draft, collecting data, resources; MAA, review and edit- ing; TAA, writing - review and editing; ZF, resources, investigations, and writing - review and editing. All the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. Conflict of interest: the authors declare no potential conflict of interest. Funding: this research is supported by a research grant from [DPPM Universitas Muhammadiyah Malang] with contract number [E.2.a/811/BAA-UMM/VIII/2023]. Ethics approval and consent to participate: this research has received eth- ical approval from the Health Research Ethics Commission, Faculty of Medicine, Muhammadiyah University of Malang based on ethical certifi- cate No.E.5.a/073/KEPK-UMM/IV/2023. During the research, the researcher paid attention to the information ethics principles of consent, respect for human rights, beneficence and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received: 3 December 2023. Accepted: 18 December 2023. Early access: 26 January 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11909 doi:10.4081/hls.2024.11909 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 198] [Healthcare in Low-resource Settings 2024;12:11909] Non -co mmerc ial us e o nly and non-pharmacological approaches.18,19 Pharmacological therapy involves the use of chemical drugs designed to quickly control psychosis symptoms by affecting neurotransmitters in the brain. Individuals with schizophrenia require long-term treatment and recovery.20 However, the extended use of drugs may result in side effects, such as stickiness of the tongue, loss of motivation, body discomfort, hypersalivation, and symptoms resembling Parkinson’s disease, which may lead people with schizophrenia to be reluctant to take medication. Non-pharmacological treatment includes modality therapy, and/or a mainstay in psychiatric nursing aimed at progressively developing a personality style or model.21,22 Modality therapy encompasses seven types: cognitive therapy, logotherapy, family therapy, environmental therapy, psychoreli- gious therapy, group therapy, and discharge planning programs.23– 25 Considering the cultural background in Indonesia, where hallu- cinatory content, such as occult/mystical sounds, is prevalent, a spiritual approach is considered more effective in managing symp- toms of auditory hallucinations.26,27 A study suggest that Qu’ran recitation (referred to as the Qu’ran Recitation Approach, QRP) is useful not only for relieving anxiety related to specific medical conditions, but also for psychosocial ones.28 Spiritual therapy, specifically Qur’anic Healing therapy, involves listening to the recitation of the holy verses of the Qur’an, coupled with one’s intentions and beliefs.29 Religious therapy, par- ticularly psycho-religious therapy, has been found to be beneficial for schizophrenic patients, as demonstrated by Ridwan Haris.30 The study’s findings indicated that patients undergoing psycho- religious therapy were able to diminish the clinical symptoms of schizophrenia. This resulted in quicker control of positive symp- toms, a shorter duration of hospitalization, faster wound healing, and a more rapid development of adaptive abilities.31 Qur’anic Healing can be administered through the Murottal therapy method, involving the reading of Qur’anic verses to pro- duce a beneficial impact on the body.31 Murottal therapy serves as a potent brain stimulant. When individuals listen to the holy verses of the Qur’an, it induces a relaxed, calm, and comfortable response. Therapy utilizing the strains of Qur’an recitation can be considered an alternative and superior relaxation therapy com- pared to other audio therapies because the Qur’an’s stimulation can activate delta waves.32,33 Several studies have demonstrated that listening to Murottal Qur’an has a positive effect on emotions. The advantageous impact of Al-Qu’ran Murottal therapy on emotional changes has piqued researchers’ interest, particularly in its application as therapy for individuals experiencing physical pain in previous studies. This research, however, focuses on informal caregivers of schizophre- nia patients.33 Building on the aforementioned research, the Qur’an shows promise in reducing the frequency of hallucinations in patients. Therefore, the primary objective of this study is to examine the effect of Qur’anic Healing on decreasing the frequency of auditory hallucinations in individuals with schizophrenia. Materials and Methods Research design The researcher employed pre-experimental design, specifically utilizing a one-group pre-post-test design. This research type was chosen to analyze the application of Qur’anic healing in schizophrenia patients exhibiting symptoms of auditory hallucina- tions. The study aims to elucidate changes in hallucination fre- quency scores before and after administering Qur’anic healing therapy, which are subsequently analyzed. Study participants The study’s population consisted of 180 patients diagnosed with schizophrenia in the Social Rehabilitation Unit of East Java Province, Indonesia. However, the sample size involved in this study was 35 patients. Researchers employed purposive sampling to determine the sample, with inclusion criteria specifying patients diagnosed with schizophrenia who exhibit coherent thought flow, experience auditory hallucinations, and practice the Muslim faith. Exclusion criteria encompassed patients in the crisis phase and those with impaired thought flow. Variables, instruments and data collection The independent variable in this research is Qur’anic healing therapy, while the dependent variable is the frequency of auditory hallucinations. In this study, the measurement instrument used was the Auditory Hallucination Rating Scale (AHRS). This question- naire has been validated in a clinical trial in France, yielding sig- nificant results.34 Other researchers have also conducted studies utilizing similar instruments to assess the frequency of auditory hallucinations in schizophrenia patients.35,36 The AHRS instrument includes various indicators assessing the scale of auditory halluci- nations, covering frequency, duration, location, sound strength, belief in the origin of the sound, amount and intensity of negative sound content, distress caused by the sound, and the patient’s con- trol over the sound. AHRS assigns scores of 0 (none), 1-11 (mild), 12-22 (moderate), 23-33 (severe), and 34-44 (very severe). Data collection took place over one month in March 2023, during which the Qur’anic healing intervention occurred in three sessions. Session 1 focused on establishing trust with the respondent. In Session 2, participants listened to the holy verses of the Qur’an (specifically Ar-Rahman verses 1-78) for 10 minutes using person- al headsets. Researchers observed the patient’s response during and after listening to the verses. Both Session 2 and Session 3 involved providing Qur’anic healing twice daily, in the morning and evening. Data analysis The data analysis employs the Wilcoxon test using SPSS 12 software. This test is utilized to assess comparative hypotheses for data within a single group of paired samples. It is suitable for freely distributed ordinal data or interval and ratio data that do not follow a normal distribution. The test is specifically designed for paired samples, meaning there is one group of samples with two related sets of data. Ethical clearance This research has obtained ethical approval from the Health Research Ethics Commission, Faculty of Medicine, Muhammadiyah University, Malang, as evidenced by Ethical Certificate No. E.5.a/073/KEPK-UMM/IV/2023. It has been deemed ethically appropriate in accordance with the 7 WHO standards, which include 1) Social Value, 2) Scientific Value, 3) Equitable Assessment and Benefits, 4) Risk, 5) Persuasion/Exploitation, 6) Confidentiality and Privacy, and 7) Informed Concern. For a detailed understanding of the accuracy of indicators for each standard, please refer to the CIMOS 16 guidelines. Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [Healthcare in Low-resource Settings 2024;12:11909] [page 199] Non -co mmerc ial us e o nly Results Respondent characteristics are described based on age and gender. Table 1, which presents demographic data, reveals that respon- dents who underwent psychiatric rehabilitation at Psychotic Rehabilitation East Java, Indonesia, fall into the early elderly age group (46-55 years). The majority of elderly individuals experienc- ing auditory hallucinations received a diagnosis of schizophrenia in their earlier years before entering old age. They underwent reha- bilitation for mental disorders in rehabilitation centers, encounter- ing various predisposing factors for mental disorders, encompass- ing biological, psychological, and socio-cultural aspects. The majority of respondents underwent rehabilitation for a duration exceeding three years, totaling 19 individuals. This data indicates a lack of preparedness within families to care for patients with hallucinations upon their return home. Additionally, there is a societal rejection in the community where the patient resides. Some patients have a background of homelessness, lacking a per- manent place of residence, which compels them to continue treat- ment throughout their lives. Table 2 has demonstrated a reduction in auditory hallucination scores among schizophrenia patients who underwent Qur’anic healing therapy. Patients who initially had a very severe score of 4 saw a decrease to 0 after therapy, indicating an improvement in their AHRS level towards sensory enhancement. Similarly, for patients with a severe level of 10 before therapy, the score reduced to 1. The majority of respondents exhibited an enhancement in their AHRS level towards the Mild category. The Wilcoxon analy- sis test remarkably established high significance, with a P-value of 0.000. This signifies that Qur’anic healing is effective and capable of reducing the frequency of auditory hallucinations in schizophre- nia patients. Discussion Prior to the administration of Qur’anic healing, the majority of participants exhibited moderate auditory hallucinations, compris- ing 19 people (54.3%). The remainder had mild auditory halluci- nations (2 people, 5.7%), severe auditory hallucinations (10 peo- ple, 28.6%), and very severe auditory hallucinations (4 people, 11.4%). According to the research results, the auditory hallucina- tion stage of the respondents is categorized as stage 2 (non-psychi- atric/condemning patient). The symptoms of hallucinations mani- fest through the behavior of respondents, who consistently report hearing voices that others cannot hear. Patients also display signs of being unconcentrated, staring unfocused, frequently covering their ears, and experiencing difficulty in controlling their halluci- nations.37 When patients experience hallucinations, they typically exhibit emotions such as unexplained anger, engaging in self-talk or laughter, experiencing unfounded fears, and disruption of their daily activities. Sleep disturbances often occur, potentially leading to depression or stress. According to the researchers, several fac- tors contribute to managing patients with auditory hallucinations, including knowledge, seeking treatment at health facilities, adher- ing to prescribed medications, self-intention to recover, family support, and consistent adherence to a therapy schedule. Consequently, the researchers have chosen to implement Qur’anic healing therapy as an approach. The results indicate a decrease in the level of auditory hallucinations, as illustrated in Table 1. Before the Qur’anic healing therapy was administered, the majority expe- rienced moderate auditory hallucinations, comprising 19 people (54.3%). After undergoing Qur’anic Healing therapy, there was a reduction in the level of auditory hallucinations, with the majority now exhibiting mild auditory hallucinations, accounting for 21 people (60%). The remaining respondents displayed moderate lev- els of auditory hallucinations, totaling 13 people (37.1%), and severe auditory hallucinations, represented by 1 person (2.9%). This shift suggests that the respondents became calmer, refrained from talking to themselves, and demonstrated increased concentra- tion on following therapy. According to research, Qur’anic healing through listening to the Murottal of Surah Ar-Rahman can posi- tively impact the body and cultivate a sense of calm and comfort.38 In patients experiencing hallucinations, there is an imbalance of the dopamine hormone, leading to false perceptions even in the Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Demographic characteristics of respondents. Variable Respondent (n=35) n % Age Adolescent (17-25 years) 2 5.7 Early adulthood (26-35 years) 7 20 Late adulthood (36-45 yrs) 9 25.7 Early elderly (46-55 yrs) 16 45.7 Late elderly (56-65 yrs) 1 2.9 Total 35 100 Gender Man 20 57.1 Woman 15 42.9 Total 35 100 Duration of rehabilitation <3 months 2 5.7 4-8 months 6 17.1 9-12 months 3 8.6 1-3 years 5 14.3 >3 years 19 54.3 Total 35 100 Table 2. Auditory Hallucination Ratting Score (AHRS). Category Score AHRS Pre-Therapy Score AHRS Post- Therapy p F % F % No hallucinations 0 0 0 0 0.000 Mild 2 5.7 21 60 Moderate 19 54.3 13 37.1 Severe 10 28.6 1 2.9 Very Severe 4 11.4 0 0 Total 35 100 35 100 n=100 [page 200] [Healthcare in Low-resource Settings 2024;12:11909] Non -co mmerc ial us e o nly absence of external stimuli. Based on research findings, Qur’anic Healing therapy can stimulate the brain to reduce stress hormones and activate the production of natural endorphins, specifically serotonin. Consequently, the impact on the body is a heightened sense of calm, increased focus, reduced feelings of anxiety and ten- sion. Individuals who regularly listen to the verses of the holy Qur’an may experience a decrease in depression levels.33 The research suggests that Qur’anic healing is effective in reducing the frequency of hallucination symptoms in schizophrenic patients.29 Reading and listening to the recitation of the holy verses of the Qur’an stabilize neuron vibrations and lower cortisol levels, result- ing in a sense of calm. This effect on respondents may empower them to control their hallucinations. The results revealed that before receiving Qur’anic healing therapy, respondents frequently heard voices at various times, with durations extending up to hours. The sources of these sounds var- ied and were often very strong, leading to confusion for the respon- dents in distinguishing between reality and auditory stimuli. They sometimes spoke alone, resulting in a moderate level of auditory hallucinations, involving 19 people (54.3%). The remaining respondents experienced mild auditory hallucinations (2 people, 5.7%), severe auditory hallucinations (10 people, 28.6%), and very severe auditory hallucinations (4 people, 11.4%). After undergoing Qur’anic Healing therapy for two weeks, with a 5-minute duration in both morning and evening sessions, there was a notable decrease in the level of auditory hallucinations. The majority of respondents exhibited mild auditory hallucinations, accounting for 21 people (60%). The remaining respondents displayed moderate auditory hallucinations (13 people, 37.1%) and severe auditory hallucina- tions (1 person, 2.9%). Furthermore, respondents became calmer, refrained from talking to themselves, and demonstrated increased concentration. The Wilcoxon test results, which compare the pre- test and post-test scores before and after Qur’anic healing therapy, yielded a p-value of 0.000 (p<0.05). This implies a significant effect in reducing the level of auditory hallucinations in schizophrenic patients through Qur’anic Healing. Religious activities such as reading the Qu’ran, prayer, and dhikr have a positive impact on patients’ physical and mental health, attention, and concentration. Negative physical and emo- tional impacts are experienced when patients neglect prayer and dhikr.39 The audio of Surah Ar-Rahman, previously studied, has demonstrated effectiveness in reducing levels of violent behavior and assisting patients in expressing their emotions in a more adap- tive manner. This form of audio therapy is cost-effective and does not result in side effects. The recitation of the holy verses of the Qur’an generates a range of frequencies that reach the ears and subsequently affect brain cells through electromagnetic fields. Additional studies elaborate on the idea that the sound of Qur’anic recitation can enhance psychological and physiological parameters. This includes reducing heart rate, anxiety, and stress, as well as improving mental health and memory performance for both children and adults. Consequently, listening to and reciting the Qur’an can be recommended as a supportive treatment to enhance psychological well-being.40 Conclusions The research results indicate that Qu’ranic Healing has the potential to reduce the frequency of auditory hallucinations expe- rienced by schizophrenia patients if administered regularly twice a day for an entire month. Researchers recommend that nurses man- aging patients with auditory hallucinations in hospitals or rehabil- itation centers incorporate this therapy as a primary supportive treatment alongside patients receiving psychopharmaceutical ther- apy. This approach aims for a more holistic treatment, capitalizing on advantages such as the psychospiritual aspect, with the hope that it will not only diminish hallucinations but also fortify the spir- itual well-being of schizophrenia patients. It underscores that ful- filling mental health needs involves not only enhancing physical function through antipsychotic drugs but also addressing mental and spiritual aspects. The provision of Qur’anic healing to halluci- nation patients significantly impacts the reduction of hallucination frequency, contributing to a sense of calmness, cooperation, and improved religious coping mechanisms in Muslim patients. References 1. Jimeno N, Gomez-Pilar J, Poza J, et al. 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