Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11958 The effect of light massage and Spiritual Emotional Freedom Technique interventions on blood pressure among hypertension patients in Indonesia Arsyawina Arsyawina, Rivan Firdaus, Diah Setiani, Raisyah Chaiarunnisya Nursing Study Program, Politeknik Kesehatan Kemenkes Kalimantan Timur, Samarinda, Indonesia Abstract Hypertension remains a significant global public health con- cern. Non-pharmacological interventions such as light massage and the Spiritual Emotional Freedom Technique (SEFT) offer potential avenues to mitigate sustained increases in blood pressure among patients with hypertension. However, research exploring these methods as alternative therapies, particularly in Indonesia, is limited. This study aimed to investigate the effects of light mas- sage and SEFT on the blood pressure of hypertensive individuals. Employing a quasi-experimental design with a time series approach, the study utilized purposive sampling to select 27 par- ticipants. Light massage and SEFT were considered independent variables, while blood pressure served as the dependent variable. Data analysis involved repeated measures ANOVA and one-way ANOVA tests. The results revealed significant differences in mean blood pressure before and after the light massage intervention (p- values: 0.002, <0.001, <0.001). The intervention sessions yielded the most significant results (p-values: <0.001, 0.002, <0.001), whereas no differences were observed in the control group (sys- tolic and Mean Arterial Pressure, MAP, p-values: 0.012 and 0.017, respectively). Notably, there were discrepancies in mean blood pressure before and after interventions in both the light massage and SEFT groups, indicating a potential benefit of these interven- tions. Conversely, no such differences were noted in the control group. These results highlight the potential benefits of integrating light massage and SEFT into holistic approaches for managing hypertension, potentially improving outcomes and quality of life for affected individuals. Introduction Hypertension is classified as a Noncommunicable Disease (NCD).1,2 It refers to a condition characterized by abnormally high blood pressure in the arteries, persisting over time.3 The term “hypertension” stems from the combination of “hyper,” meaning excessive, and “tension,” referring to pressure, denoting an eleva- tion in blood pressure beyond the normal range due to circulatory system disorders.4-6 According to data collected by the World Health Organization (WHO) in 2015, approximately 1.13 billion people worldwide, or one in three individuals globally, are diag- nosed with hypertension. With the escalating number of hyperten- sion cases annually, it is projected that by 2025, there will be 1.5 billion individuals living with hypertension. Moreover, hyperten- sion and its complications contribute to an estimated 9.4 million deaths annually.1 In Indonesia, based on the National Health Survey, the preva- lence of hypertension among individuals aged 18 years and above is 34.1%. The highest prevalence is observed in South Kalimantan, while the lowest is in Papua. The estimated number of hypertension cases in Indonesia is 63,309,620, with 427,218 deaths attributed to hypertension. In East Borneo Province, specif- ically, the number of hypertension cases among individuals aged 18 years and above was 8,957 in 2018, reflecting a 39.30% Correspondence: Rivan Firdaus, Nursing Study Program, Politeknik Kesehatan Kemenkes Kalimantan Timur, Samarinda, Indonesia. E-mail: poltekkeskaltim.rivan@gmail.com Key words: blood pressure; hypertension; light massage; Spiritual Emotional Freedom Technique (SEFT). Contributions: AA, conceptualization, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; RF, conceptualization, data curation, investigation, methodology, validation, and writing – original draft, review & editing; DS, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; RC, methodology, visualization, writing – review & 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 conflict of interest. Funding: none. Ethics approval and consent to participate: the research has received eth- ical approval from the Health Research Ethics Commission, East Kalimantan Ministry of Health Polytechnic, based on ethical certificate 07742-KEPK. During the research, the researcher pays attention to the ethical principles of information to 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. Acknowledgements: we would like to thank Bengkuring Community Health Center for their valuable insights and contributions to this study. We also wish to acknowledge the valuable contributions of the mentoring program conducted by the Research Centre of Excellence in Advancing Community Health (REACH) in Surabaya, Indonesia. Received: 12 October 2023. Accepted: 27 May 2024. Early access: 1 July 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; 12:11958 doi:10.4081/hls.2024.11958 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 558] [Healthcare in Low-resource Settings 2024;12:11958] Non -co mmerc ial us e o nly increase compared to 2017.1 Recent estimations from the Samarinda City Health Office in 2022 reported approximately 9,936 hypertension cases in Samarinda, with 897 cases recorded at the Bengkuring Samarinda Public Health Center. Various factors contribute to the development of hypertension, including internal factors such as gender, age, and genetics, as well as external factors like smoking, alcohol consumption, physical inactivity, and obesity.7,8 If left unaddressed, hypertension can lead to organ damage and heart disease.9-12 Non-pharmacological thera- pies, such as light massage and the Spiritual Emotional Freedom Technique (SEFT), can be administered to hypertension patients to prevent sustained increases in blood pressure. These therapies induce relaxation, alleviate muscle stiffness, and dilate blood ves- sels, resulting in a gradual decrease in blood pressure.4,13 SEFT combines energy medicine and spiritual therapy, involving tapping techniques on specific points along the body’s energy meridians to stimulate key points and promote relaxation.5 Research conducted by Wijaya demonstrated the efficacy of SEFT therapy in reducing blood pressure, establishing it as a viable alternative for managing hypertension.14 Similarly, studies by Maswarni10 and Permatasari15 concluded that SEFT therapy effectively lowers blood pressure in hypertensive patients. Given the preliminary study’s indication of a high prevalence of hyper- tension in Samarinda City, particularly at the Bengkuring Community Health Center where 897 cases were recorded. The objective of this study was to assess the effects of light massage and SEFT on the blood pressure of hypertensive patients and to compare their efficacy in reducing blood pressure. Materials and Methods Research design This research was conducted in the working area of Bengkuring Public Health Center in Samarinda from February to April 2023. The study employed a quasi-experimental design with a time-series approach, utilizing a pre- and post-test design with a control group. Study participants The study population consisted of hypertension patients at the Bengkuring Health Center in Samarinda, comprising a total of 27 individuals divided into three groups, with 9 participants in each group: a control group, a light massage group, and an SEFT group. The sampling method utilized was purposive sampling to select the total sample, which was then randomized into the two groups. Inclusion criteria included patients diagnosed with hypertension by a physician, absence of other complicating diseases, ability to communicate effectively, and no hearing impairments. Study procedure Data collection involved pre-test blood pressure measure- ments, followed by either intervention of light massage or SEFT. Light massage, characterized by gentle movements on soft tissues, including wiping and rubbing, aims to induce comfort, release muscle tension, and enhance blood circulation.16 SEFT, a comple- mentary therapy targeting physical, emotional, and spiritual responses, employs gentle tapping on 18 meridian points to pro- mote relaxation. This method integrates energy medicine and spir- itual therapy, incorporating client affirmations or prayers at the beginning and end of sessions.17,18 Both light massage and SEFT were administered once daily for three consecutive days, each ses- sion lasting 15-20 minutes in the morning. Similar interventions were repeated on the second and third day, followed by post-test measurements. The control group did not receive any intervention. Variable and instrument The independent variables consist of light massage and the SEFT method, while the dependent variable is blood pressure, which is measured in terms of systolic, diastolic, and Mean Arterial Pressure (MAP). MAP is calculated by adding one-third of the pulse pressure to the diastolic pressure. The research instru- ments utilized include a digital sphygmomanometer, olive oil, Standard Operating Procedures (SOPs) for light massage and SEFT, as well as research observation sheets. Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions Table 1. Frequency distribution of blood pressure across groups (N=27). Group Mean ±SD Min-Max Light massage Pre-test systolic 153.83 14.44 137-179 Post-test systolic 1 137.11 13.98 116-159 Post-test systolic 2 135.22 16.58 115-169 Post-test systolic 3 128.67 9.93 118-151 Pre-test diastolic 95 6.91 83-103 Post-test diastolic 1 84 5.45 75-91 Post-test diastolic 2 88.11 8.08 78-103 Post-test diastolic 3 80.33 7.79 71-95 MAP pre-test 114.67 8.67 101-126 MAP post-test 1 101.78 7.64 91-114 MAP post-test 2 103.67 10.29 92-125 MAP post-test 3 96.44 7.97 89-109 SEFT Pre-test systolic 163 24,28 131-202 Post-test systolic 1 159.22 23.73 128-198 Post-test systolic 2 158.44 21.73 133-194 Post-test systolic 3 153.22 24.18 121-189 Pre-test diastolic 99 8.95 89-113 Post-test diastolic 1 98 8.41 86-112 Post-test diastolic 2 97 6.89 89-108 Post-test diastolic 3 92 9.43 81-107 MAP pre-test 120.33 10.87 104-135 MAP post-test 1 119.22 10.87 100-132 MAP post-test 2 116.67 9.79 104-131 MAP post-test 3 112.44 11.9 98-129 Control Pre-test systolic 150.11 17.23 129-176 Post-test systolic 1 149.89 18.23 126-179 Post-test systolic 2 144 16.52 118-174 Post-test systolic 3 155.56 12.3 136-169 Pre-test diastolic 99.11 14.78 80-116 Post-test diastolic 1 100.56 14.95 82-118 Post-test diastolic 2 96.11 14.12 72-113 Post-test diastolic 3 101 15.52 78-119 MAP pre-test 116.11 14.27 97-138 MAP post-test 1 116.78 15.02 98-138 MAP post-test 2 112.11 14.34 87-133 MAP post-test 3 119.11 13.43 98-134 MAP, Mean Arterial Pressure; SEFT, Spiritual Emotional Freedom Technique. [Healthcare in Low-resource Settings 2024;12:11958] [page 559] Non -co mmerc ial us e o nly Data analysis Each group will undergo testing using repeated ANOVA. To compare means between groups, researchers will employ one-way ANOVA with a significance level of 5% or a p-value of 0.05. Ethical clearance The research has received ethical approval from the Health Research Ethics Commission at the East Kalimantan Ministry of Health Polytechnic, based on Ethical Certificate 07742-KEPK. Throughout the research process, the researcher has adhered to eth- ical principles including informed consent, respect for human rights, beneficence, and non-maleficence. Results Table 1 compares the blood pressure measurements before and after interventions in three groups: light massage, SEFT, and a con- trol group. In the light massage group, pre-test systolic blood pres- sure ranged from 137 mmHg to 179 mmHg, and diastolic blood pressure from 83 mmHg to 103 mmHg, with mean values of 153.83 mmHg and 95.00 mmHg, respectively. Post-test measure- ments showed a decrease in both systolic and diastolic blood pres- sure. For the SEFT group, pre-test systolic blood pressure ranged from 131 mmHg to 202 mmHg, and diastolic blood pressure from 89 mmHg to 113 mmHg, with mean values of 163.00 mmHg and 99.00 mmHg, respectively. Post-test measurements indicated a decrease in both systolic and diastolic blood pressure. In the con- trol group, pre-test systolic blood pressure ranged from 129 mmHg to 176 mmHg, and diastolic blood pressure from 80 mmHg to 116 mmHg, with mean values of 150.11 mmHg and 99.11 mmHg, respectively. Overall, there were differences in mean blood pres- sure values before and after interventions in both the light massage and SEFT groups, while the control group showed less change. Table 2 presents the results of mean blood pressure differences before and after interventions in the light massage, SEFT, and con- trol groups. In the light massage group, significant differences were observed in systolic, diastolic, and MAP measurements on day 3 post-intervention (p-value<0.05). Conversely, the SEFT group showed significant differences only in systolic and diastolic measurements on the same day (p-value<0.05). No significant dif- ferences were observed in the control group’s blood pressure val- ues. Table 3 presents the significance values of the post-test systolic blood pressure, diastolic blood pressure, and MAP for both the intervention light massage group, SEFT group, and the control group, with p-values of 0.004, 0.003, and 0.001, respectively, all of which are less than 0.05. Based on these values, it can be concluded that there is a significant difference in blood pressure among the three groups. Table 4 presents the results of a one-way ANOVA test compar- ing mean blood pressure differences between the intervention group (light massage and SEFT) and the control group among hypertensive patients in the Bengkuring Community Health Center’s working area. The results indicate significant differences in blood pressure among the three groups. Specifically, the light massage intervention group exhibited more significant differences compared to the SEFT group, with mean systolic, diastolic, and MAP differences of -24.6, -11.7, and -16, respectively, with p-val- ues of 0.012, 0.097, and 0.017. Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 560] [Healthcare in Low-resource Settings 2024;12:11958] Table 2. Frequency distribution of blood pressure across groups (N=27). Blood pressure Repeated ANOVA Test Mean difference CI 95% p Light massage group Pre-test systolic vs post-test 1 16.8 7.5-26 0.001 Pre-test vs post-test 2 18.7 1.6-35.7 0.031 Pre-test vs post-test 3 25.2 10.4-40 0.002 Post-test 1 vs post-test 2 1.9 16-19.8 1 Post-test 1 vs post-test 3 8.4 -6.9-23.8 0.552 Post-test 2 vs post-test 3 6.6 -3.3-16.4 0.298 Pre-test diastolic vs post-test 1 11 5.8-16.2 0.000 Pre-test vs post-test 2 6.9 -1.9-15.7 0.158 Pre-test vs post-test 3 14.7 9.3-20 0.000 Post-test 1 vs post-test 2 -4.1 -13.9-5.7 1 Post-test 1 vs post-test 3 3.7 -2.1-9.4 0.348 Post-test 2 vs post-test 3 7.8 0.9-14.7 0.026 MAP pre-test vs post-test 1 12.9 7.1-18.7 0.000 Pre-test vs post-test 2 11 0.1-21.9 0.048 Pre-test vs post-test 3 18.2 10.3-21.9 0 Post-test 1 vs post-test 2 -1.9 -14-10.3 1 Post-test 1 vs post-test 3 5.3 -3.2-13.9 0.370 Pre-test vs post-test 3 14.7 9.3-20 0.000 Post-test 1 vs post-test 2 -4.1 -13.9-5.7 1 SEFT group Pre-test systolic vs post-test 1 3.8 2.5-5 0.000 Pre-test vs post-test 2 4.6 -1-9.7 0.094 Pre-test vs post-test 3 9.8 6.5-13.1 0.000 Post-test 1 vs post-test 2 0.8 -3.6-5.2 1 Post-test 1 vs post-test 3 6 2.3-9.7 0.003 Post-test 2 vs post-test 3 5.2 -0.1-10.5 0.054 Pre-test diastolic vs post-test 1 0.1 -8.8-9 1 Pre-test vs post-test 2 2 -12 1 Pre-test vs post-test 3 7 2.9-11.1 0.002 Post-test 1 vs post-test 2 1.9 2.4-6.2 0.979 Post-test 1 vs post-test 3 6.9 2.4-16.2 0.194 Post-test 2 vs post-test 3 5 -0.7-10.7 0.093 Pre-test MAP vs post-test 1 1.1 -4.8-7 1 Pre-test vs post-test 2 3.7 -1.9-9.2 0.306 Pre-test vs post-test 3 7.9 -1.9-9.2 0.000 Post-test 1 vs post-test 2 2.6 -2.7-7.8 0.774 Post-test 1 vs post-test 3 6.8 0.4-13.1 0.035 Control group Pre-test systolic vs post-test 1 0.2 -2.8-3.2 1 Pre-test vs post-test 2 6.1 -7.1-19.3 0.872 Pre-test vs post-test 3 -5.4 -15.6-4.7 0.590 Post-test 1 vs post-test 2 -5.9 -8.5-20.3 1 Post-test 1 vs post-test 3 -5.7 -17.9-6.6 0.874 Post-test 2 vs post-test 3 -11.6 -25.8-2.7 0.136 Pre-test diastolic vs post-test 1 -1.4 -5.6-2.7 1 Pre-test vs post-test 2 3 -8.1-14.1 1 Pre-test vs post-test 3 -1.9 -11.3-7.5 1 Post-test 1 vs post-test 2 4.4 -5.2-14.1 0.887 Post-test 1 vs post-test 3 -0.4 -9.2-8.4 0.1 Post-test 2 vs post-test 3 -4.9 -10.7-0.9 0.115 Pre-test MAP vs post-test 1 -0.7 -3.8-2.5 1 Pre-test vs post-test 2 4 -22 1 Pre-test vs post-test 3 -3 -10.6-4.6 1 Post-test 1 vs post-test 2 4.7 -6-15.4 1 Post-test 1 vs post-test 3 -2.3 -11.1-6.5 1 Post-test 2 vs post-test 3 -7 -14.7-0.7 0.080 MAP, Mean Arterial Pressure; SEFT, Spiritual Emotional Freedom Technique Non -co mmerc ial us e o nly Discussion The study results in the light massage intervention group revealed a significant difference between the average pre-test and post-test systolic and diastolic blood pressure, indicating that light massage effectively lowers blood pressure in patients with primary hypertension. This process involves inducing relaxation in the smooth muscles of arteries, veins, and other muscles throughout the body, leading to reduced levels of norepinephrine in the blood.19 Sihotang’s study,20 which utilized paired sample t-tests, found significant data with a p-value of 0.000 for post-reflexology foot massage systolic blood pressure and 0.037 for post-reflexolo- gy foot massage diastolic blood pressure. This suggests a tangible difference in blood pressure before and after reflexology massage, highlighting its potential to reduce hypertension.13 However, it’s worth noting that four respondents experienced an increase in blood pressure on the second day of the three-day intervention, as per the researchers’ observations. The study results within the SEFT intervention group revealed a notable disparity between the mean pre-test and post-test systolic and diastolic blood pressure. Huda’s study,21 showcased a signifi- cant reduction in both systolic and diastolic blood pressure among participants undergoing SEFT therapy, indicating its efficacy in mitigating hypertension. SEFT therapy fosters a sense of comfort and relaxation, alleviating physical complaints such as dizziness, muscle pain, neck pain, and lower back pain. Huda’s findings,21 employing paired t-tests for data analysis in the intervention group, yielded a calculated t-value of 8.699 for systolic blood pressure with a p-value of 0.000. Consequently, it is evident that SEFT ther- apy brings about a significant difference between pre and post- SEFT therapy measurements. The researchers hypothesized that blood pressure would signif- icantly decrease in the treatment group following SEFT therapy. This expectation stems from the combined effect of tapping stimuli on the body’s meridian points and the inclusion of spiritual ele- ments such as prayer, which may induce a calming effect known to lower blood pressure. However, during the three-day intervention, on the second day, three respondents experienced an increase in blood pressure compared to the previous day. One respondent attributed this to overwhelming thoughts causing dizziness and stress, while another mentioned it was due to post-work activities. The results from the control group indicated no significant dif- ference between the average pre-test and post-test systolic and diastolic blood pressure. However, a noteworthy finding emerged regarding MAP in the control group, showing a significant differ- ence between pre-test and post-test averages. Thus, it can be inferred that there’s no substantial variance in blood pressure lev- els within the control group before and after testing. Additionally, Arwani’s study,8 focusing on the control group receiving standard pharmacological therapy without additional interventions, observed that six respondents experienced a decrease in blood pressure compared to the previous day during the three-day research period. Reasons cited included respondents just waking up and engaging in minimal activity, such as watching television or using mobile phones. The researchers attributed this to the noticeable relaxation experienced by respondents during the light massage intervention, with some even falling asleep. The technique involved gentle pressing, rubbing, and massaging various body parts. Notably, the majority of respondents in the light massage group were house- wives who reported feeling fatigued and stressed due to their daily routines. Consequently, the light massage intervention induced feelings of reduced fatigue, enhanced relaxation, and calmness, leading to a significant decrease in blood pressure. In contrast, the SEFT interventions primarily involved tapping at specific points, which may not have elicited the same level of relaxation and sub- sequent blood pressure reduction. Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [Healthcare in Low-resource Settings 2024;12:11958] [page 561] Table 3. Comparing blood pressure changes between intervention and control groups (N=27). Blood pressure One-way ANOVA Average p Systolic Light massage 128.7 (9.9) 0.004 SEFT 153.2 (24.2) Control 155.6 (12.3) Diastolic Light massage 80.3 (7.8) 0.003 SEFT 92 (9.4) Control 101 (15.5) MAP Light massage 96.4 (2.7) 0.001 SEFT 112.4 (4) Control 119.1 (4.5) MAP, Mean Arterial Pressure; SEFT, Spiritual Emotional Freedom Technique. Table 4. One-way ANOVA comparing blood pressure changes post-test between intervention and control groups (N=27). Blood pressure One-way ANOVA Average difference Min Max p Systolic Light massage vs SEFT -24.6 -44.2 -4.9 0.012 Light massage vs control -26.9 -46.5 -7.3 0.006 SEFT vs control -2.3 -22 17.3 0.953 Diastolic Light massage vs SEFT -11.7 -25.1 1.8 0.097 Light massage vs control -20.7 -34.1 -7.2 0.002 SEFT vs control -1.4 -22.4 4.4 0.236 MAP Light massage vs SEFT -16 -29.3 -2.7 0.017 Light massage vs control -22.7 -36 -9.3 0.001 SEFT vs control -6.7 -20 6.7 0.438 MAP, Mean Arterial Pressure; SEFT, Spiritual Emotional Freedom Technique. Non -co mmerc ial us e o nly Conclusions Based on the results of the repeated ANOVA mean difference test, significant differences in blood pressure were observed between pre-test and post-test measurements in both the light mas- sage and SEFT intervention groups. The most notable discrepan- cies were noted in systolic, diastolic, and MAP values on the third day for both interventions. 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