Hrev_master Healthcare in Low-resource Settings 2024; volume 12:12189 The effect of spiritual emotional freedom technique impact to pain in cervical cancer post-chemoradiation: a review article Hamidah Hamidah,1 Syahrul Rauf,2 Sharvianty Arifuddin,2 Andi Muhammad Takdir Musba,2 Prihantono Prihantono,2 Nugraha Utama Pelupessy,2 Irfan Idris,2 Agussalim Bukhari,2 Andriany Qanitha,2 Fatimah Fatimah,1 Elli Hidayati,1 Tria Astika Endah Permatasari3 1Faculty of Medicine and Health, Universitas Muhammadiyah Jakarta; 2Faculty of Medicine, Universitas Hasanuddin, Makassar; 3Department of Nutrition, Faculty of Medicine and Health Universitas Muhammadiyah Jakarta, Indonesia Abstract Chronic pain that is subjective is experienced by patients with advanced cervical cancer. Simple movements are used in spiritual emotional freedom technique (SEFT) therapy, a therapeutic approach that improves performance and achievement, addresses psychological and physical pain issues, and promotes happiness and serenity in life. In this systematic review study, we evaluate how SEFT affects patients with cervical cancer who have had chemotherapy and radiation treatment. Using databases from 2003 to 2023, including Google Scholar, PubMed, ScienceDirect, PsycINFO, and Ovid, this study employs a systematic review methodology. The keywords “spiritual emotional freedom tech- nique (SEFT)”, “emotional freedom technique (EFT)”, and “cer- vical cancer” form the basis of the search strategy. Experiments and observational studies with a minimum sample size of two par- ticipants involving patients with cervical cancer meet the inclu- sion criteria. The results show that among patients with post- chemoradiation cervical cancer, SEFT therapy is beneficial in lowering pain, stress, and depression. Cancer patients who experi- ence pain may see a reduction in their quality of life as well as physical health issues. Cervical cancer patients can experience marked improvements in their pain, stress, and depression when the SEFT therapy theory is applied. Introduction Most cases of cervical cancer are caused by infection with human papillomavirus (HPV) containing deoxyribonucleic acid. HPV is identified in approximately 95% of malignant cervical lesions. The majority of HPV infections are temporary and will resolve spontaneously. Various risk factors for developing cervical cancer have been identified, encompassing as many as 14 factors, including low socioeconomic status, low education level, early age at first coitus, multiple sexual partners, early age at first preg- nancy, multiparity, long-term use of oral contraceptives, history of sexually transmitted infections (including herpes simplex virus type 2), history of genital warts, smoking, a tablediet low in folate, carotene, and vitamin C, lack of routine cytological screening or previous abnormal smears, human immunodeficiency virus, and immunosuppression.1 Cervical cancer ranks as the fourth most common cancer among women globally, with an estimated 604,000 new cases and 342,000 deaths in 2020. Approximately 90% of new cases and deaths worldwide in 2020 occurred in low- and middle-income countries.2 According to 2020 Global Cancer Observatory data, as many as 36,633 (17.2%) new cases were diagnosed in Indonesia, placing cervical cancer as the second most common cancer after breast cancer. Based on the report, cervical cancer cases occur at a rate of 24.4 per 100,000 population, with an average death rate of 14.9 per 100,000 population.3 Chemotherapy is a treatment for diagnosed cervical cancer patients. The impact of chemotherapy includes nausea, vomiting, pain, fatigue, diarrhea, and hair loss, as well as psychological effects such as worry and anxiety.4 Pain is the most common com- plaint among cervical cancer patients. Uncontrolled severe pain can interfere with daily activities and necessitates adequate pain management to maintain functionality. Pain management includes pharmacological and non-pharmacological approaches.5-7 In phar- macological management, patients receive painkillers post- chemotherapy. Non-pharmacological pain management methods, such as spiritual emotional freedom technique (SEFT) therapy, are implemented in the treatment room by nurses. SEFT is an adaptation of Emotional Freedom Technique (EFT) therapy, which has been utilized in various studies world- wide to address fear, paranoia, obsessiveness, depression, and other psychological disorders.8 Emotional Freedom Technique, the keyword contained is the free flow of energy meridians in the Correspondence: Tria Astika Endah Permatasari, Department of Nutrition, Faculty of Medicine and Health Universitas Muhammadiyah Jakarta, Indonesia. E-mail: tria.astika@umj.ac.id Key words: spiritual emotional freedom technique; pain; cervical cancer. Conflict of interest: the authors declare no potential conflict of interest. Ethical approval and consent to participate: not applicable. Availability of data and material: all data generated or analyzed during this study are included in this published article. Consent for publication: not applicable. Received: 14 December 2023. Accepted: 19 June 2024. Early access: 22 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; 12:12189 doi:10.4081/hls.2024.12189 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 632] [Healthcare in Low-resource Settings 2024;12:12189] Non -co mmerc ial us e o nly human body.9 To overcome pain and fear in dealing with a disease, the method is considered effective and efficient because it costs nothing, is easy to do, and doesn’t take long as long as the patient is routine and requires concentration to do it.8 The advantages of SEFT compared to other techniques or methods of therapy or counseling or training are: i) easy to learn and easy to practice by anyone; ii) quickly feel the results; iii) cheap (once learned we can use it forever, at various problems); iv) the effectiveness is relatively permanent; v) if practiced correctly, there are no pain or side effects, so it is very safe to be practiced by anyone; vi) universal (can be applied to any physical or emo- tional problems).8 This SEFT will also help with pain due to cancer treatment, such as cervical cancer. The chemotherapy method of treatment has side effects caused by the drugs used, not only destroying can- cer cells but also attacking healthy cells, especially cells that divide very quickly. The effects that appear in cervical cancer patients undergoing chemotherapy are the physical, physiological, social, and spiritual responses.10-12 In terms of physiological impact and benefits, EFT has been shown to: i) lower levels of stress hormones such as cortisol; ii) reduce symptoms such as pain and traumatic brain injury; iii) pro- duce epigenetic effects on stress gene expression; iv) improving general markers of health such as resting heart rate, blood pressure, and immunoglobulins.13 Research by Rumambi et al. demonstrated that SEFT interven- tion can serve as a non-pharmacological therapy for pain manage- ment in advanced breast cancer patients.14 Based on this data, the authors aim to conduct a systematic review of the effect of SEFT on pain in cervical cancer patients post-chemoradiation. Materials and Methods The systematic review conducted in this study adhered to the rigorous guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020, as shown in Figure 1.15 The search for journals used as sources in this study came from journals related to the research topic using Google Scholar, PubMed, ScienceDirect, PsycINFO, and Ovid databases with publications from 2003-2023. The keywords used were based on the terms ‘Spiritual Emotional Freedom Technique (SEFT)’ AND ‘Emotional Freedom Technique (EFT)’ AND ‘cervi- cal cancer’. After identifying the included articles, cross-refer- ences were examined to discover any additional relevant studies. In evaluating the validity of the study, the critical appraisal tool developed by the critical appraisal skills program was employed. This tool facilitated the systematic assessment of key aspects of the systematic review, ensuring methodological rigor and minimizing bias. By addressing key questions pertaining to the validity of the study, the results obtained from this systematic review can be inter- preted with confidence. Additionally, the systematic review’s find- ings, once synthesized and analyzed, will provide valuable insights into the efficacy of SEFT and EFT in the context of cervical cancer management. This, in turn, has the potential to inform clinical practice and guide decision-making at the local level, ultimately contributing to improved patient outcomes. All selected studies fulfilled the following criteria: experimen- tal studies and case studies reporting the effect of SEFT or EFT in cervical cancer patients and the minimum research sample is two people. Excluded were studies that did not report the effect of SEFT or EFT, participants who were not cervical cancer patients, and articles for which the full text was not available. Cross-sec- tional, cohort, and systematic reviews were also omitted. Results Based on the results of a systematic review of the six articles collected and the author’s analysis, it was found that there was a significant effect on the levels of pain, depression, and stress after the SEFT intervention, there was a decrease in the levels of pain, depression, and stress in cervical cancer patients (Table 1).16-21 Discussions Conditions of chronic pain and fatigue pose a challenge to biomedical models due to psychological factors associated with their etiology and maintenance, including depression, anxiety, and somatization. Individuals with chronic pain and fatigue are more likely to use prayer and seek spiritual support as coping methods than the general population. People with chronic pain and fatigue who are both religious and spiritual are more likely to experience better psychological well-being and employ positive coping strate- Review Figure 1. Preferred reporting items for systematic reviews and meta-analyses of included studies. [Healthcare in Low-resource Settings 2024;12:12189] [page 633] Non -co mmerc ial us e o nly gies.22 SEFT therapy incorporates relaxation techniques, which are a form of mind-body therapy from complementary and alternative therapies in nursing. SEFT is a technique that combines the body’s energy system (energy medicine) and spiritual healing by tapping certain points in the body. There are two versions of SEFT: the full version and the shortcut version. Both consist of three simple steps, with the difference lying only in the third step (the tapping). In the shortcut version, tapping is done at only nine points, while in the full version, tapping is performed at 18 points.8 The three steps SEFT technique is a suggestion to stimulate the nerves of the brain. The set-up The set-up aims to ensure that our body’s energy flow is direct- ed properly. Steps were taken to neutralize “psychological rever- sal” or psychological resistance (usually in the form of sponta- neous negative thoughts or beliefs. For example: (I am sad because I often get angry). The sentence to say is “Oh Allah/God… even though my head is dizzy because I am often angry, I am sincere, I completely surrender to You”. The set-up consists of two activities. First, is to say the sentence above with full humility, and sincerity, and surrender three times. The second, is to say it with feeling, pressing the chest precisely in the afternoon spot (pain point = the area around the upper chest which if pressed feels a bit painful) or tapping with two fingertips on the karate chop. After pressing the pain point or tapping on the karate chop while saying the set-up sentence as above, we continue with the second step “the tune-in”. The tune-in For physical problems, do a tune-in by feeling the pain experi- enced, then directing the mind to the place of pain, accompanied by heart and mouth saying: “Oh Allah/God, I am sincere, I surren- der...” or “Oh Allah/God, I sincerely accept my pain Here, I surren- der to You my healing.” For emotional problems, tune-in is done by thinking about cer- tain specific things or events that can generate negative emotions that we want to get rid of. When there is a negative reaction (anger, sadness, fear, and so on), our hearts and mouths say, “Oh Allah/God... I am sincere, I surrender”. Simultaneously with this tune-in we do the third step, namely tapping. All of the above steps were carried out 3 times for 30 minutes. When finished, respondents were asked to express their feelings when doing SEFT and the obstacles they faced. In addition, respondents’ feelings were also examined after SEFT (on a scale of 1-10) and ended with a post-test. In this process, tune-in accompa- nied by tapping, we neutralize negative emotions or physical pain. The tapping Tapping is tapping lightly with two fingertips at certain points on the body while continuing to tune-in. These points are the key points of the major energy meridians which if we tap a few times will have an impact on neutralizing emotional disturbances or pain that is felt so that the body’s energy flow runs normally and is back in balance. The following details the key points of the major ener- gy meridians. For the short version, tapping is only done on the first nine points (gamut procedure) in the table. As for the full version after completing the nine gamut procedures, the final step is to repeat the tapping from the first to the 17th point (ending in the karate chop) and ends by taking a deep breath and exhaling while giving thanks (Alhamdulillah).8 Of the six journals reviewed, three demonstrate that SEFT therapy can effectively reduce pain in cervical cancer patients. Research by Hakam et al. found that the combination of SEFT intervention and analgesic therapy is more effective for reducing pain in cancer patients than analgesic therapy alone. Quasi-exper- Review Table 1. Studies enrolled in this systematic review. [page 634] [Healthcare in Low-resource Settings 2024;12:12189] Non -co mmerc ial us e o nly imental were used in this study using pre-test and post-test designs with a control group. Samples, 20 respondents (in two groups). The intervention group received SEFT intervention combined with analgesic therapy and the control group was given only analgesic therapy. SEFT intervention was implemented after administrating analgesic, for 5-10 minutes every day for five days. The pain was measured using a numeric rating scale (NRS). The average pain of respondents with stage IIb cervical cancer in the intervention group using analgesic therapy in combination with SEFT tended to lower the average pain scale compared to the control group using only analgesic therapy. For further research, it is recommended that the number of respondents be greater and the type of pain that is acute.16 Research by Safitri and Machmudah showed a decrease in the pain scale from moderate to mild in stage IIIB cervical cancer patients with deep breathing relaxation therapy intervention and SEFT therapy.17 Case analysis For the first day, the pain scale was 4, until on the third day the pain scale decreased to 3, for cases the first 2 days the pain scale was 3, until the third day it decreased to 2. The results of this case study indicate that deep breathing relaxation and therapy SEFT can reduce the pain scale. In this case, the researchers used two respon- dents of cervical cancer patients with stage IIIB. The SEFT works on more or less the same principles as acupuncture and acupres- sure. This technique seeks to stimulate key points along the 12 energy pathways (energy meridians) of the body which are very influential on our health. Non-pharmacological therapy of breath- ing relaxation and SEFT therapy can reduce pain scale in cervical cancer patients. The weakness of this case study is the room con- straints when the therapy was carried out, namely the situation that was not a little supportive because of the crowds of patient atten- dants which resulted in the ineffectiveness of the actions taken. Patients become less concentrated when doing therapy. Future research is expected to increase the number of samples and therapy is carried out in calm environmental conditions so that the sample can feel the solemnity of this therapy.17 Research by Niken showed there were differences before and after SEFT therapy in participants who complained of pain. The changes that occurred physiologically and psychologically were felt by each participant. The implementation of this therapy begins with the patient being able to tell in advance the negative feelings he is feeling. The results of interviews regarding SEFT therapy showed that participants said that they had experienced and expe- rienced a lot of changes after 3 consecutive days of SEFT therapy, especially in their thoughts, feelings of peace, calm and feeling lighter, relaxed, and accepting of what was happening. This shows that the participants become aware of the spiritual side which helps calm the participants’ souls, so that the participants are calmer, relaxed, and think positively. The spiritual beliefs that the partici- pants already have provide a sense of relaxation and positive hope so that they are expected to reduce the pain they are experiencing. The application of case studies using SEFT theory has a meaning- ful influence on reducing pain.18 In line with previous studies that showed that SEFT therapy affected reducing pain in patients after transurethral prostate resec- tion surgery.23 Previous studies have found that 30 minutes of EFT therapy can reduce severe to moderate pain in 40% of patients.24 In a study conducted by Church and Nelms, in a population with a frozen shoulder, 30 minutes of EFT therapy was associated with a reduction in psychological distress and pain.25 Another study con- ducted on 216 healthcare workers found a significant 68% reduc- tion in pain and a 41% reduction in pain in patients with post-trau- matic distress syndrome (PTSD).9,26 Functional magnetic reso- nance imaging analysis showed the post-EFT treatment signifi- cantly decreased connectivity between the medial prefrontal cortex (pain modulation area) and bilateral gray matter areas in the poste- rior cingulate cortex and thalamus, both areas associated with pain modulation and catastrophe. Psychological respondents were also found to support the effect of EFT interventions in reducing chron- ic pain and its impact.27 The relaxed condition elicited after SEFT can reduce the pain intensity of cervical cancer patients, thus reducing the patient’s stress. Of the six journals that have been reviewed, two of them show that SEFT therapy can reduce stress in cervical cancer patients. The research conducted by Desmaniarti and Avianti used a quasi- experiment design in stage I to III cervical cancer patients under- going chemotherapy as many as 68 people divided into two groups, namely the treatment group of 34 people and the control group of 34 people. The treatment group received SEFT guidance individually. The research showed that stress in cervical cancer patients decreased significantly after the SEFT intervention. Although the decrease in stress occurred in both groups of respon- dents, it appeared that the average decrease in stress in the treat- ment group was greater than that in the control group.19 In line with previous studies showing that the SEFT interven- tion helps reduce stress in patients with acute coronary syndrome.28 Spiritual therapy affects the activity of the sympathetic nervous system, the effect of relaxation is that the rhythm of breathing becomes slower, the pulse slows down, and blood pressure drops reducing oxygen consumption of the heart muscle and muscle ten- sion. The relaxation response also affects the mental state and reduces muscle tension to create a comfortable atmosphere, which can reduce stress and also affect psychoneuroendocrine interac- tions.29 Of the six journals that have been reviewed, one of them shows that SEFT therapy can reduce the level of depression in cervical cancer patients. Based on the facts shown in the research by Wijayati et al., SEFT therapy reduces the level of depression in cervical cancer patients. Respondents experienced depression, a psychological reaction that can appear after a patient is diagnosed with cervical cancer. Generally, they feel mental shock, fear, unable to accept reality, to a state of depression. Management of depression in patients with cervical cancer can be done through independent nursing actions in the form of SEFT. It is necessary to develop a minimal quasi-experimental research design by includ- ing a control group to reduce research bias.21 Depression in cancer patients can be caused by several factors, namely related to the disease (prognosis, severity, pain, and diag- nosis), and the patient’s individual internal (fear of death, feelings of helplessness, changes in self-image, age, education, and social roles). Treatment (side effects, therapy costs, length of treatment, repeated treatment), and the medical team (lack of communication and information).30 With SEFT therapy, the patient is more willing to accept the disease in his body. In line with previous research which found an effect before and after SEFT therapy in depressed patients. The use of SEFT therapy must be carried out properly, starting from the therapeutic steps to the pronunciation of the therapy, because it is very influential in depressed patients.31 The results of other studies state that there is a difference in the decrease in the level of depression in heart fail- ure patients who receive spiritual guidance, where spiritual guid- ance can increase social motivation, and physical symptoms and improve the health status associated with depression.32 A meta- analysis study showed that clinical EFT was highly effective in Review [Healthcare in Low-resource Settings 2024;12:12189] [page 635] Non -co mmerc ial us e o nly reducing depressive symptoms in various populations.33 The study by Bach et al. adds to the evidence base for EFT as being an effec- tive mental health intervention. It also shows that EFT simultane- ously enhances various health markers in various physiological systems. Experienced participants significant reduction in pain, anxiety, depression, and PTSD.34 The findings from the six review articles can be used to sup- port or strengthen statements regarding the impact of SEFT on pain reduction. The study by Hakam et al. (2009) indicates that the combination of SEFT intervention with analgesic therapy is more effective in reducing pain in cancer patients compared to using analgesic therapy alone. This suggests that SEFT can provide addi- tional benefits in managing pain in cancer patients. The findings of the case study by Safitri and Machmudah state that relaxation techniques, deep breathing, and SEFT therapy can reduce the pain scale. This suggests that SEFT could be part of an effective approach in reducing pain in patients.17 The findings by Niken et al. show that the application of case studies using the SEFT theory has a significant effect in reducing pain. This provides additional support for the effectiveness of SEFT in managing pain at the individual level.18 The study by Desmaniarti and Avianti indicates that stress in cervical cancer patients significantly decreases after SEFT inter- vention. This reduction in stress can positively influence patients’ perception and experience of pain.19 The findings from Maryatun’s research show differences in stress levels before and after SEFT intervention in the intervention group. With these statistically significant differences, it can be con- cluded that SEFT has the potential to reduce stress levels in patients.20 The results of the study by Wijayati et al. demonstrate a signif- icant decrease in depression scores after SEFT intervention. This significant decrease in depression scores suggests that SEFT can help reduce not only physical pain but also the emotional burden associated with cancer.21 In SEFT practice, the patient’s spiritual aspects are given more attention by emphasizing solemn, sincere, and surrender aspects, and patients are convinced that the results to be obtained depend on the patient’s sincerity, submission, and belief in God. The more sincere, the more resigned, and the more confident God is who heals or calms the heart, the more optimal the results. The SEFT method is very useful in improving health, where the SEFT method can provide a relaxing effect to reduce or reduce pain. Stress and depression in cervical cancer patients also decreased significantly after the SEFT intervention. The limitation of SEFT is that the key to the success of this method is a combination of five elements, namely belief, solemni- ty, sincerity, surrender, and gratitude starting from the stages of Set-Up, Tune-In, to Tapping. Various studies show that many of the main causes of treatment failure are neglect of one or all three of these things. In fact, the condition of the five elements in a person, especially in post-chemoradiation cervical cancer patients, is still difficult to control so that they have the same level for all aspects, which is the cause of the failure of the method.35 The limitations of this study are the lack of SEFT or EFT studies on pain in cervical cancer patients. Conclusions Based on research findings, SEFT demonstrates promise in reducing pain, depression, and stress levels among cervical cancer patients following chemoradiation treatment, potentially improv- ing their quality of life and physical well-being. The integration of SEFT as an independent intervention by nurses is recommended for managing pain, depression, and stress in cancer patients. Techniques incorporating spiritual and emotional elements may effectively reduce stress and enhance relaxation, potentially allevi- ating pain perception. Recommendations for patients include studying SEFT with a qualified practitioner, incorporating medita- tion or yoga practices, and maintaining open communication with their medical team to optimize pain management and receive emo- tional and spiritual support. References 1. Small W, Bacon MA, Bajaj A, et al. Cervical cancer: A global health crisis. Cancer 2017;123:2404-12. 2. Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin 2021;71:209-49. 3. World Health Organization. Global Cancer Observatory (Globocan) 2020 in Indonesia. 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