Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s1):13182 Benson’s spiritual relaxation and lavender aromatherapy toward anxiety, sleep quality, and blood pressure Eppy Setiyowati,1 Umdatus Soleha,1 Mulyadi Mulyadi,2 Muhammad Basuni3,4 1Department of Nursing, Faculty of Nursing and Midwifery, Universitas Nahdlatul Ulama Surabaya; 2Universitas Nahdlatul Ulama Surabaya; 3Student of the applied Nursing Magister program, Faculty of Nursing and Midwifery, Universitas Nahdlatul Ulama Surabaya; 4Indonesian National Army, Navy Hospital Dr. Oepomo, Surabaya, Indonesia Abstract Anxiety caused by illness is one of the factors contributing to elevated hypertension across all age groups. Therefore, in addition to pharmacological treatment, non-pharmacological therapy is essential to reduce anxiety, lower blood pressure, and improve sleep quality in hypertensive patients. This study aimed to analyze the effects of Benson’s spiritual relaxation and lavender aro- matherapy on anxiety, sleep quality, and blood pressure in hyper- tensive patients. This research employed a quasi-experimental design with a pretest-posttest control group approach. The popu- lation consisted of 97 hypertensive patients at the Indonesian National Army-Navy Hospital, with a sample size of 44 respon- dents selected through purposive sampling. The independent vari- ables were Benson’s spiritual relaxation and lavender aromathera- py, while the dependent variables were anxiety, sleep quality, and blood pressure. Data were analyzed using multivariate analysis with a significance level of <0.05. The results indicated a signifi- cant effect of Benson’s spiritual relaxation and lavender aro- matherapy on anxiety (p=0.000), sleep quality (p=0.000), systolic blood pressure (p=0.000), and diastolic blood pressure (p=0.000). These techniques are simple to implement, making them a viable nursing intervention in inpatient settings and contributing to nurs- ing science development in hospitals. Introduction Hypertension is a non-communicable disease that can cause various health problems if not treated promptly. It is characterized by an increase in blood pressure above normal limits, specifically systolic and diastolic values exceeding 140/90 mmHg.1,2 Anxiety caused by illness is one of the factors that contribute to hyperten- sion or elevated blood pressure across all age groups.3 If left undi- agnosed or untreated, hypertension can lead to various comorbidi- ties, which may result in fatal outcomes.4 In addition to pharmacological treatments, non-pharmacolog- ical therapies are essential to reduce anxiety, lower blood pressure, and improve sleep quality in hypertensive patients.5,6 Patients with acute hypertension who experience prolonged anxiety often suffer from increased sympathetic nervous system activity, which can gradually elevate blood pressure and lead to sleep disturbances.7 Previous studies have demonstrated a significant relationship between anxiety levels and blood pressure in hypertensive patients, indicating that higher anxiety levels correlate with higher blood pressure. As anticipated, anxiety management in hypertensive patients can be achieved through pharmacological or non-pharmacological Correspondence: Eppy Setiyowati, Department of Nursing, Faculty of Nursing and Midwifery, Universitas Nahdlatul Ulama Surabaya Indonesia. E-mail: eppy@unusa.ac.id Key words: anxiety; aromatherapy; Benson relaxation; blood pressure. Contributions: ES, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; US, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; MM, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; MB, methodology, visualization, writing – review & editing. Conflict of interest: the authors declare no potential conflict of interest. Ethics approval and consent to participate: the research has received eth- ical approval from the Health Research Ethics Commission, Chakra Brahmanda Lentera Institution, based on ethical certificate 145/025/XII/EC/KEP/LCBL/2023. During the research, the researcher paid attention to the ethical principles of information, consent, respect for human rights, beneficence and non-maleficence. 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. Funding: this research was supported by a research grant from the Ministry of Education, Culture, Research and Technology - Republic of Indonesia, with contract number 104/SPK/D.D4/PPK.01. APTV/III/ 2024. Acknowledgments: the research team would like to thank the Ministry of Education, Culture, Research and Technology - Republic of Indonesia through the academic directorate of vocational higher education, with decision letter number 104/SPK/D.D4/PPK.01.APTV/III/2024; 008/SP2H/PPKM-PTV/LL7/2024; 772/UNUSA-LPPM/Adm.I/IV/2024. We also thank the Rector of Universitas Nahdlatul Ulama Surabaya and the TNI AL Dr. Oepomo Hospital, Indonesia, for providing permission and research space. Received: 11 September 2024. Accepted: 7 November 2024. Early access: 29 January 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13(s1):13182 doi:10.4081/hls.2025.13182 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 prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13(s1):13182] [page 63] interventions, including Benson’s spiritual relaxation and lavender aromatherapy.8 Benson’s relaxation therapy has been demonstrated to reduce anxiety levels, lower blood pressure, and enhance sleep quality. Additionally, this therapy has shown effectiveness in reducing anxiety among at-risk pregnant women and improving sleep quality for older adults, making it a promising non-pharma- cological treatment option.9-13 The addition of lavender aromatherapy has been explored to enhance the effectiveness of Benson’s spiritual relaxation.14 Spirituality is a multidimensional concept that encompasses existential and religious dimensions. While the existential dimen- sion focuses on the purpose and meaning of life, the religious dimension emphasizes an individual’s relationship with God.15,16 Spiritual therapy has been shown to significantly reduce systolic and diastolic blood pressure and pulse rates in hypertensive patients.17 Higher levels of spirituality are associated with better- controlled blood pressure and lower anxiety levels.18,19 Lavender aromatherapy, similarly, has been found to lower anxiety and improve sleep quality, particularly in cancer patients undergoing chemotherapy.20 The purpose of this study was to ana- lyze the effects of Benson’s spiritual relaxation and lavender aro- matherapy on anxiety, sleep quality, and blood pressure in hyper- tensive patients. Materials and Methods This study used a quasi-experimental design with a pretest- posttest control group approach. The population consisted of 97 hypertension patients at the Indonesian National Army Hospital. The sample size was 44 respondents, selected using purposive sampling techniques. The inclusion criteria were: i) cooperative patients willing to be respondents, ii) patients with uncomplicated hypertension, iii) patients with GCS: 456, iv) patients with a mod- erate to high level of anxiety as measured by the Zung Self-Rating Anxiety Scale (SAS/SRAS), v) patients with a lower level of sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI), and vi) patients who have never been treated with a combination of Benson’s relaxation and lavender aromatherapy (SBR-AL). The exclusion criteria were as follows: i) hypertensive patients with complications, ii) patients with consciousness below GCS: 456, and iii) patients with respiratory disorders and allergies. The study was conducted from April 2024 to August 2024. The independent variables in this study were Benson’s spiritual relaxation and lavender aromatherapy, while the dependent variables included anxiety, sleep quality, and systolic and diastolic blood pressure. The intervention involved the application of Benson’s spiritual relaxation and lavender aromatherapy, guided by a module with ISBN number 978-623-8283-56-9. Before the research com- menced, the protocol underwent an ethical review and was deemed ethically acceptable under approval number 145/025/XII/EC/KEP/ LCBL/2023. Instruments Anxiety was measured using the Zung Emergency Questionnaire Self-Rating Anxiety Scale (SAS/SRAS). This ques- tionnaire consists of 20 questions, where each question is rated 1- 4 (1: never, 2: sometimes, 3: part of the time, 4: almost all the time). The criteria are “not anxious” (score 20-44), “light” (score 45-59), “medium” (score 60-74), and “heavy” (score 75-80). Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI), which consists of 19 subjective points grouped into seven assessment components. The points assessed are about sleep qual- ity, length of sleep, sleep latency, daily sleep efficiency, medication use, disturbances experienced during sleep, and the impact experi- enced the next day. Each point has the same weight on a scale of 0-3, with a total score of 21 points, which means the worst quality that can be assessed. The scores of the seven components are summed up into one global score with a range of 0–21. An overall score of 5 or more indicates poor sleep quality; the higher the value, the worse the sleep quality. Blood pressure was measured using standard techniques for systolic and diastolic readings, mea- sured with a digital sphygmomanometer (mmHg). Low blood pres- sure (hypotension) is a decrease in systolic blood pressure by more than 20-30% compared to baseline measurements or systolic blood pressure <100 mmHg. Normal blood pressure (normal tension) in adults is around 120/80 mmHg. High blood pressure (hyperten- sion) is where the systolic pressure value is above 140 mmHg and the diastolic pressure value is above 90 mmHg. Intervention Benson’s spiritual relaxation and lavender aromatherapy involved relaxation techniques designed to calm the mind and body. The intervention included progressive muscle relaxation, deep breathing, recitation of motivational words, expressions of gratitude, and prayers adapted to participants’ beliefs, all while inhaling lavender aromatherapy. The goal was to create a medium for relaxation, provide a sense of comfort, relax muscle tension, reduce anxiety, improve sleep quality, and lower blood pressure in hypertensive patients. The intervention steps in this study were as follows: 1) relax the muscles as much as possible, starting from the legs, calves, thighs, and abdomen and continuing to all the muscles of the body. Hands and arms are stretched out, then relaxed, and allowed to droop naturally. Try to stay relaxed; 2) start breathing slowly and naturally, and say one word or sentence in your heart according to the patient’s beliefs. The sentence used is the patient’s choice. When inhaling, say the sentence in your heart, and after exhaling, repeat the sentence in your heart. While continuing to do this step, relax your whole body, accompanied by a resigned atti- tude. During the practice, participants inhaled lavender aromather- apy. This intervention was conducted twice a day, for 10–15 min- utes per session, five days a week over the study period. While per- Special issue Pathways of Change Table 1. Participants demographic data (N=13). Characteristics Percentage (%) Age (mean) 53.1 years Gender Female 53.8 Male 46.1 Religion Islam 100 Education Elementary School 54.0 Junior High School 15.3 Senior High School 30.7 Duration as a traditional healer (mean) 21.9 years Age <50 years 46.2 >50 years 53.8 Occupation Farmer 46.2 Housewife 38.4 Entrepreneur 15.4 [page 64] [Healthcare in Low-resource Settings 2025;13(s1):13182] forming these steps and inhaling lavender aromatherapy, partici- pants could silently recite prayers or affirmations according to their beliefs and choices. Analysis The statistical analysis was performed using paired t-tests and MANOVA, with a significance level set at p<0.05. Results The results of the study, as presented in Tables 1 and 2, reveal several important findings regarding the effects of Benson relax- ation and lavender aromatherapy on anxiety, sleep quality, and blood pressure in hypertensive patients. Special issue Pathways of Change Table 2. The main themes and sub-themes. Quotes Code Category Theme "Yes, we perform ruqyah, Ruqyah Doing spiritual therapy Traditional treatment methods for schizophrenia patients like teaching them regular Quranic recitations, and we neutralize them first before we start the treatment." (P1), "Regular prayer is performed Prayer independently, while we guide them properly in what they do." (P3) "In treatment, apart from prayer, Sholawat we also cleanse them before we perform the treatment." (P2) "In the ruqyah treatment we provide, Ruqyah in addition to reciting the Quran, we also suggest prayers." (P6) "Uh, this treatment we do, Treatment must be gradual Routine treatment for if they want to recover, early-stage schizophrenia the treatment must be gradual." (P1) patients "Those who seek treatment, not just once, Treatment to three times they must receive treatment up to three times for any changes to happen." (P7) "In the healing process, patients must follow Gradual treatment the treatment guidelines we provide because if they don't, the results won't be as effective." (P8) "Actually, during my treatment, I've heard Healed with traditional medicine Believe the disease can be cured from patients that they recover faster with traditional remedies than in the hospital. That's what the patients tell me." (P6) "Sometimes I get confused when patients Healed with traditional medicine trust me and come, saying they didn't recover in the hospital but did with traditional remedies." (P7) "Oh, well, in my treatment, I usually Usually use leaves Treatment with herbal remedies Treatments affecting the effectiveness use leaves, the same ones that have been of healing in schizophrenia patients used for generations." (P5) "In my treatment, I use pure coconut oil because Using pure coconut oil we know its contents are beneficial." (P6) "If we believe the illness is from Allah, then, Believing the illness is from Allah Treatment based on faith Supernatural treatment for schizophrenia patients God willing, we can recover with the effort we make and the patient's belief." (P9) "When I treat them, my hope and belief are that they Believing in recovery will recover if they continue to make an effort." (P8). Yes, I believe everything can be resolved, as long as All problems can be solved we remain determined to find a solution." (P9) "The patients who seek treatment receive Islamic Treatment for patients of the Islamic faith Religion-based treatment treatment, as I use ruqyah in my treatments." (P10) "I hope that these patients can recover and return Returning to normal Regular treatment Traditional healers' hope for patients with schizophrenia to their normal state before experiencing this mental disorder." (P12) "I hope they recover and can work as Can recover they used to." (P13). “Sangat besar harapan saya tuh bu,, semoga bisa Can work again sembuh dan bisa bekerja lagi seperti dulu.”(P3) "Yes, I hope that they recover and can speak again Can talk again as they used to because, during their illness, they wouldn't speak; they would just remain silent." (P9) [Healthcare in Low-resource Settings 2025;13(s1):13182] [page 65] Table 1 presents the demographic characteristics of the respon- dents in both the intervention and control groups, showing that the two groups were well-matched. The majority of participants in both groups were aged between 41 and 60 years (59.1%). The gen- der distribution was similar, with most participants being male (77.3% in the intervention group and 72.7% in the control group). In terms of education, more than half of the participants in both groups had a basic education (54.5%), and a significant portion of respondents were not working (59.1% in the intervention group and 63.6% in the control group). These similarities ensure that the two groups were comparable and that the results could be attribut- ed to the interventions rather than demographic differences. The results in Table 2 indicate that the intervention of Benson’s spiritual relaxation and lavender aromatherapy significantly reduced anxiety, improved sleep quality, and lowered blood pres- sure in the intervention group. Specifically, anxiety levels decreased significantly (mean change = 18.045, p<0.001), sleep quality improved (mean change = 9.182, p<0.001), and both sys- tolic (mean change = 20.545, p<0.001) and diastolic blood pres- sure (mean change = 10.773, p<0.001) were reduced. In contrast, the control group showed no significant changes in these variables, with anxiety, sleep quality, and blood pressure remaining largely unchanged. The results in Table 3 demonstrated that Benson’s spiritual relaxation and lavender aromatherapy significantly reduced anxi- ety, improved sleep quality, and lowered systolic and diastolic blood pressure in the intervention group compared to the control group (p<0.05). These findings indicate the effectiveness of this non-pharmacological intervention for hypertensive patients. Discussion Hypertensive patients experience both physiological and psychological problems. After undergoing the intervention of Benson relaxation and lavender aromatherapy, a decrease in anxiety was observed. This is because the intervention, applied slowly, helped the patient relax, enabling them to accept their condition while remaining calm, enthusiastic, and surrendering to God Almighty.8 Research has shown that spiritual therapy can lower anxiety. Benson relaxation, as a spiritual intervention, has been effective in addressing anxiety in patients with chronic kid- ney failure.21 Lavender aromatherapy has also been shown to reduce anxiety.22 The combination of Benson relaxation, spiritual therapy, and lavender aromatherapy has proven to be very effective in reducing anxiety in hemodialysis patients.23 Regular and consis- tent use of complementary therapies like Benson’s spiritual relax- ation and lavender aromatherapy can significantly lower anxiety levels in hypertensive patients.24,25 Furthermore, Benson relaxation and lavender aromatherapy have an effect on improving the sleep quality of hypertensive patients, dialysis patients, and the elderly,26-29 and exert a signifi- cant effect on changes in blood pressure in hypertensive patients.30 Systolic blood pressure before and after the intervention of Benson’s spiritual relaxation and lavender aromatherapy, based on paired t-tests showed an effect on the reduction of both systolic and diastolic blood pressure.31,32 In contrast, the control group’s pre- and post-intervention blood pressure tests revealed no significant change in systolic and diastolic blood pressure. This indicates that there is a significant effect in reducing both systolic and diastolic blood pressure in hypertensive patients through the intervention of spiritual relaxation and lavender aromatherapy. Benson’s spiritual relaxation and lavender aromatherapy have no direct effect on hypertensive patients’ blood pressure; however, they can reduce anxiety and improve sleep quality, which indirect- ly leads to lower blood pressure. As a result, patients can better change their habits and live a healthier lifestyle.33,34 This, in turn, has a positive impact on the physiological functions of the body, leading to a reduction in blood pressure and better control of hypertension. The effect of Benson relaxation and lavender aro- matherapy on anxiety, sleep quality, and blood pressure in hyper- tensive patients shows that sleep quality is the variable most influ- enced by these interventions. The mechanism at play during the interventions is the creation of relaxation in hypertensive patients: patients are taught spiritual relaxation, which helps them achieve a comfortable and pleasant state, thereby reducing anxiety and improving sleep quality.31 The analysis showed that the p-value for anxiety was 0.000. These results indicate that Benson’s spiritual relaxation and lavender aromatherapy have a significant effect on anxiety, sleep quality, and blood pressure in hypertensive patients. Among the three variables, sleep quality had the most significant influence, as evidenced by the highest partial Eta squared value of 0.743 (Table 3). Sentences in prayer and lavender aromatherapy regulate emotions by decreasing amygdala activation. Furthermore, the stimulus is sent to the prefrontal cortex, where it is processed through careful learning involving the selection, orga- nization, and interpretation of the stressors received. This leads to a change in self-perspective, fostering awareness, wisdom, and self-acceptance of the current condition.35 This technique is easy to perform and can be applied as a nursing intervention. Conclusions In conclusion, the combination of Benson’s spiritual relaxation and lavender aromatherapy has proven to be an effective interven- tion for hypertensive patients. These techniques significantly reduce anxiety, improve sleep quality and lower both systolic and diastolic blood pressure. The interventions work by inducing a state of relaxation, which helps patients manage stress, enhance emotional well-being, and adopt healthier lifestyle habits. With their demonstrated effectiveness, these therapies offer a practical and non-invasive option for managing hypertension and can be easily incorporated into nursing care practices to improve patient outcomes. References 1. Pranata R, Lim MA, Huang I, et al. Hypertension is associated with increased mortality and severity of disease in COVID-19 pneumonia: A systematic review, meta-analysis and meta- regression. J Renin Angiotensin Aldosterone Syst 2020;21. 2. Lestari D. Evaluation of monitoring hypertension case based on nine surveillance attributes in Jombang district health office in 2018. Indones J Public Health 2021;16:89-100. 3. Iswatun, Yusuf A, Efendi F, et al. Relationship between anxiety and spiritual well-being of the elderly with hyper tension dur- ing the COVID-19 pandemic. J Pak Med Assoc 2023;73:S46- 9. 4. Cahyono I, Puspitasari Y, Prasetyo J. Penyuluhan terkait Menurunkan Kecemasan pada Penderita Hipertensi dengan Terapi Komplementer Progressive Muscle Relaxation. 2024;3:76-82. Special issue Pathways of Change [page 66] [Healthcare in Low-resource Settings 2025;13(s1):13182] 5. Beyliklioğlu A, Arslan S. Effect of Lavender Oil on the Anxiety of Patients Before Breast Surgery. J Perianesth Nurs 2019;34:587-93. 6. Fitriyah R, Fernandez G V, Samudera WS, et al. Deep Breathing Relaxation for Decreasing Blood Pressure in People with Hypertension. Jurnal Ners 2019;14:141-5. 7. Fitriani N, Khasanah S, Suandika M. Pengaruh Tindakan Non Farmakologi Terhadap Peningkatan Kualitas Tidur Pada Lansia Penderita Hipertensi Dengan Gangguan Tidur. J Nurs Health 2022;7:108-10. 8. Atul Angga Fiari D, Aini N, Octary T, et al. The Effectiveness of Spiritual Therapy in Reducing the Anxiety Level of Preoperative Patients. KnE Medicine 2023;2023:420-6. 9. Mahyuvi T, Tukirahmawati D. Spiritual benson relaxation in pre-dialysis chronic kidney failure patients with anxiety prob- lems: case study. J App Nurs Health 2022;4. 10. Rani RH, Harmayetty H, Kusumaningrum T. The combination of benson relaxation and pelvic tilting on the scale of low back pain in pregnant women. Nurs J 2020;6. 11. Bakar A, Suhartatik S, Hidayati L. Combined Benson and dhikr relaxation reduces anxiety and pulse frequency of inpa- tient cardiacs in hospitals. Int J Pharm Res 2020;12:1747-53. 12. Wang Z, Yang T, Fu H. Prevalence of diabetes and hyperten- sion and their interaction effects on cardio-cerebrovascular dis- eases: a cross-sectional study. BMC Public Health 2021; 21:1224. 13. Marasabessy NB, Herawati L, Achmad I. Benson’s relaxation therapy and sleep quality among elderly at a social institution in inakaka, Indonesia. Kesmas 2020;15:65-72. 14. Setiyowati E, Agustina AN, Yuddha AS, et al. Self- Management to Change of Perception and Clinical and Pharmacological Knowledge of COVID-19. J Pharm Negat Results 2022;13:1-6. 15. Yusuf A, Nihayati HE, Iswari MF, Okviasanti F. Kebutuhan Spiritual Konsep Dan Aplikasi Dalam Asuhan Keperawatan. Jakarta: Mitra Wacana Media; 2016. 16. Anwar S, Peng LS, Mahmudiono T. The importance of spiritu- ality, physical activity and sleep duration to prevent hyperten- sion among elderly in Aceh-Indonesia. Sys Rev Pharm [Internet]. 2020;11:1366-70. Available from: https://www.sco- pus.com/inward/record.uri?eid=2-s2.0-85105897071& doi=10.31838%2Fsrp.2020.11.194&partnerID=40&md5=2de aee4342f983978f19d5f0e0777398 17. Muslim A, Arofiati F. Efektifitas Kombinasi Latihan Pernafasan Dalam Dan Terapi Spiritual Terhadap Perubahan Parameter Kardiovaskuler Pada Pasien Hipertensi Di Desa Darungan Kabupaten Kediri. Jurnal Keperawatan 2019;17:30- 9. 18. Fiari DAA, Aini N, Octary T, et al. The Effectiveness of Spiritual Therapy in Reducing the Anxiety Level of Preoperative Patients. KnE Medicine 2023. 19. Ahmed A, Elmetwaly M, Gaad El Moula Shaaban E, et al. Benson Relaxation Technique: Reducing Pain Intensity, Anxiety level and Improving Sleep Quality among Patients Undergoing Thoracic Surgery. Egypt J Health Care. 2020;11. 20. Özkaraman A, Dügüm Ö, Yılmaz HÖ, Yeşilbalkan ÖU. Aromatherapy: The effect of lavender on anxiety and sleep quality in patients treated with chemotherapy. Clin J Oncol Nurs 2018;22:203-10. 21. Mahyuvi T, Tukirahmawati D. Spiritual Benson Relaxation in Pre-Dialysis Chronic Kidney Failure Patients with Anxiety Problems: Case Study. J App Nurs Health 2022;4:356-63. 22. Veronica SY, Dwiningrum R. The effect of giving lavender aromatherapy on anxiety level in final stage students of DIII midwifery at aisyah university of pringsewu. Jurnal Aisyah : Jurnal Ilmu Kesehatan 2023;8:339-42. 23. Kuling S, Widyawati IY, Makhfudli. Pengaruh Kombinasi Intervensi Relaksasi Benson, Terapi Spiritual Dzikir dan Aroma Terapi Lavender Terhadap Kecemasan Pada Pasien Hemodialisis. Jurnal Keperawatan 2024;16:1-10. 24. Pakseresht S, Jahandoost H, Khalesi ZB, Leilie EK. Effect of Lavender Aromatherapy on the Pain Level after Cesarean Section. Herb Med J 2020;5:11-20. 25. Maulana FH, Haryanto J, Ulfiana E. The effect of lower extremity massage with lavender essential oil on decreasing blood pressure in elderly with hypertension in uptd griya werd- ha surabaya. Indian J Public Health Res Dev 2019;10:1488-93. 26. Marasabessy NB, Herawati L, Achmad I. Benson’s relaxation therapy and sleep quality among elderly at a social institution in inakaka, Indonesia. Kesmas 2020;15:65-72. 27. Sunairattanaporn U, Phuchum P, Darmawati I. The Effectiveness of Benson’s Relaxation Therapy on Sleep Quality in Hemodialysis Patient: A Narrative Literature Review. Jurnal Pendidikan Keperawatan Indonesia 2022;8:48- 54. 28. Sulistyowati D, Rahmawati AD. Efektivitas Kombinasi Terapi Benson Dan Aroma Terapi Lavender Terhadap Kualitas Tidur Pada Lansia Dengan Gangguan Tidur. Penerbit Tahta Media 2023. 29. Ibrahim A, Koyuncu G, Koyuncu N, et al. The effect of Benson relaxation method on anxiety in the emergency care. Medicine (United States) 2019;98. 30. Abdelhakim AM, Hussein AS, Doheim MF, Sayed AK. The effect of inhalation aromatherapy in patients undergoing car- diac surgery: A systematic review and meta-analysis of ran- domized controlled trials. Vol. 48, Complementary Therapies in Medicine. Churchill Livingstone; 2020. 31. Kim M, Nam ES, Lee Y, Kang HJ. Effects of lavender on anx- iety, depression, and physiological parameters: systematic review and meta-analysis. Vol. 15, Asian Nursing Research. Korean Society of Nursing Science; 2021 p. 279-90. 32. Puspitasari Y, Nurhidayah R, Katmini K. Effectiveness of aro- matherapy on lowering blood pressure of preeclampsia mother during conservative treatment. Jurnal Keperawatan 2022;14:157-62. 33. Supriyanto S, Ernawaty, Setyawan FEB, Lestari R. Enhancing family medicine practice in developing countries through a holistic-comprehensive care model: A review. Indian J Public Health Res Dev 2019;10:774-8. 34. Sariati S, Sholikhah DU, Narendri CM, et al. Music Therapy and Aromatherapy Interventions in Patients undergoing Hemodialysis: A Systematic Review. Jurnal Ners 2019;14:81- 5. 35. Wang Z, Yang T, Fu H. Prevalence of diabetes and hyperten- sion and their interaction effects on cardio-cerebrovascular dis- eases: a cross-sectional study. BMC Public Health 2021;21:1224. Special issue Pathways of Change [Healthcare in Low-resource Settings 2025;13(s1):13182] [page 67]