Journal Of Nursing Practice
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The Effect of Benson and Autogenic Relaxation Therapy on Sleep
Quality, Blood Pressure and Anxiety of Hypertension Patients
Sutrisno1*, Nursalam2
1 Department of Nursing, Faculty of Nurse and Midwifery, Institut Ilmu Kesehatan STRADA Indonesia
2 Department of Nursing, Universitas Airlangga, Indonesia
*Corresponding author: sutrisno12@iik-strada.ac.id
ABSTRACT
Background: Hypertension increases with age, and causes several signs and symptoms that
can interfere with the patient's quality of life, including sleep quality and anxiety.
Purpose: This study aims to analyze the effect of Benson and Autogenic therapy on blood
pressure, anxiety and sleep quality in patients with hypertension.
Methods: This study used Pre-experimental research design with one group pre-test and post-
test design. This research was conducted in the working area of Pukesmas Balowerti, Kediri
City, with a sample of 20 respondents determined by purposive sampling technique.
Results: Statistical test it is known that the P value 0.000 < 0.05 on blood pressure reduction,
P value 0.001 < 0.05 on sleep quality, P value 0.000 < 0.05 on anxiety levels, it can be
concluded that there is an effect of relaxation therapy benson and autogenic to decrease blood
pressure, anxiety level and sleep quality of hypertensive patients.
Conclusion: Benson and deep autogenic relaxation techniques can be used by someone who
is healthy or sick and is a non-pharmacological effort to help reduce muscle tension so that the
body becomes comfortable, relaxed, reduces pain and stress intensity, increases pulmonary
ventilation and increases blood oxygenation.
Keywords: anxiety, benson and autogenic therapy, hypertension, sleep quality
Received February 10, 2023; Revised March 12, 2023; Accepted April 3, 2023
DOI: https://doi.org/10.30994/jnp.v6i2.379
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ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.214-220
215
BACKGROUND
Hypertension is a non-communicable disease (NCD). Hypertension or known as the
silent killer which attacks many people as the cause of death and causes the highest disease.
The risk of developing hypertension increases with age, as a person ages, the incidence of
hypertension increases. This was analyzed because of changes in cardiovascular structure and
function, hypertension often occurs in the elderly (Bruner and Suddart, 2013). Hypertension is
the main cause of premature death in the world. One of the global goals of NCD is to reduce
the prevalence of hypertension by 25% by 2025. The number of adults aged 30-79 with high
blood pressure (hypertension) is expected to nearly double to 1.28 billion between 1990 and
2019, mainly due to population growth and aging. There has been little change in the overall
rate of hypertension globally, although the burden has been shifted from high pours to low and
low states (WHO, 2022).
Riskesdas data (2018) shows a prevalence of hypertension of 34.11%. The prevalence
of hypertension in women is 36.85%, higher than in men 31.34%. It is estimated that the
number of cases of hypertension in Indonesia is 63,309,620, while the death rate due to
hypertension in Indonesia is 427,218. Data from the East Java Health Service (Dinkes) stated
that the total number of hypertension sufferers in East Java in 2017 was 335,524 patients. This
data was taken from the Integrated Disease Surveillance of Community Health Centers in East
Java. This amount is calculated from January to September. Data from the East Java Health
Office stated that the number of hypertension sufferers in all East Java Health Centers in 2017
reached 15,321 visits. The results of observations on April 22, 2022 at the Balowarti Health
Center found 36.3% with a total of 4789 male sufferers and 4868 female sufferers with 700
male and 1504 female sufferers and a total of 2204 (22.82), while the achievements on in 2021
the number of residents served at least once a year is 22.82% based on the services served at
the Balowarti health center (pustu & fktp network). The results of interviews with 10 patients
found that those with hypertension also had a high level of anxiety, with a percentage of 7
people (70%) and 3 people (30%) having moderate anxiety. Anxiety that arises can be due to
fear of comorbidities that arise due to hypertension, thinking too much about the illness without
any significant cause, lack of motivation or support from the family. In addition to anxiety and
stress, there are sleep disturbances that are felt by some hypertensive patients, namely they find
it difficult to get to sleep, 4 of the respondents cannot start sleeping within 30 minutes, sleep
time is less than 7 hours and 1 of them even uses sleeping pills 2 times a week. Two respondents
also admitted that they often experienced pain, even waking up at night.
This is in accordance with research by Suwartika and Cahyati (2015) that most
respondents who suffer from heart disease have poor sleep quality. People with high blood
pressure also experience symptoms such as dizziness, fatigue, dyspnea, sleep disturbances, and
mild tiredness. These symptoms can cause sufferers to wake up from sleep, so it usually takes
longer to fall asleep, sleep less, and affect activity (Potter & Perry, 2010).
One of the non-pharmacological therapies in lowering blood pressure is relaxation
techniques. The Benson relaxation method can control the nervous system which is useful for
lowering blood pressure (Suiraoka, 2016). The basic concept of relaxation techniques is
essentially a way of relaxation that is needed to reduce tension in the muscles which can
improve pulse, blood pressure and breathing (Aspiani, 2015). Relaxation therapy can help
individuals develop cognitive skills to reduce negative energy and respond according to the
surrounding environment (Perry & Potter, 2010).
Benson Relaxation is a method of relaxation techniques created by Herbert Benson, a
medical researcher from the Harvard Medical School who examines some of the health benefits
of prayer and meditation. This relaxation is a combination of relaxation response techniques
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with individual belief systems or faith factors. The focus of this relaxation is on certain phrases
that are repeated using a regular rhythm accompanied by a resigned attitude. The expressions
used can be in the form of God's names or words that have a calming meaning for the patient
himself. The Benson relaxation is done by doing a long inspiration which will slowly stimulate
the lung stretch receptors due to lung inflammation. This situation provides a signal which is
then sent to the medulla oblongata which will provide information about increased blood flow.
This information will be forwarded to the brainstem, as a result the parasympathetic nerves
experience increased activity and the sympathetic nerves experience decreased activity on the
chemoreceptors, so that an increase in blood pressure and lung inflammation will reduce the
heart rate and cause vasodilation in a number of blood vessels (Atmojo et al., 2019).
In addition to the Benson relaxation, there are also the Autogenic relaxation techniques.
The Autogenic relaxation is relaxation that seems to put oneself into a mild hypnotic state. This
therapy orders the legs and arms to feel heavy and warm, the heart rate and breathing rate are
stable, the stomach is relaxed, and the forehead is clean and cold. Then you repeat the easiest
and most relevant command to deal with stress symptoms, for example ordering the forehead
to feel cool and to relieve headaches, while repeating it by bringing your fingers together (Kanji
et al, 2006). The Autogenic relaxation will help the body carry out orders through
autosuggestion to relax so that it can control breathing, blood pressure, heart rate and body
temperature. Visual imagination and verbal mantras that make the body feel warm, heavy and
relaxed are standard autogenic relaxation exercises (Lutfi, 2019). This study aims to analyze
the effect of the Benson and Autogenic therapy on blood pressure, anxiety and sleep quality in
hypertensive patients.
METHODS
Pre-Experimental research design with one group pre-test and post-test design. This
research was conducted in the working area of the Balowerti Community Health Center, Kediri
City, with a sample size of 20 respondents determined by purposive sampling technique. The
instruments used were the HARS (Hamilton Anxiety Rating Scale) questionnaire to measure
anxiety levels which contained 14 assessment indicators, a digital tensimeter and the PSQI
(The Pittsburgh Sleep Quality Index) questionnaire to measure sleep quality levels which
contained 7 assessment indicators. The analytical test used is the Wilcokson test.
RESULTS
The results showed that the characteristics of the respondents were the majority of
women 12 respondents (66.7%), the age of the majority was more than 60 years as many as 10
respondents (55.6%), the occupation of the majority of housewives was 9 respondents (50%).
Table 1. Characteristics of variables based on anxiety levels before and after being given
therapy
Category anxiety
Pre Post
Frequency Percent Frequency Percent
Mild 5 25%
Moderate 7 35% 12 60%
Severe 13 65% 3 15%
Total 20 100% 20 100%
Based on table 1, it was found that the level of anxiety before the intervention was
mostly in the severe category, 13 respondents (65%), while after the intervention, most of the
12 respondents (60%) were in the moderate category.
Table 2. Characteristics of variables based on the level of sleep quality before and after being
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ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.214-220
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given therapy
Categori sleep quality
Pre Post
Frequency Percent Frequency Percent
Bad 16 80% 4 20%
Good 4 20% 16 80%
Total 20 100% 20 100%
Based on table 2, it shows the quality of sleep before the intervention. Most were in the
bad category, 16 respondents (80%), while after the intervention, most respondens were in the
good category, 16 respondents (80%).
Table 3. Characteristics of variables based on the level of hypertension before and after being
given therapy
Category level of
hypertension
Pre Post
Frequency Percent Frequency Percent
Pre Hypertension 9 45%
Mild hypertension 12 60% 10 50%
Moderate hypertension 8 40% 1 5%
Total 20 100% 20 100%
Based on table 3, it shows that most of the hypertension before being given therapy was
in the mild hypertension category, 12 respondents (60%), while the category after being given
the intervention, the majority of mild hypertension were 10 respondents (50%).
Statistical test results showed that the P value is 0.000 <0.05 for decreased blood
pressure, the P Value is 0.001 <0.05 for sleep quality, the P Value P value is 0.000 <0.05 for
anxiety levels, so it can be concluded that there is an effect of therapy benson and autogenic
relaxation to decrease blood pressure, anxiety level and quality of sleep in hypertensive
patients.
DISCUSSION
The results showed that the characteristics of the respondents were the majority of
women, 12 respondents (66.7%), the age of the majority were more than 60 years, 10
respondents (55.6%), the occupation of the majority of housewives was 9 respondents (50%).
This is in accordance with the theory which states that as get older, the risk of developing
hypertension and heart disease increases and the increased age factor also indicates the
menopause phase in women, this increases the risk of hypertension and heart disease.
Menopausal conditions cause a decrease in the hormone estrogen in women, this is what is
considered to cause an increased risk of developing hypertension or heart disease (Prince and
Wilson, 2012).
The results of the study were also related to the level of anxiety before the intervention,
namely the majority were in the severe category, 13 respondents (65%), while after the
intervention, most were in the moderate category, 12 respondents (60%). Meanwhile, the
respondents' hypertension level was mostly hypertension before being given therapy in the mild
hypertension category, 12 respondents (60%), while the majority after intervention was given
the mild hypertension category, 10 respondents (50%). The quality of sleep before the
intervention was mostly in the bad category, 16 respondents (80%), while after the intervention,
the majority were in the good category, 16 respondents (80%). Statistical test results show that
the P value is 0.000 <0.05 for decreased blood pressure, the P Value is 0.001 <0.05 for sleep
quality, the P Value P value is 0.000 <0.05 for anxiety levels, it can be concluded that there is
an effect of therapy benson and autogenic relaxation to decrease blood pressure, anxiety level
and quality of sleep in hypertensive patients.
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Based on the results of the sleep quality measurement (PSQI) study after relaxation
therapy, it was shown that the majority of respondents had good sleep quality, as many as 16
respondents (80%). This means that the sleep quality of hypertensive patients after being
treated experienced an increase in sleep quality with a good category. The quality of a person's
sleep is said to be good if it is marked by a calm sleep, feeling fresh in the morning, and feeling
enthusiastic about doing activities, showing no signs of sleep deprivation and not having
problems sleeping. The results of this study are in line with research conducted by Indah
Maulinda (2017) on "The Influence of Benson Relaxation Therapy on the Sleep Quality of
Elderly at Posyandu Permadi Tlogomas Malang City" which is known that the quality of sleep
in the elderly at Posyandu Permadi Tlogomas Malang City that performs Benson relaxation is
partly categorized as good, as many as 7 people (70.0%). Sleep quality was categorized as good
in the group that did Benson relaxation because there was an increase in sleep quality in the
elderly, where previously it was not good enough in this case. These results are supported by
research conducted by Dewi (2021) which shows that the average score for sleep quality in
pre-test patients was 15.21, with the majority of bad categories experiencing a decrease in score
to 7.18 with the majority of good categories. This means that there is an increase in the quality
of the respondent's sleep after the therapy is better.
The results of the study also showed a decrease in the respondent's level of anxiety and
blood pressure, this is because the Benson Relaxation technique is a religious therapy that
involves religious belief factors. In the elderly, they tend to improve their spirituality and get
closer to God so that the right relaxation technique to do in dealing with discomfort is the
Benson relaxation technique (Novitasari, 2014). The goal is to increase alveoli ventilation,
maintain gas exchange, prevent lung atelectasis, increase cough efficiency, reduce stress both
physical and emotional stress, namely reducing pain intensity and reducing anxiety and
reducing systolic and diastolic blood pressure (Soeharto, 2009). While the Autogenic relaxation
techniques have the benefit of increasing concentration and increasing a sense of well-being in
the body and providing a sense of comfort and not causing any side effects. Besides that,
Autogenic relaxation can reduce heart rate, blood pressure, and respiratory rate, and reduce
oxygen demand, feelings of peace, and reduce muscle tension and metabolic rate (Aji &
Armiyati, 2017). The relaxation techniques have benefits for our minds, one of which is to
increase alpha (α) waves in the brain so that a relaxed state is achieved, increased concentration
and increased sense of well-being in the body (Potter & Perry, 2010).
The Benson relaxation is also the development of a breathing relaxation response
method by involving the patient's belief factor that can create an internal environment so that
it can help patients achieve a higher state of health and well-being. The Benson relaxation has
several advantages, namely the method is simple because it relies on deep breathing efforts
interspersed with prayers to God Almighty, this technique can also be done anytime and
anywhere without the need for a very special room. The Benson's relaxation will produce an
alpha wave frequency in the brain which can cause feelings of happiness, joy, excitement and
confidence so that it can suppress the release of the hormones cortisol, epinephrine and
norepinephrine which are strong vasoconstrictors in blood vessels. Suppression of these
hormones can result in dilation of blood vessels which results in a decrease in vascular
resistance so that the end result is a decrease in blood pressure (Price and Wilson, 2012). While
the Autogenic relaxation can be said to be a technique that can reduce hypertension because
relaxation is expected to eliminate tension where the person imagines a quiet place and then
focuses on different physical sensations from the feet to the head, while progressive muscle
relaxation is a deep muscle relaxation technique. Which does not require imagination,
persistence, or suggestion, this relaxation technique focuses attention on a muscle activity by
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ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.214-220
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identifying tense muscles and then reducing tension by performing relaxation techniques to get
a relaxed feeling. Relaxation is essentially a way of being treated to reduce muscle tension
which can improve pulse rate, hypertension and respiratory rates. The response from relaxation
will return the body to a state of balance. Pupils, hearing, blood pressure, heart rate, breathing
and circulation will return to normal and muscles will relax (Dewi, 2017).
This research is also in line with research conducted by Vera, et al (2021), which shows
the results of a bivariate test using the Wilcoxon test. The results showed a p-value of 0.000
<0.05. It was concluded that autogenic relaxation techniques could significantly affect anxiety
levels in Primigravid pregnant women. Another study by Mardiani (2014), the results showed
that there were differences in anxiety levels before and after being given the Benson relaxation
technique and deep breathing (p-value= 0.000). This research is in line with research conducted
by Ismasyah (2021), showing the results of statistical tests using the paired T test obtained a P
value= 0.000 <0.05. The conclusion of the research results is that there is a significant
difference in pain scores between before and after being given interventions, both Autogenic
relaxation and Benson relaxation interventions, with a P value= 0.000 <0.05. These results
indicate that there is a difference in the pain scores of fracture patients between those who were
given Autogenic relaxation interventions and Benson relaxation, where Benson relaxation was
more effective in reducing fracture patient pain.
Researcher argue that the Benson and Autogenic relaxation therapy can be used as a
way to reduce anxiety levels, improve sleep quality and help hypertensive patients control
blood pressure so that they can be used as psychotherapy methods, because it will make the
heart peaceful, calm and peaceful. Based on this, it is proven that the level of anxiety, sleep
quality and blood pressure in hypertensive patients can be reduced through the Benson and
Autogenic relaxation therapy. These changes also show that researchers have received positive
responses from patients in the working area of the Balowerti Health Center in Kediri City and
provided changes in the form of changes in anxiety levels, sleep quality and blood pressure in
hypertensive patients.
CONCLUSION
The Benson and deep Autogenic relaxation techniques can be used by someone in a
healthy or sick condition and are a non-pharmacological effort to help reduce muscle tension
so that the body becomes comfortable, relaxed, reduces pain and stress intensity, increases lung
ventilation and increases blood oxygenation. These techniques can reduce anxiety, improve
sleep quality and lower blood pressure in hypertensive patients.
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