E:\IBUK\NERS DESEMBER 2021\5--j 295Girianto, Widayati, Agusti, Butterfly Hug to Reduce Anxiety on Elderly Butterfly Hug to Reduce Anxiety on Elderly Pria Wahyu Romadhon Girianto1, Dhina Widayati2, Syahdila Sabrina Agusti3 123Bachelor Nursing Program, Karya Husada Institute of Health Science, Indonesia JURNAL NERS DAN KEBIDANAN (JOURNAL OF NERS AND MIDWIFERY) http://jnk.phb.ac.id/index.php/jnk JNK History Article: Received, 05/09/2021 Accepted, 19/10/2021 Published, 15/12/2021 Keywords: Butterfly Hug, Elderly, Anxiety Level Article Information Abstract The problem that often occurs in the elderly is anxiety. Anxiety can lead to cognitive impairment, mood disorders, and other emotional disabilities. But- terfly Hug is a non-pharmacological therapy to reduce anxiety levels. This research aims to determine the effectiveness of the butterfly hug on the level of anxiety in the elderly. The research design was a pre-experimental design with a one-group pre and post test design approach. The research popula- tion was 60 people and a sample of 18 respondents was taken by purposive sampling technique. Anxiety level instrument using the GAI questionnaire. Data analysis was used the Wilcoxon test. The results of the pre-test showed that half of the respondents (50.0%) experienced severe anxiety, half of the respondents (50.0%) experienced moderate anxiety. The post-test results showed that half of the respondents (50.0%) experienced moderate anxiety and half of the respondents (50.0%) experienced mild anxiety. p-value 0.003 and = 0.05 (0.003 0.05) meaning that there is an influence of the Butterfly Hug on the level of anxiety in the elderly. The Butterfly Hug is done by gently clapping hands, which gives a comfortable sensation while breathing. This method can activate LHPA, stimulate the hypothalamus and CRH hormone secretion. ACTH is activated and stimulates the production of serotonin and endorphin hormones which make you feel relaxed and safe, so that anxiety decreases. It is recommended to use the Butterfly Hug as an alternative to reduce the level of anxiety in the elderly at UPT PSTW Jombang-Kediri. © 2021 Journal of Ners and Midwifery 295 Correspondence Address: Karya Husada Institute of Health Science – East Java, Indonesia P-ISSN : 2355-052X Email: priawahyu88@gmail.com E-ISSN : 2548-3811 DOI: 10.26699/jnk.v8i3.ART.p295–300 This is an Open Access article under the CC BY-SA license (http://creativecommons.org/licenses/by-sa/4.0/) https://doi.org/10.26699/jnk.v8i3.ART.p295-300 https://crossmark.crossref.org/dialog/?doi=10.26699/jnk.v8i3.ART.p295-300&domain=pdf&date_stamp=2021-12-26 296 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 295–300 INTRODUCTION The elderly are a group of people aged 60 years and over [1]. Aging is a process that starts at birth and is commonly experienced by all living things. Aging can be seen from three perspectives, namely biological age, psychological age, and social age. Everyone will experience the process of aging and old age is the last period of human life. Anxiety is one of mental disorder which com- monly found among elderly. Anxiety disorder in eld- erly were triggered by various condition such as try to accept their situation and feel resigned, biologi- cal degeneration accompanied by various suffer- ings, such as several diseases, and the realization that everyone will die, so anxiety becomes an im- portant psychological problem for the elderly. Anxiety is a state of personality feeling, uncer- tainty, fear of reality or the perception of threats from actual sources that are not known or known. Anxiety is characterized by physical symptoms, in- cluding: cold fingers, faster heart rate, cold sweats, headache, decreased appetite, sleeplessness, and chest tightness. Symptoms of a mental nature are fear of feeling threatened by danger, unable to fo- cus, uneasy, wanting to run away from reality. Fac- tors that influence anxiety are frustration, conflict, threat, environment in the form of social support, education, age, and gender [2]. Several factors af- fect anxiety in the elderly, such as loneliness and other factors. Anxiety problems that often occur in the elderly are worries. Anxiety can lead to cogni- tive impairment, mood disorders, and other emo- tional disabilities [3]. Data from the United States Census Bureau estimates that Indonesia will experience the largest increase in elderly people worldwide in 1990-2025, which is 414%. Data from the United States Popu- lation Service, the number of the elderly population aged 60 years is estimated at almost 600 million people and is predicted to be 2 billion in 2050. Cur- rently, in Indonesia, there are 23.9 million people classified as elderly. From data obtained by the Ministry of Social Affairs, 3 million (2.9 million to be exact) of them are displaced. Indonesia is the fifth country that has the largest elderly population in the world. In 1990, the number of elderly people was around 12.7 million (6.29 percent) and in 2000 it reached 14.4 million (7.18 percent). In 2020, it is estimated to be 28.8 million people, or 11.34 per- cent of the total population of Indonesia [4]. East Java, as one of the provinces in Indone- sia, has the third highest percentage of elderly people after Central Java and Yogyakarta Special Region [5]. The percentage of the elderly in East Java reached 12.253% of the total population. So every year, the elderly in Indonesia experience a signifi- cant increase. The increasing number of elderly people re- quires serious treatment because, naturally, the eld- erly experience a decline both in terms of physical, biological, and mental health, and this can not be separated from economic, social, and cultural prob- lems, so there is a need for family participation and a social role in handling it. The decline in the func- tion of various organs of the elderly makes them vulnerable to diseases that are acute or chronic. There is a tendency for degenerative diseases, metabolic diseases, psychosocial disorders, and in- fectious diseases to increase. Other problems that often occur in the elderly are loss, poverty, not being accepted/rejected, not yet finding the meaning of life, feeling dependent, helpless, and giving up easily, fear of death, sad- ness because of the death of others, physical and mental decline, depression, and feelings of sadness [6]. Loneliness is a condition that often threatens the lives of the elderly when family members live apart from them, lose a life partner, lose friends, and are powerless to live independently. It is estimated that 15% to 20% of people over the age of 65 have mental disorders. Mental disor- ders that are often found in the elderly are insom- nia, stress, depression, anxiety, dementia, and de- lirium or psychiatry. Research conducted by Eric J. Lenze, MD, at the University of Pittsburgh School of Medicine, shows that anxiety disorders are more common in older people, with 7% of anxiety occur- ring in older people. In addition, a research pub- lished in the American Journal of Psychiatry found that 10% of adults aged 55-85 years experience anxiety [7]. In the results of Heningsih’s research, regard- ing the description of the level of anxiety in 52 eld- erly people at Panti Werdha Darma Bakti Kasih Surakarta, it was found that 15% did not experi- ence anxiety, 36.5% mild anxiety, 42.3% moderate anxiety, and 5.8% severe anxiety [8]. Based on data obtained by researchers at the Tresna Werdha Jombang Social Service, Kediri, the officer explained that 60.2% of the 60 elderly living in the Tresna Werdha Social Service experienced signs of anxi- 297Girianto, Widayati, Agusti, Butterfly Hug to Reduce Anxiety on Elderly ety such as restlessness, worry, irritability and con- fusion. This is due to economic problems, leaving their spouse/family, having biological children and siblings, but they don’t have much time because they are busy working all day. So far, the routine activities at UPT PSTW Jombang-Kediri are pray- ing and there is no special intervention for the eld- erly who experience anxiety. The Butterfly Hug is an alternative solution to overcome anxiety in lonely elderly people, it car- ried out is by crossing both hands on the chest and then clapping both hands like the flapping wings of a butterfly. Do it while inhaling slowly and exhaling slowly. The butterfly hug is a method of direct bi- lateral stimulation (such as eye movement or pres- sure) to reduce anxiety and calm oneself. This method was developed by therapists Lucina Artigas and Ignacio Jarero during their work with survivors of Hurricane Pauline [7]. Generally, people with trauma disorders can experience symptoms again if they remember or experience things that triggered anxiety. To man- age these triggers can be done by trying to calm yourself and your mind. The response of the auto- nomic nervous system to fear and anxiety causes involuntary activities in the body which are included in the self-defense mechanism. Physiologically, stressful situations activate the hypothalamus, which in turn activates two main stress pathways, namely the endocrine system (adrenal cortex) and the au- tonomic nervous system (sympathetic and parasym- pathetic).  To activate the endocrine system, after the hypothalamus receives a stress or anxiety stimulus, the anterior part of the hypothalamus releases Cor- ticotropin Releasing Hormone (CRH), which in- structs the anterior pituitary gland to secrete Adrenocorticotropin Hormone (ACTH). With the secretion of the hormone ACTH into the blood, this hormone activates the zona fasciculata of the ad- renal cortex to secrete the glucorticoid hormone, namely cortisol. This hormone, cortisol, also plays a role in the negative feedback process that is de- livered to the hypothalamus and then the signal is transmitted to the amygdala to strengthen the ef- fect of stress on one’s emotions. In addition, this negative feedback will stimu- late the anterior hypothalamus to release thyrotro- pic releasing hormone (TRH) and will instruct the anterior pituitary gland to release thyrotropic hor- mone (TTH). This TTH will stimulate the thyroid gland to secrete the hormone thyroxine, which causes changes in blood pressure, pulse rate, in- creased free fatty acids, and also increased anxi- ety.  The Butterfly Hug method was used by many psychiatrists to reduce anxiety, especially for trauma patients. In addition to trauma, anxiety is often ex- perienced by lonely elderly people. Because lonely elderly people will usually experience anxiety due to being left by their family and others. So the eld- erly need action to overcome the anxiety they ex- perience. And the Butterfly Hug method is an al- ternative solution to calm the mind by using sug- gestions that can provide comfort and tranquility for the elderly. This method can be used easily and can be done at anytime by the elderly. METHOD The research design was used a pre-experi- mental design with a one-group pre and post test design approach. Research was done at UPT PSTW Jombang-Kediri for 1 week. The sampling technique was used “purposive sampling” or satu- rated sampling, which was adjusted to the research objectives and selected based on inclusion criteria, namely the elderly who experienced anxiety, the elderly who were willing to participate in the re- search, the elderly who were not physically disabled, the femae elderly, and the elderly who are 60 years old and over. The sample who met the inclusion criteria, as many as 18 elderly. Before treatment, the researcher introduced themselves to respondent in order to build trust and created therapeutic environment. Geriatric Anxiety Inventory (GAI) were distributed to respondents to measure anxiety level before intervention. But- terfly Hug was conducted every 1 week meeting, were held 3 times, and every 1 meeting lasted 30 minutes/until calm. The last stage, researcher evalu- ating the level of anxiety in the elderly, to know if the level of anxiety decreases or increases after Butterfly Hug therapy. RESULT The presentation of respondents characteris- tic data includes age, education history, employment status, marital status, and daily activities. Based on Table 1, it could be conclude that the age distribution of most respondents (61.1%) aged 66-70 years. Distribution of the last education, all 298 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 295–300 Based on Table 2, it could be conclude that the respondents (50.0%) have a moderate level of anxi- ety. And half of the respondents (50.0%) have a severe level of anxiety. Based on Table 3, it could be conclude that the respondents (50.0%) have a moderate level of anxi- ety. And half of the respondents (50.0%) had a mild level of anxiety. Based on Table 4, the average pretest was 10.22, while the posttest showed an average of 15.11. The Wilcoxon test result obtained p-value 0.003 (0.05) then hypothesis was accepted, so it could be concluded that there was an effect of the Butterfly Hug method on the level of anxiety in the elderly at UPT PSTW Jombang-Kediri. DISCUSSION After being given treatment in the form of the Butterfly Hug method for 1 week with 3 meetings, there was a change in the level of anxiety at UPT PSTW Jombang-Kediri. A change was found in all respondents. Changes in respondents were proven by the results of the GAI questionnaire scores, where the results obtained after being given the Butterfly Hug method showed half of the respon- dents (50.0%) experienced moderate anxiety and half of the respondents (50.0%) experienced mild anxiety. Differences in respondent characteristics also affect the decrease in anxiety levels. In re- spondent number 7, there is an increase in GAI score by 12 points, while in respondent number 3, there is only an increase in GAI score by 2 points. Respondent number 7 is more open to the prob- lems experienced, while respondent number 3 is easier to feel annoyed with his friends. The de- crease in anxiety in respondents makes respondents more able to adapt to the surrounding environment, Variable f % Age 60-65 years old 7 38,9 66-70 years old 11 61,1 Education Elementary School 18 100,0 Employment Unemployment 18 100,0 Marital State Married 3 17,7 Widow 15 83,3 Daily Activity Stay at Room 12 66,7 Chat with others 2 11,1 Make Crafts 4 22,2 Table 1 Respondents Characteristic Category f % No Anxiety 0 0 Mild Anxiety 0 0 Moderate Anxiety 9 50,0 Severe Anxiety 9 50,0 Panic 0 0 Total 18 100,0 Tabel 2 Pretest Anxiety Level Data Category f % No Anxiety 0 0 Mild Anxiety 9 50,0 Moderate Anxiety 9 50,0 Severe Anxiety 0 0 Panic 0 0 Total 18 100,0 Tabel 3 Posttest Anxiety Level Data Category Pre-Test Post-test N (%) N (%) No Anxiety 0 0 0 0 Mild Anxiety 0 0 9 50,0 Moderate Anxiety 9 50,0 9 50,0 Severe Anxiety 9 50,0 0 0 Panik 0 0 0 0 Total 18 18 Mean 10,22 15,11 Wilcoxon Test p-value 0.003<0.05 Tabel 4 Statistical Analysis (100%) were at the elementary school level. The distribution of work entirely (100%) was not work- ing. The distribution of marital status was almost entirely (83.3%) widows. The distribution of daily activities mostly (66.7%) sat or stayed in the room. 299Girianto, Widayati, Agusti, Butterfly Hug to Reduce Anxiety on Elderly actively participate in activities and more able to establish interpersonal relationships. This is in ac- cordance with the results of Untari, I & Rohmawati research that one of the causes of anxiety is one’s work or activity. Too much or too little can cause anxiety [9]. Based on the results of data analysis using the Wilcoxon test, it is known that p value = 0.003 and = 0.05, so p value 0.003 < 0.05, which means that there is an effect of the Butterfly Hug method on anxiety levels in the elderly at UPT PST W Jombang-Kediri. In accordance with the functional consequence theory by Miller, giving an interven- tion can change a negative functional consequence into a positive functional consequence [3]. In this research, giving an intervention in the form of the Butterfly Hug method changed the negative func- tional consequences of anxiety into positive func- tional consequences, namely a decrease in anxiety levels. This research is in line with previous re- search by Siti Aisyah. In this research, the results obtained a significant effect of the intervention of the Butterfly Hug method on stress levels, but the application of the Butterfly Hug method on anxiety still needs to be studied further [10]. The Butterfly Hug method has advantages in its application. The advantage is that it can be done at any time and place, allowing the elderly to re- duce anxiety. As we know, the Butterfly Hug method is a type of bilateral stimulation, namely the use of external visual, auditory, or tactile stimuli sequen- tially to help clients process traumatic memories. According to the Association for Comprehensive Energy Psychology, this method can also make the heart feel spacious, balance the left and right brain, so that lonely seniors can resolve the intense emo- tions they are experiencing. Most of the respondents admitted that they were comfortable when doing the Butterfly Hug method. Complaints of anxiety and worry that are felt slowly disappear. Other respondents showed optimistic thinking or did not tend to think about bad things that would happen in the future. This agrees with the research that the Butterfly Hug method provides benefits for the formation of a better mood, so that the elderly who regularly participate in ac- tivities will always feel comfortable. A comfortable feeling condition makes individuals able to optimize functioning mental processes and also affects the individual’s ability to deal with any problems that could cause stress [10]. In addition, all respondents said they were happy to participate in activities because there were new activities that could provide a feeling of comfort and safety and create a sense of joy and together- ness among the elderly. Therefore, the Butterfly Hug method still plays a role in changing the level of anxiety in the elderly. Suardiman argues that when a person is in a state of anxiety and physiological tension, it activates the Limbic Hypothalamus Puitutory Adrenal Axis (LHPA), which stimulates the hypothalamus and causes the secretion of cor- ticotrophin releasing hormone (CRH). This causes the activation of Adeno Cortico Trophin Hormone (ACTH) which stimulates the production of sero- tonin and endorphins hormones which will make individuals happy, happy, comfortable, sleep better, and keep the mind fresh. In addition to physical activity and exercise, psychological mechanisms will appear. and neurobiology so that antidepressant and anxiolytic effects can occur which can reduce anxi- ety levels [11]. CONCLUSION There was an effect of the butterfly hug method on the level of anxiety in the elderly at UPT PSTW Jombang-Kediri. SUGGESTION Suggestion for further researchers, they can develop the same theme with a larger number of samples in order to get maximum results. In addi- tion, it can add a control group as a comparison in the research, so that the research can be more per- fect.  REFERENCES Sunaryo. 2016. Faktor yang Mempengaruhi Tingkat Kecemasan pada Lanjut Usia (LANSIA) di RW 1, Kelurahan Ploso, Kecamatan Tambaksari, Kota Surabaya (Skripsi: Universitas Airlangga Surabaya) Stuart & Sundeen. 2016. Keperawatan Psikiatrik : Buku Saku Keperawatan Jiwa. Edisi 5. Jakarta:EGC Miller, C.A. 2017. Nursing for Wellness in Older Adults. 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