International Journal of Nursing and

Health Services (IJNHS)

http://ijnhs.net/index.php/ijnhs/home
Volume 4, Issue 1, February 20th, 2020, pp 9-16
e-ISSN: 2654-6310

The Effectiveness of Recitation Al-Qur’an Intervention

and Deep Breathing Exercise on Improving Vital Sign
and anxiety Level among Congestive Heart Failure
(CHF) Patients
Yudi Herdiana1*, Ta’adi2, Masrifan Djamil3
1
Nursing Student, Postgraduate Program, Master of Applied Health
2-3
Politeknik KesehatanKemenkesSemarang, Semarang, Indonesia

Article info Abstract

Congestive heart failure (CHF) is a non-communicable disease
Article history: caused by failure to pump blood. An alternative treatment with
Received; July 19th, 2020 complementary therapies, such as recitation Al-Qur'an
Revised: August 23th, 2020 intervention and deep breathing exercise, improved oxygen
Accepted: September 20th, 2020 saturation, and anxiety levels CHF patients. This study aimed to
examine the effectiveness of recitation Al-Qur'an intervention and
deep breathing exercises on strengthening the vital signs (oxygen
Correspondence author: saturation) and anxiety level among patients with congestive heart
Yudi Herdiana failure (CHF). The true experimental study approach post-test
E-mail:
only with a control group design was applied in this study. Forty
yudimst20@gmail.com
congestive heart failure (CHF) patients were selected through
simple random sampling. The intervention group received the
DOI: recitation Al-Qur'an therapy and deep breathing exercise, while
http://doi.org.10.35654/ijnhs.v4i1.36 the control group only received the medical treatment according
9 to hospital standards. The findings showed that the intervention
group was better on oxygen saturation and lowering anxiety levels
than the control group (p-value = <0.05). In conclusion, recitation
Al-Qur'an intervention and deep breathing exercises are useful to
increase oxygen saturation and lowering anxiety levels in patients
with congestive heart failure (CHF). This study can be used as a
source for further research with larger sample size and better
control over medical therapy.

Keywords: deep breathing, vital sign, oxygen saturation, anxiety

level, congestive heart failure

This is an Open Access article distributed under the terms of the

Creative Commons Attribution 4.0 International License CC BY -4.0

International Journal of Nursing and Health Services (IJNHS), Volume 4, Issue 1, February 20th, 2020 9
INTRODUCTION
Indonesia is experiencing an epidemiological transition in the health sector. The problem
of non-communicable diseases has not been appropriately resolved while non-communicable
diseases continue to increase. The Global Report on Non-Communicable Disease stated that the
incidence of non-communicable diseases causes death by 70% of all causes (1). Heart and blood
vessel disease is a progressive health problem with high mortality and morbidity rates in Indonesia
(2).
Basic health research data in 2018 showed that the prevalence of heart disease in Indonesia
was 1.5% from the total population. The highest prevalence of heart disease from North Kalimantan
(2.2%), Yogyakarta province was 2%, and Gorontalo province was 2% (2). In addition, the medical
record data of regional public hospital 45 Kuningan Regency reported that the incidence of heart
disease in 2018 reached 769 people from 9,368 all hospitalized patients.
The commonly of heart disease was congestive heart failure. Congestive heart failure due
to inability to pump blood to meet the body's cells for adequate nutrients and oxygen. CHF is in a
chronic phase affecting patients' quality of life with various causes, so it becomes a severe problem
in the health care system (3). Dyspnea is a symptom most often felt by sufferers due to a lack of
oxygen supply due to pulmonary malfunction (4).
Changes in the vital signs that occur in CHF patients, namely respiratory rate, blood
pressure, heart rate, and decreased oxygen saturation, impact increased sensation dyspnea due to
changes in the muscles respiratory tired. This happened because fluid accumulation in the alveoli
makes the heart unable to pump blood optimally (4-5). Monitoring vital signs is very important
regarding the symptoms that arise and the interventions that will be carried out. This situation will
be harmful if not handled because it will cause other organs' failure (6).
Psychological problems occur with CHF. Psychological issues in heart disease, especially
CHF, are influenced by feelings of anger, depression, stress, and anxiety. The anxiety felt by CHF
patients has several reasons, namely anxiety because of the condition of the disease, anxiety
because of fear of death, and anxiety because of the tightness they feel. Anxiety would have a
harmful effect if left untreated and will cause increased oxygen demand and heavier heart burden
(7-8).
The management of CHF was administering diuretic therapy, vasodilator therapy, and
administration of cardiac glycosides. Meanwhile, non-medical management consisted of
maintaining physical stability, avoid behaviors that can worsen the condition, and detect early
symptoms of worsening heart failure (9). American Heart Association (AHA)states that actions
that could be implemented are providing education, increasing functional capacity, and exercising.
Giving positions and exercises can be carried out to reduce effort and improve respiratory muscle
function. Tolerable physical exercise is also an effort to increase tissue perfusion and improve
tissue circulation (10). Other non-medical treatments performed by nurses are deep breathing
exercises, meditation, yoga therapy, hypnosis, and relaxation (11).
Nirmalasari's study using deep breathing exercise therapy and active range of motion
(ROM) in CHF patients was carried out for three days, proving that deep breathing exercise and
active ROM affected dyspnea significantly (12). Another study conducted by Witowo, namely
Hypno-breathing exercise, by combining hypnosis therapy and deep breathing exercise can reduce
dyspnea and improve the hemodynamic status of CHF patients, but not all nurses can hypnosis
patients (13).
It has been researched and proven that listening to the recitation (murottal) Al-Qur'an can
reduce stress and psychological disorders. Muslims have used the Qur'an for centuries to heal and
treat people suffering from stress and psychological disorders (14). One of the advantages of
listening to the recitation Al-Qur'an is that it has a healing effect (15-16).
Mansouri examined the effects of the Koran's sound with headphones via an mp3 player on
International Journal of Nursing and Health Services (IJNHS), Volume 4, Issue 1, February 20th, 2020 10
the improvement of blood pressure, pulse, respiration, and O2 saturation in patients hospitalized in
ICU. The improvement in physiological response in treated patients is due to increased metabolism,
increasing body temperature, cardiac output, increased blood pressure, heart rate, and respiratory
rate. The results showed that after 15 minutes of listening to the Koran, there was a decrease in
systolic and diastolic blood pressure in mean arterial pressure, heart rate, and respiration and an
increase in the percentage of oxygen saturation in patients treated in the ICU (17).
Deep breathing exercises could be combined with several other types of therapy for optimal
results. Intervention combinations of spiritual relaxation with a deep breathing exercise on religion
are considered universal and positively influence perceptions. Zulkurnaini et al. proved that the
Koran verses could increase the signal Alpha band, creating a calming state (more relaxing) (15,
18).
Deep Breathing exercises aim to train how to breathe appropriately, flex and strengthen the
respiratory muscles and improve circulation (19). The deep breathing exercise has not had a
maximum effect on CHF patients. Therefore, it is necessary to provide appropriate strategies and
techniques for administration by controlling the breath before and during breathing exercises
accompanied by giving relaxation actions. One of the relaxation techniques that nurses can provide
is by listening to the recitation Al-Qur'an.
Based on this background and referring to cognitive therapy science to improve vital sign
(oxygen saturation) and CHF patients' anxiety levels, this study was investigated in this study by
combining recitation Al-Qur'an nursing intervention and deep breathing exercise.

OBJECTIVE
This study aimed to examine the effectiveness of recitation Al-Qur'an intervention and deep
breathing exercises on improving the vital signs (oxygen saturation) and anxiety level among
patients with congestive heart failure (CHF).

METHOD
The true experimental post-test only with control group design was applied in this study.
Researchers divided patients into the intervention group who received the recitation Al-Qur'an
therapy and deep breathing exercises. The control group received the medical treatment according
to hospital standards for CHF patients. Recitation Al-Qur'an therapy and deep breathing exercises
were carried out for four days for 20 minutes.
The oxygen saturation was accessed using the oximetry instruments and anxiety levels
using the Zung Self-Rating Anxiety Scale questionnaire. Measurement of oxygen saturation and
respondent anxiety was carried out on day 1 to day 4 with four measures (pretest, post-test 1, post-
test two, and post-test 3).
In this study, the populations were CHF patients classified as NYHA II and NYHA III in
the Regional Public Hospital 45 Kuningan Regency internal disease ward. We randomly selected
40 patients and allocated them to the experimental group (n=20) and control group (n=20).
In this study, researchers collected data using observation, identification, interview, and
filling out observation sheets. The collected data were analyzed through the IBM SPSS program
version 24.0 and continued with different tests, namely the parametric test (Dependent t-test and
Independent t-test). The processed data is used to discuss the problem statement, which is then
presented in tabular form to conclude.

International Journal of Nursing and Health Services (IJNHS), Volume 4, Issue 1, February 20th, 2020 11
RESULT

Demographic data
Table 1 showed the characteristic of respondents. The data showed that most of respondents
in the intervention group (65.0%) and control groups (60.0%) were male. The majority respondents
had comorbidities such as hypertension (70.0%). Meanwhile, the mean age of respondents in the
intervention group was 49.30 years with a standard deviation of 6.105. While in the control group
was 49.10 years with a standard deviation of 6.095. The significance was 0.609 which is indicated
that there is no difference between intervention group and the control group.

Table 1. Demographic data

Intervention Control
P
Characteristics (n=20) (n=20)
N % N %
Gender 0.534
Male 13 65.0 12 60.0
Female 7 35.0 8 40.0
History of
diseases
Hypertension 14 70.0 14 70.0 0.434
Diabetes Mellitus 3 15.0 2 10.0
Kidney Failure 2 10.0 2 10.0
Anemia 1 5.0 2 10.0
Total 20 100 20 100
Mean ± SD Mean ± SD
Age 49.30±6.105 49.10±6.095 0.609

Table 2 mean difference of oxygen saturation before and after receiving the intervention
among the intervention group and control group
Table 2 showed the mean difference of oxygen saturation before and after receiving the
intervention among the intervention and the control group. The mean oxygen saturation among the
intervention group increased from the first day was 1.85%, the second day was 1.80%, the third
day was 1.80%, and the fourth was 2.05%. While the increase in the mean oxygen saturation in the
control group on the first day was 0.25, the second day 0.40, the third day 0.25, and the fourth day
0.15%.

Intervention Control
Oxygen Pretest Post-test Delta p Pretest Post-test Delta p
Saturation Mean± Mean± Mean± Mean±
SD SD SD SD
Day 1 92.70± 94.55± 1.85 0.000 92.80± 93.05± 0.25 0.056
1.174 1.317 1.196 1.1317
Day 2 93.20± 95.00± 1.80 0.000 93.20± 93.60± 0.40 0.042
1.056 1.257 1.056 1.603
Day 3 93.80± 95.60± 1.80 0.000 93.75± 94.00± 0.25 0.388
1.105 1.095 1.070 1.777
Day 4 94.10± 96.15± 2.05 0.000 94.15± 94.30± 0.15 0.735
1.021 1.268 0.988 1.867
*
Dependent t-test

International Journal of Nursing and Health Services (IJNHS), Volume 4, Issue 1, February 20th, 2020 12
Table 4.3 Analysis of the differences in oxygen saturation between the intervention group and
control group
Oxygen Saturation Intervention group Control group p
Mean±SD Mean±SD
Day 1 94.55±1.317 93.05±1.317 0.001
Day 2 95.00±1.257 93.60±1.603 0.004
Day 3 95.60±1.095 94.00±1.777 0.001
Day 4 96.15±1.268 94.30±1.867 0.001
Mean for four days 95.33±0.839 93.74±1.294 0.000
*
Independent t-test
The table above shows that the mean oxygen saturation in the intervention group and the
control group after being given treatment shows a significant difference P = 0.000. After being
given treatment for four days, average oxygen saturation became 95.33%, while the control group
became 93.745%.

Table 4. Mean differences of anxiety levels before and after treatment in the intervention
group and control group
Intervention Control
Anxiety Pretest Post-test Delta p Pretest Post test Delta p
Mean± Mean± Mean± Mean±
SD SD SD SD
Day 1 52.10± 47.15± 4.95 0.000 52.00± 51.80± 0.20 0.330
4.115 4.056 4.000 4.250
Day 2 50.35± 44.65± 5.70 0.000 50.15± 49.10± 1.05 0.074
4.557 4.870 5.274 4.303
Day 3 49.05± 44.00± 5.05 0.000 49.05± 48.70± 0.35 0.358
4.582 5.211 4.536 4.092
Day 4 48.40± 43.10± 5.30 0.000 48.25± 47.50± 0.75 0.314
3.648 4.610 4.972 4.490
*
Dependent test t-test
Table 4 showed a difference of anxiety level after receiving the recitation Al-Qur'an and
deep breathing exercise among the intervention group and the control group. The average anxiety
level pretest and post-test decrease on the first day was 4.95, the second day 5.70, the third day
5.05, the fourth day 5.30. While the reduction of the average anxiety level before and after in the
control group on the first day was 0.20, the second day was 1.05, the third day was 0.35, and the
fourth day was 0.75.

Table 4.5 Analysis of the differences in anxiety levels between the intervention group and the
control group
Anxiety Intervention Group Control Group P
Mean±SD Mean±SD
Day 1 47.15±4.056 51.80 ±4.250 0.001
Day 2 44.65±4.870 49.10±4.303 0.004
Day 3 44.00±5.211 48.70±4.092 0.003
Day 4 43.10±4.610 47.50±4.490 0.001
Mean for four days 44.73±3.507 49.28±3.577 0.000
*
Independent t-test

International Journal of Nursing and Health Services (IJNHS), Volume 4, Issue 1, February 20th, 2020 13
The table above shows that the average score of anxiety levels in the intervention group and the
control group after being given treatment shows a significant difference p = 0.000. After being
given treatment for four days, the average score of anxiety level became 44.73, while the control
group became 49.28.

DISCUSSION

The effectiveness of recitation Al-Qur'an intervention and deep breathing exercises on

improvement vital sign (oxygen saturation) patients with congestive heart failure (CHF)
The picture of oxygen saturation improved in both the control and intervention groups. The
difference between the mean value of the pretest day one and the post-test day 4 in the intervention
group was higher than the control group. The oxygen saturation picture in the intervention group
increased from day 1 to day four by 3.45% compared to the control group by 1.5%. The daily
increase indicated that oxygen saturation had increased acutely during the four days of the
intervention.
Different test results for four days showed p <0.05. This suggests that recitationAL-Qur'an
interventions and deep breathing exercises effectively increase oxygen saturation levels compared
to standard hospital therapy in CHF patients. The analysis of each group in the control group and
the intervention group as a whole for four days showed p <0.05. This indicates that both groups
showed a significant change in oxygen saturation. Changes in oxygen saturation daily in the
intervention group showed more significance with a p-value <0.05. The improvement also occurred
in the control group with a significant p <0.05 every day. The results of this study have an effect
size of 1.458.
Other studies that support that carried out by Sepdianto show that breathing exercises can
increase oxygen saturation in heart failure patients by 0.8 with an effect size of 0.01 (19). Another
study conducted by Bernadi with one month of breathing exercise intervention in heart failure
patients showed an increase in oxygen saturation from 92.5%±0.3 to 93.2%±0.4 with an effect size
of 0.003. This study's results are also consistent with that of Sivakumar, who stated that deep
breathing exercises for 2-5 minutes have an acute effect on a significant increase in lung function
ability so that it can improve oxygen saturation levels (20).
Recitation Al-Qur'an intervention and deep breathing exercise will increase the need for
oxygenation. Elzaki explained that patients suffering from heart disease showed improvement in
heart function after listening to the sound of the Qur'an. Nurses' monitoring of blood pressure and
heart rate is the key to maintaining good blood circulation to keep the patient's condition (21). Deep
breathing exercises will stimulate the release of surfactants secreted by type II alveolar cells. The
surfactant that comes out will cause the surface tension on the alveoli to be lowered, thereby
improving lung function. The need for adequate oxygenation would increase oxygenation in the
tissue for increasing oxygen saturation. Slow breathing will increase the respiratory muscles and
diaphragm movement to increase the ability to activity by reducing the onset of dyspnea (20).

The effectiveness of recitation Al-Qur'an intervention and deep breathing exercises on

improvement anxiety levels patient with congestive heart failure (CHF)
The description of anxiety levels decreased in both the control group and the intervention
group. The difference between the value of mean pretest day one and post-test day 4 in the
intervention group was higher than the control group. The anxiety level score decreased gradually
from day 1 to day 4. The mean post-test value on day 4 in the intervention group was nine, while
in the control group was 4.5. The score for the decrease in anxiety indicated that it was better.
Different test results for four days showed p <0.05. This suggests that recitation Al-Qur'an
interventions and deep breathing exercises effectively reduce anxiety levels compared to standard

International Journal of Nursing and Health Services (IJNHS), Volume 4, Issue 1, February 20th, 2020 14
hospital therapy in CHF patients. The analysis of each group in the control group and the
intervention group as a whole for four days showed p <0.05. This indicates that both groups showed
a significant change in improvement in anxiety levels. Changes in anxiety level every day in the
intervention group showed more substantial-good with a p-value <0.05. The improvement also
occurred in the control group with a significant p <0.05 every day. The results of this study have
an effect size of 1,284.
Various studies related to reading the Koran as a complementary therapy to reduce anxiety
and provide calm and comfort for patients have been carried out. Research related to patient anxiety
and comfort is fundamental because it can help the patient's healing process in treatment.
Zulkurnaini's research shows that the EEG results show an increase in the alpha band before and
after listening to the Al-Qur'an. This shows that listening to the Qur'an provides a more relaxed and
calm atmosphere. This research is in line with the results of Shekah's study; listening to the
recitation of the Qur'an can generate alpha waves and can help a person to be in a relaxed state to
reduce anxiety levels (15, 22).
The research conducted by FaridHajiri, namely, the combination of recitationAl-Qur'an and
acupressure for 2x15 minutes a day, was more effective in reducing anxiety in coronary heart
patients at measurement 1 (p=0.041) and measurement 2 (p=0.002) (23).
Recitation therapy has a positive psychological impact. When the recitation is heard and
reaches the brain, this recitation will be translated by the brain. With recitation therapy, the quality
of one's awareness of God will increase, whether that person knows the meaning of the Qur'an or
not. Awareness will increase one's surrender to Allah SWT's power; in this state, the brain is in
alpha waves, which are brain waves at a frequency of 7-14 Hz, a state of optimal brain function
reduce to relieve stress (23-24).
Listening to the recitation Al-Qur'an can affect one's emotional intelligence, intellectual
intelligence, and spiritual intelligence. Listening to recitation will have a calm and relaxing effect
on CHF patients, so it will also contribute to reducing anxiety (25).

CONCLUSION
Based on data processing and analysis regarding recitation, Al-Qur'an interventions and
deep breathing exercise an alternative, complementary therapies. It concluded that the average
increase in oxygen saturation and decrease in anxiety levels in the intervention group is more than
the average oxygen saturation and anxiety levels in the control group with a p-value <0.05. In
conclusion, recitation Al-Qur'an therapy and deep breathing exercise effectively improve vital sign
values (oxygen saturation) and anxiety levels, so the intervention group is better than the control
group.

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