The Effect Benson Relaxation Technique with Anxiety in Hemodyalisis Patients in YOGYAKARTA

Hemodialysis is a treatment that must be done by patients with chronic renal failure. Hemodialysis can changes the various aspects of life of patients, and it cause anxiety. One of the method that can used to reduce anxiety is Benson relaxation techniques. This technique is a combination of relaxation and elements of religious beliefs espoused. To determine the effect of Benson relaxation techniques for anxiety in patients undergoing hemodialysis therapy. Quasi Experiment pre post test design with comparison groups with simple randomization tech- niques conducted, the number of respondents is 30 people were di- vided into intervention group (n = 14) were given relaxation Benson for 2 weeks every day at 6 am and 5 pm and the comparison group (n = 16) were not given the intervention. Anxiety measurements performed twice pretest and posttest with Analog Anxiety Scale (AAS). The average of respondent's anxiety pre dan post relaxation tecnic Benson in the inter- vention group 21,93 and 13,59. And in the comparison group 17,19 and 12,94. This study showed that there was a significant decrease in anxiety scores in the intervention group p=0.001 (p<0.05) and com- parison group p=0,014 (p<0,05). The study showed that the interven- tion group obtained a average difference of 8.36, while in the control group obtained a average difference of 4.25 with p value 0.118 (p> 0.05). There are no significant differences in the average difference of anxiety in both groups. Benson relaxation techniques have no effect to the de- crease anxiety scores of hemodialysis patients.


BACKGROUND
The prevalence of kidney failure in the world is quite high, with an estimated 8-16% of the total world population (Jha et. al, 2013).Based on the data in 2008, the total population of each continent, there were 17.03% of patients in United States, 19.96% in Europe and 11.5% in Asia -Australia (Zhang & Rothenbacher, 2008). While in Africa, the prevalence of renal failure was 3-4 times higher than in developed countries (Saraladevi, 2009).Those phenomenon in several continents are not much different from Indonesia. Based on the results of a community survey, it was found as much as 12.5% or approximately more than 25 million of the population in Indonesia suffers from a decreased kidney function (Pernefri, 2012). Based on the results of preliminary studies conducted by the author in the Department Kesehatan Yogyakarta and PKU Muhammadiyah Hospital Yogyakarta, showed that there are 767 patients with kidney failure of the five regencies were hospitalized.
During the period of August 2014, 319 patients were on regular hemodialysis in the hemodialysis unit of PKU Muhammadiyah Hospital in Yogyakarta.
Chronic renal failure patients undergoing hemodialysis treatment will experience changes in terms of physical, social, emotional, as well as cognitive. Those changes will effect to their quality of life (Rambod, 2013). Patients with long-term hemodialysis have some problems such as finance, unemployment, sexual drive lost, depression, and fear of death (Davidson, Reickmann, Rapp, 2005). The study conducted in the Mediterranean, got the result that as many as 3 (3.8%) hemodialysis patients did not experience anxiety, 38 (47.5%) experienced minor anxiety, and 39 (48.7%) had moderate to severe anxiety (Bossola et al, 2010). While a research conducted in Indonesia, got the prevalence of anxiety in hemodialysis patients as much as 77.8% (42 of 54 respondents) with various levels of anxiety (Luana et al, 2012). Another research showed that patients who had undergone hemodialysis for <1 month to 1 year, had a moderate to severe level of anxiety. Whereas patients who had undergone hemodialysis for 1 year to> 3 years, the rate is in the range of minor anxiety and no anxiety (Hidayat, 2007). The anxiety experienced by hemodialysis patients need an immediate treatment. The untreated anxiety leading to worsen patient health condition.
One non-pharmacological technique that can be used to reduce anxiety is relaxation techniques. Relaxation techniques can effectively decrease and prevent the psychological effects of stress (Johns, 2009). Among many relaxation techniques, Benson relaxation technique is one of the most convenient method. Benson relaxation technique is the development of methods of relaxation involving patient's confidence factor, focusing on certain words or sentence suttered repeatedly with a regular rhythm. This technique can reduce anxiety in hemodialysis patients. It is similarly stated in the study titled Implementing Benson's Relaxation Training in Hemodialysis Patients: Changes in Perceived Stress, Anxiety, and Depression (Mahdaviet al, 2013 ). Instead of requiring high cost, this technique is easy to be conducted by the patients (Kolt and Lynn, 2007).

METHODS
This research is a quantitative Research using Quasi Experiment pretest and posttest design with comparison group. Observations are conducted twice, before and after the intervention in the intervention group, and before and after in the comparison group without intervention. The research is conducted in the hemodialysis unit PKU Muhammadiyah Hospital in Yogyakarta in January 2015. The total population is 319 people. Purposive sampling is used to determine the sampling groups by average of a lottery to determine the intervention group and the comparison group. The drawing is based on timing of hemodialysis, which is morning and afternoon. Sweepstakes is done by making two papers with morning and afternoon written on them, then each is folded and shuffled. The withdrawal is done with eyes closed, the first drawn paper is treated as the intervention group.  The inclusion and exclusion criteria are < 2 years dialysis period , experience a minor anxiety (score AAS    can process the information and overcome the problem. Moreover, when someone is experiencing moderate anxiety, he will be more focused on important things. Therefore, the attention will be focused on selective things so that he will able to do something with a more targeted (Stuart & Sundeen, 1998).

THE RESULTS
In this study are different from another study regarding the provision of Benson relaxation techniques performed by Mahdavi et al., 2013. He stated that there was a significant decline in anxiety value in the intervention group, and none in the comparison group.
The anxiety pretest value of the intervention group was 8.4 ± 3.1 and 7.1 ± 2.66 posttest with p = <0.001.
As for the control group, anxiety pretest value was 7.85 ± 3.43 and 8.2 ± 3.11 for posttest with p => 0.11.
This shows that Benson relaxation technique is able to reduce the level of anxiety, whereas none was found in this study.

Table 5. Analysis of the Effect of Benson Relaxation Techniques Towards Anxiety in Hemodialysis Patients PKU Muhammadiyah Hospital in Yogyakarta
The differences of results of this research with the research conducted by Mahdavi et al., 2013, might happened due to differences in the number and characteristics of respondents, place of the study, and time of intervention. The number of respondents in this study was 30 patients with anaverage age characteristics of 45.27, having had hemodialysis for < 2 years and non-illiterate patients were included. While the research in Mahdavi et al., 2013 showed that the number of respondents is 80 patients, with a average age characteristics of 47.98, having had hemodialysis for 5 years or more and 15 respondents were illiterate. This research was conducted at PKU Muhammadiyah Hospital in Yogyakarta, within 2 weeks of intervention, while research conducted by Mahdavi et al., 2013 was done within a month time of intervention at two hospitals in Iran which are Imam Khomeini and Fatemeh Zahra Hospital. The theory states that there are some factors affecting the anxiety. Those factors are maturity, educational status, physical state, types of personality, social, culture, environment , and gender (Tarwoto & Wartonah, 2003). Another theory states that in hemodialysis patients, the occurring anxiety related to the fear of death, the cost of treatment, and lifestyle changing (Levenson, 2011). Averagewhile, those factors are not explored in this study.
Another factor that can influence anxiety in hemodialysis patients is a threat to the integrity of which includes physiological inability or the reduced capacity to perform daily life activities as well as threat to the selfsystem.This system could endanger a person's identity, self-esteem and social functions. Respondent's data in relation to physiological inability and threats to the self system, are not included in this study as well as in the study conducted by Mahdavi et al., 2013, so that it cannot be compared. Analysis using unpaired t test was performed to compare the difference in the pretest and posttest of anxiety value on both groups. The results of the analysis can be seen in Table 5.
The above table shows that the intervention group obtained a average difference of 8.36, while in the control group gained a average difference of 4.25 with p value of 0.118 (p > 0.05). So, although there are differences in the average of anxiety values , it is not so significant in both groups.
The results in this study are different with the results of research conducted by Mahdavi et al., 2013. The study showed that Benson relaxation techniques significantly affected the decrease of anxiety (p = 0.005). While in this study, it is not significant. This is probably because of a shorter intervention time given to the intervention group, ie 2 weeks, while the research in Mahdavi et al., 2013, it was carried out for 1 month. 3. The difference of average between the anxiety value before and after getting Benson relaxation technique in both groups experienced a significant decline, with p = 0.001 in the intervention group, and p = 0.014 in the control group.

For Science
It is expected to produce more theory regarding Benson relaxation techniques and other relaxation techniques to reduce anxiety.

For hemodialysis patients
It is expected to perform independently Benson relaxation technique to reduce anxiety and make the body calmer, regarding that Benson relaxation technique is very easy to do and has many benefits.

For further research
It is expected to have more research on the influence of other relaxation techniques to decrease the anxiety value