Effect of Al-Qur’an Therapy on Anxiety Cancer Patients in Aisyiah Islamic Hospital Malang, Indonesia

ABSTRACT

diagnosed with cancer are still having trouble with their survival due to the long-term side effects of treatment and the diagnosis itself. In addition to the physical consequences, several studies have shown increased levels of anxiety and depression even years after diagnosis (Inhestern, Beierlien, Bultmann, Möller, Romer, & Koch, 2017).
Cancer patients who experience physiological anxiety increase norepinephrine levels so that they often wake up at night, where will hinder the wound healing process, due to disrupted cell regeneration processes (Kozier, 1995in Faridah 2015. In various studies, it is also stated that anxiety is closely related to endurance (Setyoadi, 2011in Ali, 2015. In cancer patients, depression and anxiety have been associated with decreased medication adherence, prolonged hospitalization, decreased quality of life. Depression and anxiety are independent risk factors for early death in cancer patients (Arrieta et al., 2013;Pinquart andDuberstein, 2010 in Griffiths, et al., 2016).
In a preliminary study conducted Aisyiyah Islamic Hospital of Malang, the number of cancer patients from February to June 2017 amounted to 409 patients. Based on the results of interviews conducted with several patients, it was revealed that the anxiety they felt often appeared every time they wanted chemotherapy and during chemotherapy. Some of the patients also mentioned that they were anxious every time they had control and came to the hospital, they were worried about the possibilities that would happen to them, both in terms of their physical and social life in the family and environment. Poor prognosis is often a concern for cancer patients themselves. Based on measurements using the HARS (Hamilton Anxiety Rate Scale) it was found that the average level of anxiety was in the medium category. The data is also illustrated by signs or symptoms such as attentive voice and facial expressions, slightly increased vital signs, slightly tense patient, uncomfortable patient, dry mouth, frequent urination, and narrowed perception. Interviews with nurses mentioned that cancer patients who often experience anxiety are often found with Mamae cancer, Cervix cancer, and Colon cancer.
Common treatments given to reduce anxiety such as medication combined with psychotherapy, cognitive behavioral therapy CBT (Cognitive Behavioral Therapy), other psychotherapy, such as relaxation therapy, supportive psychotherapy, or mindfulness therapy, have been used if CBT cannot be used to treat anxiety (Bhatt, 2016). Preliminary results of the pilot study suggest that sound meditation is an effective relaxation therapy from the start of treatment. Unlike some other relaxation methods, sound meditation does not require regular practice or practice to achieve a positive effect (Rose & Weis, 2008).
Sound therapy has several advantages such as safe and simple therapy, has a low level of difficulty and costs, or is economical (Forooghy, Tabrizi, Hajizadeh, & Pishgoo, 2015). While the advantages of Quranic sound therapy itself are: (1) being able to treat diseases that cannot be treated by the medical team (Yusri, 2006in Faridah 2015. (2) creates mental and spiritual relaxation effects (Fitriatun, 2014). (3) The Qur'an makes one's heart calm, safe and comfortable (Ali, 2015). Quran sound therapy is more effective in reducing depression than music used for relaxation and depression treatment (Rafique, Anjum, & Raheem, 2017).
The sound of the Qur'an is another therapy in reducing anxiety. Several previous studies have been conducted on the effect of Quran therapy on reducing anxiety. His research on the effects of the Qur'an on humans in terms of physiology and psychology shows that listening to the Qur'an can significantly reduce reflective nervous tension and with computers, this data is measured in qualitative and quantitative forms (Ahsin W, 2007in Ali 2015. Other research on listening to the verses of the Koran affects reducing psychological stress (Fitriatun, Wiyono, & Setyanto, 2014). Another study on listening to surah al-Fatihah once and ar-rad verse 28 seven times for 20 consecutive days showed a significant reduction in anxiety levels in breast cancer patients before surgery (Ali, 2015). Another study on listening to the sound of the Qur'an on decreasing the anxiety level of patients before laparotomy surgery showed that there was an effect, where there was a decrease in the patient's level of anxiety (Faridah, 2015).
Patients who receive sound therapy will be effective and efficient in overcoming anxiety, this therapy is a recommended option for anxiety therapy as well as Al-Quran sound therapy which has been proven to have an effect in overcoming the anxiety of cancer patients who will undergo surgery and anxiety in patients who will undergo laparotomy. but there are no studies that explain the Quranic sound therapy significantly reduces anxiety in cancer patients, so the researchers wish to research the effect of Al-Quran sound therapy on reducing anxiety levels in cancer patients.

Methods
The research design used pre-experimental with a one-group pre-post test design. This research was carried out in the chemotherapy room. The sampling technique used is purposive sampling with inclusion criteria, namely patients who have been diagnosed with cancer for 5 years ago, patients who are currently undergoing chemotherapy therapy, complain of anxiety verbally, and are willing to sign an informed consent. The number of samples involved in this study was 24 patients. This research was conducted in November -December 2017 at Aisyiyah Islamic Hospital of Malang. Researchers used the Hamilton Anxiety Rating Scale (HARS) instrument to measure the level of anxiety experienced by participants, the therapy process was carried out 12 times (1 day 2 times listening to the voice of Al-Quran Surah Ar-Rahman for 22 minutes). Researchers have conducted a non-parametric test using Wilcoxon.

Demographic data of patients receiving Al-Qur'an Therapy
The characteristics of the respondents' demographic data assessed in terms of age, gender, and religion can be seen in table 1 below :

Tabel 1. Demographic data
The average age of the respondents was 48 or 49 years with the youngest age being 34 years and the oldest being 60 years. Inhestern, et al (2017) mention that young cancer patients experience more distress than older cancer patients. At a young age, they are still in the developmental and emotional stages of immaturity so they will feel more pressure and minimal control techniques, on the contrary, older cancer patients are more mature and better at controlling the pressure that comes on them.
The sex distribution of respondents is not evenly distributed, where male respondents are 7 people and 17 women are. Based on this data, the respondents in this study were dominated by women. The Ministry of Health of the Republic of Indonesia presents data on cancer patients, in which the data is also dominated by women with cervical cancer and breast cancer (Kemenkes RI, 2015). With these data, it is directly proportional to the fact that the majority of cancer sufferers are women, so there is a possibility that this is a separate threat for women.
The religious distribution of the 24 respondents in this study, was dominated by Muslims, namely 95.84% or 23 people and non-Muslims 4.16% or 1 person. Tix & Frazier (2005) stated in their research that Catholic religious traditions have a relationship with greater anxiety and depression, but Protestants have no relationship. Religion will be a factor of anxiety depending on the elements in the religion. So that different religions will also affect the anxiety felt by individuals. Before giving the Qur'an sound therapy (pre-test), respondents were explained the objectives, benefits, and research procedures. The research procedure includes filling out informed consent if you are willing to be a respondent. Anxiety measurement was carried out when the respondent was on a chemotherapy schedule and was in the chemotherapy room at RSI Aisyah Malang. The measurement was carried out using the HARS scale.

Table 2. Data on decreasing anxiety levels
The results of measuring the level of anxiety to 24 respondents obtained several levels, such as mild, moderate, and severe. Respondents with moderate levels of anxiety amounted to 10 people and 14 people with severe anxiety levels. Respondents on average feel tense, uncomfortable with the situation, restless, and focus on what they are currently experiencing. Fortinash and Worret (2012) state that the signs of moderate anxiety are: (a) physiological: Vital signs are normal or slightly high: the patient's tension is uncomfortable or excitement (indicates tense or restless) (b) Perceptual: Alert: Perception is narrowed and focused, optimal state for problem-solving and mindful learning (c) Emotional: Feelings of alert and energized challenge; engage in competitive activities and learn new skills; an interested or attentive voice and facial expression. Respondents complained about the impact after chemotherapy, this was felt when going to chemotherapy, sometimes nausea, more sensitivity, increased breadth, and chest palpitations. The anxiety of cancer patients is often caused by imminent threats such as loss, death, impaired body function, loss of role, changes in body image, and the duration of cancer symptoms (Trill, 2013). Anxiety in cancer patients if not overcome will have an impact on physiological such as the duration of symptoms of nausea and vomiting felt by the patient, the difficulty of the patient to relax so it is difficult to rest, and problems with treatment compliance where the patient experiences a decrease in coming to do chemotherapy.

Figure 1. Graph of Changes in Anxiety Levels of Cancer Patients Before and After Quran
Sound Therapy After 12 days of listening to the sound therapy of the Qur'an Surat Ar-Rahman which is done every 2 days for 20 minutes. Twenty-four respondents again took measurements of anxiety. The results of the measurement of anxiety for 24 respondents were obtained as follows, respondents with categories within normal limits amounted to 18 people and with mild anxiety levels, there were 26 people. Respondents on average feel more comfortable not being tense, and are no longer too focused on what they feel. Fortinash and Worret (2012) stated that the signs of mild anxiety are, (a) physiological: normal TTV, minimal muscle pressure, normal pupils or contractions (b) Perceptual: wide perceptual field; aware of environmental and internal stimuli; Thoughts are often random but controlled (c) Cognitive: Feelings of relative safety and comfort, relaxed and calm appearance and sound; automatic performance; Behavior like every day.

Analysis The Effect Of Murattal Therapy On Anxiety
According to Bhatt (2017) states that the part of the brain associated with anxiety begins to be studied using the development of functional and structural imaging. The brain's amygdala appears to be important in modulating fear and anxiety. An increased amygdala is a response to anxiety. The amygdala and other structures of the limbic system are connected to areas of the prefrontal cortex. Amygdala hyperresponsiveness may be related to decreased activation threshold in response to perceived social threats. Maulana (2016) The effect of this therapy appears a relaxation that arises from listening to the Qur'an. brain cells have a natural frequency that causes this effect. Resonance will appear if there is a sound response with a frequency spectrum that is directly proportional to the brain frequency. "When the resonance occurs, the cell can then be active or give a signal to the glands in the body to secrete hormones, because the health glands will be active only under certain conditions, such as sleep," this is the same when listening to the voice of the Qur'an. hormone secretion will be triggered because the glands in the body receive a signal. This condition will occur when therapy is carried out. Sound can also stimulate the pituitary gland to release more endorphins, which reduce pain and, therefore, can lower anxiety levels (Maulana, 2016).
Researchers used the Wilcoxon test to analyze the effect of Quranic sound therapy on reducing anxiety in cancer patients. The Wilcoxon test is an analysis that shows the relationship between one independent variable and one dependent variable (Lapau, 2012). By using the Wilcoxon test, the following test results were obtained. Based on the results of anxiety measurements before and after listening to Qur'an sound therapy for 24 respondents, there are differences or a decrease in anxiety. Before the distribution therapy of the patient's anxiety was, 10 people with moderate anxiety level and 14 people with severe anxiety level 19 became 1 person with moderate anxiety level, 5 people with mild anxiety level and 18 people were in normal condition. there is a decrease from before compared to after therapy, the effect of Quran sound therapy which can make it comfortable and calm is what makes the patient's anxiety less.
The results of the Wilcoxon test on the respondent's level of anxiety before and after therapy listening to the sound of the Qur'an have a significance value of p = 0.000. So that the significance value < alpha (0.000 < 0.05), then the hypothesis H1 is accepted. So it can be said that there is an effect of giving Qur'an sound therapy on the anxiety of cancer patients.

Conclusion
Based on the data obtained as well as from the discussion of the data, it can be concluded that there is an amazing potential that Qur'an sound therapy can reduce the anxiety level of cancer patients. The majority of cancer patients' anxiety levels before listening to Qur'an sound therapy are moderate and severe. The majority of cancer patients' anxiety levels after listening to Qur'an sound therapy are within the normal range