The Effectiveness of Providing Yoga Exercise Intervention with Islamic Spiritual Mindfulness Intervention on Anxiety Levels in Hypertension Patients at Ngoresan Health Center

ABSTRACT


INTRODUCTION
Hypertension imposes a staggering global burden on human quality of life and health care system resources by contributing to increased mortality and risks of cardiovascular disease, chronic kidney disease, and stroke globally.[1] It is estimated that the number of people with hypertension will reach 1.5 billion i.e, 30% of the world's population in 2025, based on an analysis of worldwide hypertension burden data.Hypertension is notoriously difficult to control, causing irreversible, permanent damage to essential systems in the body, such as the central nervous and cardiovascular systems.In addition to physical impacts, psychological disorders are also a significant concern among uncontrolled hypertensive patients.[2] Hypertensive patients who have had hypertension for a long time and are undergoing treatment will usually experience psychological changes, namely Anxiety.Anxiety experienced by hypertensive patients is manifested directly through physiological changes (trembling, increased heart rate, shortness of breath) and changes in behavior (Anxiety, startled reactions).Anxiety is a situation that is difficult to handle, and a natural human attitude forms the body's  186 response when facing a threat.[3] One of the efforts to overcome Anxiety is to get closer to one's religious beliefs and relax the body so that it becomes calmer.[4] Based on data from the World Health Organization (WHO) 2020 shows that the prevalence of hypertension in developing countries has reached 65.74% or reached 65 million people.[5] Based on the findings from Riskesdas 2018, it was found that the prevalence of hypertension in women (40.17%) was higher than in men (43.83%).The estimated number of people suffering from hypertension aged ≥15 years 2021 will reach 8,700,512 people, equivalent to 30.4% of the entire population aged ≥15 years.As many as 4,431,538 of them have received health services.[6] Hypertension is a form of non-communicable disease (PTM) that has the highest proportion among all types of PTM, which is reported to reach 70%.The number of cases detected in 2020 reached 26,875, with a significant increase in 2021 to 34,917.[7] However, efforts to deal with Anxiety in the elderly with hypertension in the community are not yet familiar with the interventions of yoga and Islamic spiritual Mindfulness.However, the advantages of yoga exercises are appropriate for the elderly in reducing Anxiety, which can make the body calm and relaxed.[8] Islamic spiritual Mindfulness is perfect for the elderly who are beginners in reducing [9]Anxiety.Interest in and use of complementary medicine approaches is increasing in the Western medical setting, with mind-body approaches such as yoga showing promise in relieving symptoms caused by hypertension medication.Yoga is a mind-body practice focusing on breathing, relaxation, and meditation.The benefits of yoga exercise are to improve health, quality of life, and Anxiety, depression.[10] One of the solutions to overcome anxiety disorders in the elderly is yoga movement training.Yoga is a type of exercise that combines movement with breathing.Yoga practice positively impacts physical health, emotional balance, and inner peace; this is also a type of physical activity recommended for the elderly.[11] 11 Doing yoga movements will affect the hypothalamus, thereby increasing the production of beta-endorphins, which are natural body compounds similar to morphine that contribute to emotional stability and feelings of calm.This calm and relaxed state greatly influences adequate quality sleep.[12] The Islamic spiritual mindfulness approach refers to methods of mind and body alignment (such as meditation and relaxation) to relieve Anxiety through Mindfulness.[13] The spiritual aspect refers to an individual's belief in their connection with the creator, Allah.Spiritual power in Islam has the potential to strengthen individual beliefs internally, thereby bringing inner peace.[14] This study aims to compare the yoga exercise intervention and the Islamic spiritual mindfulness intervention, which is more effective for reducing Anxiety in the elderly with hypertension.

METHOD
This research is quantitative; namely, the data processing is done statistically by comparing the differences before and after being given treatment.The design of this research is Quasi Experiment with Group Pretest-posttest Design.This study compared Group 1, yoga exercise, and Group 2, Islamic spiritual Mindfulness.
The population of this study was hypertensive elderly in the work area of the Ngoresan Health Center in 2022, totaling 443.The sample used was 60 l hypertensive elderly who met the inclusion criteria; a) Age 60-75 years and over, b) Hypertensive patients who have systolic blood pressure ≥140-169 mmHg and diastolic ≥90 -109 mmHg,c) Hypertensive patients who experience mild and moderate Anxiety, d) Are Muslim, e) Patients who are willing to be respondents.f) Patients who are not taking hypertension medication.
The research instruments were the DASS Anxiety Questionnaire, Yoga Exercise SOP, and Islamic Spiritual Mindfulness.Variable Operational Definitions in this study, namely Islamic Spiritual Mindfulness: Individual efforts in practicing self-awareness with a spiritual approach and involving Allah; this activity is carried out six times in 3 weeks with a time of 25-30 minutes.Yoga exercise: nonpharmacological therapy to relax the body to reduce Anxiety in patients, carried out for 30 minutes for six meetings in 3 weeks.Anxiety: The fear of something that is not certain to happen.Physical, psychological, and cognitive disturbances characterize the resulting reactions.
The data were analyzed using the Paired t-test to determine whether there was an influence on the intervention.The Independent t-test was used to compare which of the interventions of yoga exercise and Islamic spiritual Mindfulness was more effective.
Research ethics include informed consent, anonymity, confidentiality, and ethical consent.Ethical clearance in this study was carried out at 'Aisyiyah University, Surakarta, with a number.068/Ⅳ/AUEC/2023.  2 shows the results of Anxiety before being given intervention in the yoga group; the majority experienced mild Anxiety, as many as 21 people (70%).Whereas after being given the intervention, the majority of the standard yoga group was 20 0 people (66.7%).In the Islamic Spiritual Mindfulness group, before being given the intervention, the majority experienced mild Anxiety, as many as 20 people (66.7%).Whereas after being given the intervention, the majority became routine, as many as 26 people (86.7%).The statistical test results of the parried sample t-test showed an average value of Anxiety before the Yoga Exercise therapy was 55.33, and the average after being given the Yoga Exercise therapy was 26.33.These data were then analyzed using the Paired t-test with SPSS software to obtain a significant p-value value (0.000) <0.05.This means there are differences in the level of Anxiety in the elderly with hypertension, and Yoga Exercise therapy affects the level of Anxiety in the elderly with hypertension at the Ngoresan Health Center.Based on table 4 above shows that the average value of Anxiety before Islamic Spiritual Mindfulness therapy is 55.67, and the average after being given Islamic Spiritual Mindfulness therapy is 22.93.This data was then analyzed using the parried t-test with SPSS software to obtain a significant value.

RESULTS AND DISCUSSION
The statistical test results show that the p-value (0.000) is lower than the significance level (0.05).This indicates a significant difference in anxiety levels in the elderly with hypertension.In addition, Islamic spiritual mindfulness therapy also significantly influences the anxiety level of the elderly with hypertension who are at the Ngoresan Health Center.Based on the results of the Z test, which aims to find out the difference between 2 unpaired samples, sig (2-tailed) 0.039 <0.05, which means that there is a difference between the averages of the two therapies or the average difference between Yoga Exercise Therapy and Islamic Spiritual Mindfulness with Anxiety level.The average result for Yoga therapy is 26.33, and for Islamic Spiritual Mindfulness, the average result is 22.93.From these results, it can be concluded that Yoga Therapy is more effective than Islamic Spiritual Mindfulness Therapy.
The results of this study indicate that before the yoga exercise intervention was carried out in treatment group 1, the majority of the elderly who suffered from hypertension experienced Anxiety at a mild anxiety level, namely 21 people (70%).Meanwhile, in the moderate anxiety category, there were nine people (30%).Meanwhile, before the Islamic spiritual mindfulness intervention was carried out in treatment group 2, most older adults who experienced hypertension also experienced the same level of Anxiety, namely mild Anxiety by 20 people (66.7%) and moderate Anxiety by ten people (33.3%).
This research is supported by previous research conducted [15]using the Depression Anxiety Scale (DASS) score, which shows that most elderly experience a relatively mild level of Anxiety.The findings from this study are the results of research conducted, by [16]which revealed that the majority of the elderly experienced different levels of Anxiety, namely moderate anxiety levels in as many as 26 people (46.4%), high anxiety levels in as many as 21 people (37.5%), and severe anxiety level as many as two people (3.6%).Psychological effects during this period include post-traumatic stress disorder, confusion, Anxiety, frustration, fear of infection, sleep problems (insomnia), and feelings of helplessness.Several experts in psychiatry and psychology note that almost all types of mental disorders, from mild to severe, can potentially arise in this condition.
Based on the study results, there was a change in the average before the yoga exercise intervention from 55.33 to 26.33 after the exercise; there was a decrease in anxiety levels in the elderly population with hypertension.In treatment group 2, the average change before undergoing the Islamic spiritual mindfulness intervention was recorded from 55.67 to 22.93.after the Islamic spiritual mindfulness intervention, there was a significant decrease in the level of Anxiety in the elderly who experienced hypertension.
Based on the results of the study, an independent t-test was carried out to find out which is more effective between yoga exercise intervention and Islamic spiritual mindfulness intervention in reducing Anxiety in elderly hypertensives.Islamic Spiritual Mindfulness 22.93 From these results, it can be concluded that Yoga Exercise therapy is more effective than Islamic Spiritual Mindfulness Therapy.
The decrease in anxiety levels is the effect of the intervention of yoga and Islamic spiritual Mindfulness given six times for three weeks.The results of this study are in line with.[17] The elderly who experience Anxiety are advised to undergo yoga sessions because yoga combines various elements, such as breathing techniques, relaxation, meditating, and stretching exercises.All of these aim to relieve Anxiety and create peace of mind, as other studies have revealed.[18] Spiritual Mindfulness aims to help individuals achieve more profound calm and overcome Anxiety through a religion-based approach.This is by the theory explained by [19] who argue that applying Islamic spiritual Mindfulness can overcome and reduce Anxiety on a religious basis.As a result, Mindfulness has been shown to positively impact reducing Anxiety and providing inner peace.Another research conducted by [20] concluded that Mindfulness training with an Islamic approach can strengthen peace of mind and a healthy spirit of spirit.This finding aligns with the context of research involving the elderly who experience Anxiety due to hypertension.
The results of the analysis of anxiety level data before and after the intervention indicated that there was a significant difference.Therefore, the researchers concluded that the intervention had affected the level of Anxiety in the elderly with hypertension.In this study, the anxiety level of the elderly experiencing hypertension decreased.This factor can be attributed to a combination of yoga exercises involving body movements and Islamic spiritual mindfulness interventions that help achieve a state of physical relaxation and serenity.[21] This is also balanced with the activeness of the respondents and their routine in participating in yoga exercises and Islamic spiritual Mindfulness.

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The yoga exercise technique in this study places more emphasis on breathing.Breathing exercises and relaxation techniques are beneficial for creating calm and comfort, which in turn helps maintain the stability of the psychological condition of the elderly.[22]This relaxation method is in great demand by the elderly because it is considered safe to do and effective in reducing feelings of Anxiety by producing peace of mind.[23]A mindfulness approach that has a positive impact on individual mental health, especially for individuals who experience Anxiety.The symptoms of individuals experiencing Anxiety can decrease when an Islamic Spiritual Mindfulness intervention is carried out.[24] The effect of this intervention makes the individual experience a decrease in Anxiety.It can feel the well-being of the mind and soul, which in turn has a positive impact on the body's physiological health.Mindfulness training through Mindfulness was found to have a positive impact on physical health.[25] this study showed significant differences in anxiety levels through the intervention before and after the intervention group (p=0.000<0.05).
This yoga exercise can make a person reduce and overcome negative thought patterns that arise and develop in their minds.As a result, individuals will be able to reflect on their thoughts.[21] This yoga exercise technique also includes breathing control exercises.This exercise helps individuals manage their physical and mental conditions, thus creating a calmer state of mind and controlled emotions and producing a more stable response.[26] The process of individuals undergoing Islamic Spiritual Mindfulness therapy to overcome Anxiety will produce feelings of loving and compassionate Divine power.The heart (Qolbu) will reach a certain level of calm.In a physical context, in individuals who experience Anxiety, accepting views of resignation and trust in God can slow down the activity of the sympathetic nervous system.The depressing effect on the sympathetic nervous system will reduce the use of oxygen in the blood, which impacts the relaxing of the body's muscles.This state of relaxation can create a feeling of calm and comfort for the individual.Stimulation of relaxation in the muscles can also affect the hypothalamus to trigger the production of Corticotropin Releasing Factor (CRF).[27]

CONCLUSION
Before implementing Islamic Yoga and Spiritual Mindfulness interventions, most older adults who experienced hypertension faced anxiety levels in the mild and moderate categories.In contrast, none experienced Anxiety levels included in the severe category.After going through the intervention of Islamic Yoga and Spiritual Mindfulness, the majority of elderly who suffer from hypertension experience levels of Anxiety that fall into the standard category, and none are in the moderate category.There is a difference in the level of Anxiety in the elderly who suffer from hypertension before and after the intervention of Islamic Yoga and Spiritual Mindfulness at the Ngoresan Health Center can be observed.It is important to note that the Yoga Exercise intervention proved to be more successful in reducing anxiety levels in the elderly with hypertension than the Islamic Spiritual Mindfulness intervention.This study's results can be used as a guide in developing treatments related to Anxiety, hypertension, and health education efforts.This study shows that there is room for further research by extending the observation period for the hypertension variable, involving a larger sample, and applying a variety of research designs so that research results can be more diverse and beneficial to society.

Table 1
shows that most of the elderly in the yoga group are 19 women (63.3%).The majority in the Islamic Spiritual Mindfulness group are women, 26 people (86.6%).The elderly in the group are also women.Seventeen people (56.7%) are 60-65 years old; in the Islamic Spiritual Mindfulness group, the majority are 66-70 years old, and 13 people (43.3%).