Journal of Religion and Health

https://doi.org/10.1007/s10943-022-01664-9

ORIGINAL PAPER

The Effect of Listening to the Holy Qur’an and a Back

Massage on Fatigue and Quality of Life for Participants
Undergoing Hemodialysis: A Quasi-Experimental Study

Ade Komariah1 · Erna Rochmawati1

Accepted: 2 September 2022

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature
2022

Abstract
This study examined the effects of combining listening to the Holy Qur’an and back
massage on fatigue and the quality of life in participants undergoing hemodialysis
in Indonesia. This nonrandomized clinical trial was conducted in 40 patients (n = 20
intervention group, n = 20 control group). The FACIT-fatigue scale was used to
measure fatigue, and the KDQOL scale was used to measure quality of life. After
the intervention, the mean score on the FACIT-fatigue scale in the intervention
group was 36.7 ± 2.1, whereas it was 23.4 ± 5.8 in the control group. Likewise, while
the average KDQOL score was 61.2 ± 5.8 in the intervention group, it was 49.5 ± 8.6
in the control group. In the between-group comparisons, fatigue score was signifi-
cantly lower in the intervention group compared to the control group (p < 0.05), and
the between-group comparison also demonstrated a significant difference favoring
the intervention group. We conclude that the combination of listening to the Holy
Qur’an and back massage improve participant’s fatigue and quality of life.

Keywords Chronic kidney disease · Fatigue · Hemodialysis · Indonesia · Listening

to the Qur’an · Slow stroke back massage · Quality of life

Introduction

The global prevalence of chronic kidney disease (CKD) increases every year. A
majority of the participants with end-stage renal disease (ESRD) need maintenance
hemodialysis as renal replacement therapy (United States Renal Data System, 2014).
The need for dialysis has been predicted to double by 2030, from 2.62 million peo-
ple in 2010 (Liyanage et al., 2015).

* Erna Rochmawati
erna.rochmawati@umy.ac.id
1
School of Nursing, Universitas Muhammadiyah Yogyakarta, Kasman Singodimejo Postgraduate
Building, Level 2, Jl Brawijaya, Tamantirto, Bantul, Yogyakarta, Indonesia

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 Journal of Religion and Health

Participants undergoing maintenance hemodialysis experience a number of

associated symptoms. Fatigue and a low quality of life remain challenges for par-
ticipants with chronic kidney disease (CKD). Fatigue is one of the most com-
mon and most distressing symptoms of participants with CKD (Almutary et al.,
2016). The prevalence of fatigue increases as the CKD stages advance (Senanay-
ake et al., 2017). Approximately 70–80% of participants with CKD report fatigue
in the week prior to hemodialysis, with up to 25% reporting severe fatigue (Gregg
et al., 2021; Joshwa et al., 2020). Fatigue is associated with poor quality of life,
mortality, and hospitalization (Gregg et al., 2021).
Today, patients’ health-related quality of life is considered equally important
as other clinical outcomes (Chesnaye et al., 2022). Among participants undergo-
ing renal replacement therapy for advanced CKD, there are significant differences
in quality of life by treatment modality (Wilk & Lea, 2019). A previous study
identifies that the quality of life among participants undergoing hemodialysis is
lower than participants undergoing peritoneal and home dialysis (Chuasuwan
et al., 2020). Moreover, the physical and mental components summary of quality
of life can decline quickly (Chesnaye et al., 2022).
The clinical management of fatigue and quality of life is often neglected in
comparison with other non-invasive and visible symptoms of a disease. There
are several complementary and integrative therapy used to improve outcomes of
fatigue, including massages (Çeçen & Lafcı, 2021; Habibzadeh et al., 2020) and
aromatherapy (Ahmady et al., 2019; Karadag & Samancioglu Baglama, 2019).
Therapies that can improve the physical component and overall quality of life
include exercise (Rochmawati et al., 2021). Therapies to improve mental com-
ponent of quality of life in terms of anxiety and depression include listening to a
holy book and religious activities (Amir et al., 2022; Jabbari et al., 2020; Rafique
et al., 2019; Saged et al., 2020; Yadak et al., 2019).
Evidence on the effectiveness of massages on quality of life varies. Two studies
found that massages can improve fatigue but not significantly the quality of life
(Bullen et al., 2018; Habibzadeh et al., 2020), but another study shows massages
can improve quality of life (Döner & Taşcı, 2021). Quality of life, particularly the
physical and mental components summary, can decrease rapidly in participants
undergoing hemodialysis; complementary and integrative therapy should be able
to facilitate the improvement of these two components. However, a review of the
literature did not find any research that combined two interventions, a massage
and listening to the Holy Qur’an, to reduce complications in hemodialysis par-
ticipants. Therefore, given the complications and high costs of managing them,
the present study aimed to explore the impact of combining listening to the Holy
Qur’an and a massage on the severity of fatigue and quality of life of participants
undergoing maintenance hemodialysis. It is hypothesized that a combination of
slow stroke back massage and listening to the Holy Qur’an can reduce fatigue and
improve the quality of life of patients undergoing maintenance hemodialysis. Our
findings can inform strategies for healthcare professionals to reduce fatigue and
improve the quality of life to enhance the quality of care.

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Method

This study employed quasi-experimental design convenient sampling, a pretest

and posttest control group study to examine the effects of combination of listen-
ing to the Holy Qur’an and receiving a slow stroke back massage on fatigue and
quality of life among participants undergoing maintenance hemodialysis. The
study was conducted at the hemodialysis unit of a medical center in a central part
of Indonesia. To determine the sample size at a 95% confidence level and 80%
test power, with a mean difference of at least 0.72 and a standard deviation of
1.22 in the intervention group and 1.22 in the control group, based on the study
of (Habibzadeh et al., 2020), and according to the sample size formula, we deter-
mined a requirement of 20 participants in each group. Forty participants were
recruited and allocated to either the experimental group (n = 20) or the control
group (n = 20).
Participants were recruited if they were: (1) 18 years of age or over; (2) under-
going hemodialysis for a minimum of three months; (3) undergoing hemodialysis
twice a week; (4) diagnosed with a maximum of two comorbidities; (5) affiliated
to Islam; and (6) not hearing-impaired. Participants were excluded if they had
(1) a skin disorder, (2) muscle problems, and (3) unstable vital signs. A thorough
review of participant charts was performed to confirm they met the inclusion
and exclusion criteria. Participants then were randomly assigned to two different
groups based on their hemodialysis schedule.

Procedures

Experimental group (listened to Holy Qur’an and slow stroke back massage)

Participants in the intervention group received twice a week combination of lis-

tening to Holy Qur’an and back massage for three weeks. The interventions were
conducted during the first hour of hemodialysis procedure. The intervention session
included 15 min of listening to Holy Qur’an recitation and back massage with slow
strokes. The chapter (Surat) Ar-Rahman of the Holy Qur’an was recited by Muzam-
mil Hasballah. The Surat was chosen because the portion of Surat concentrate on the
Allah’s blessings to His creatures and the hereafter (reward and punishment). The
Surat gives a constant reminder for every Muslim to develop a loving disposition
toward Allah and His creatures. We chose the reciter because Muzammil Hasballah
is very popular among Indonesian Muslim for his heart-touching and relaxing voice.
The recitation was listened using an individual MP3 player with earphone for the
duration of 15 min. The loudness of the recital was adjusted to respondent’s prefer-
ence. The position of the respondent during the intervention was side lateral. During
listening the recitation, a slow stroke massage was conducted by the researchers who
were trained on conducting slow stroke back massage. The patients had 15 min of
a slow, gentle, and rhythmic hand movements on their back. The massage was con-
ducted at a steady speed with mild and gentle pressure.

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Control group

The same measurement of demographic characteristics (age, gender, and duration of

treatment with hemodialysis), fatigue, and quality of life as intervention group were
conducted from the control group. The measurement was conducted at baseline and
after the third week.
While the intervention group (n = 20) received a combination of listening to Holy
Qur’an and slow stroke back massage, the control group (n = 20) received standard
care without receiving the combination of listening to the Holy Qur’an and a slow
stroke back massage. The data collection flowchart is presented in Fig. 1.

Measures

The measurement of demographic and illness-related characteristics; the Functional

Assessment of Chronic Illness Therapy—fatigue (FACIT-fatigue) and Kidney Dis-
ease Quality of Life (KDQOL) were conducted at the baseline and after the third
week.
The FACIT-fatigue scale was used to measure participant fatigue. FACIT-fatigue
has 13 items to assess fatigue and its impact on functioning and daily activities in
a number of chronic diseases, with five-point response options from 0 to 4. The
total score ranges from 0 to 52, where a higher total score reflects less fatigue. The
items include tiredness, listlessness, weakness, lack of energy, and impact on daily

Fig. 1 Data collection flowchart for this study

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functioning such as sleeping and social activities. FACIT-fatigue has excellent

internal consistency and test–retest reliability (Wang et al., 2015). In the study, a
validated Indonesian version of FACIT-fatigue was utilized. This version has been
tested on 52 participants with CKD and has good internal reliability with a Cron-
bach’s alpha of 0.62 (Sihombing et al., 2016).
Quality of life was measured twice using the Indonesian version of the validated
KDQOL, before the intervention started and after the third week. KDQOL is a self-
administered questionnaire designed to measure the multidimensional perception of
health and functioning in participants with kidney disease. It has 43 items, with each
item scored from 0 to 4, and the total scale ranges from 0 (worst health) to 100
(best health). The KDQOL consisted of five scales including two generic of health-
related quality of life and three kidney specific scales (Burden of Kidney Disease;
Symptom and problems with Kidney Disease and Effect of Kidney Disease) (Peipert
et al., 2019). The Indonesian version of KDQOL was tested on 103 participants and
showed good internal consistency reliability, with Cronbach’s alpha at > 0.7 for all
scales (Supriyadi et al., 2019).

Statistical method

Statistical analyses were performed with SPSS version 23.0 (IBM Corp., Armonk,
NY, USA). Baseline information between experiment and control group for demo-
graphic and medical characteristics was compared by chi-square test for categori-
cal variables and independent t-test for continuous variables. The score difference
between experimental and control groups was evaluated with independent-samples
t-test; and the score difference between pre and posttest of the same group was eval-
uated with the paired-sample t test. Statistical significance was set at p < 0.05.

Ethical and research approvals

The hospital review board approved the study protocol (079/kep-PKU/II/2022). All
participants were asked to consent prior to participating in the study. This study was
conducted in accordance with the Declaration of Helsinki and was registered with
the Clinical Trial database (NCT05183815).

Results

A total of 40 participants were separated equally into the intervention and control
groups; none dropped out after three weeks of intervention (Fig. 1). The demo-
graphic and clinical characteristics of the study population are presented in Table 1.
Overall, there were no significant differences in the demographic and clinical-
related characteristics between groups. The data showed that 20 participants (50%)
were male, and 28 (70%) had an age ranging from 46–55 in both groups. More than

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Table 1 Participant demographic characteristics

Characteristic respond Control (n = 20) Intervention (n = 20) P value
Frequency (%) Frequency (%)

Age
36–45 years old 5 25 7 35 0.154a
46–55 years old 15 75 13 65
Gender
Male 10 50 10 50 1.000b
Female 10 50 10 50
Education Level
Primary school 15 70 15 75 0.875b
High school 5 25 5 25
Comorbid
Hypertension 14 70 14 70 1.000b
Diabetes mellitus 6 30 6 30
Length of receiving hemodialysis
< 12 months 6 30 7 35 0.187b
12–35 months 11 55 8 40
> 35 months 3 15 5 25
a
Independent t test to check difference between group for continuous variables
b
Chi-square analysis for gender, education, length of receiving hemodialysis, gender
All parameters showed nonsignificant difference

two-thirds (28, 70%) had hypertension, and 50% had been undergoing hemodialysis
for 12–35 months.

Outcomes

Fatigue

Table 2 shows there was significant change in participants’ fatigue in the experi-
mental group from baseline to the third week (p = 0.000). The results indicate that
listening to the Holy Qur’an and receiving a slow stroke back massage positively
influence fatigue between group (Table 3). In this sample, a significant difference in
improvement was found between the groups from baseline to week three (p = 0.000).

Quality of life

After three weeks of the intervention, there was a significant improvement in

the intervention in the total QOL p = 0.000 (Table 2). In week three, significant
differences between group in role limitation due to physical health, pain, health
perception in general, social function and energy were found between groups

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 Table 2 Paired sample t test in study with and without combination of back massage and listening to the Holy Qur’an
Measurement Intervention group (n = 20) Control (n = 20)
Journal of Religion and Health

Baseline After 3 weeks P value (95% CI) Baseline After 3 weeks P value (95% CI)

Fatigue 23.45 ± 5.85 36.70 ± 2.11 0.000 25.55 ± 4.17 23.45 ± 5.85 0.199
Quality of life
Overall 47.25 ± 7.29 61.20 ± 5.80 0.000 48.29 ± 7.09 49.50 ± 8.63 0.138
Physical health 56.25 ± 20.83 56 ± 13.92 0.930 57 ± 13.51 56.50 ± 15.57 0.880
Role limitations due to physical health 27.50 ± 21.31 51.25 ± 25.81 0.036 30 ± 26.41 35.00 ± 20.52 0.741
Pain 52.38 ± 26.30 94.38 ± 7.60 0.000 56.50 ± 29.14 52.88 ± 28.74 0.401
Health Perceptions in General 35..75 ± 26.30 63.75 ± 11.46 0.000 43.57 ± 10.75 44.50 ± 10.75 0.017
Mental health composite 52.60 ± 7.39 52.40 ± 12.84 0.950 51.80 ± 8.15 52.20 ± 7.40 0.679
Emotional composite 51.67 ± 36.64 41.67 ± 32.22 0.071 51.67 ± 29.57 56.67 ± 26.71 1.000
Social function 61.88 ± 26.74 73.13 ± 10.15 0.001 55.63 ± 20.47 55.00 ± 20.03 0.461
Energy 39.00 ± 17.29 57 ± 13.61 0.011 40 ± 15.131 43.25 ± 14.71 0.830

The comparison of fatigue and quality of life before and after intervention in case and control group, CI confidence interval, n number. FACIT-fatigue scale was used to
measure fatigue. KDQOL was used to measure quality of life

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Table 3 Independent t-test of fatigue and quality of life between intervention and control groups at post-
test
Domain Intervention group Control group Mean difference P value (95% CI)
(n = 20) Mean ± SD (n = 20)
Mean ± SD

Fatigue 36.70 ± 2.105 23.45 ± 5.85 − 13.25 0.000

Quality of life 61.20 ± 5.80 49.50 ± 8.107 − 11.7 0.000
Physical health 56 ± 13.92 56.50 ± 15.57 0.50 0.915
Role limitations due to 51.25 ± 26.25 35.00 ± 20.52 − 16.25 0.035
physical health
Pain 94.38 ± 7.60 52.88 ± 28.74 − 41.50 0.000
Health Perceptions in 63.75 ± 11.46 44.50 ± 10.75 − 19.25 0.000
General
Mental health composite 52.40 ± 12.84 52.20 ± 7.40 − 0.20 0.952
Emotional composite 41.67 ± 32.22 56.67 ± 26.71 15.00 0.117
Social function 73.13 ± 10.16 55.00 ± 20.03 − 18.13 0.001
Energy 57.00 ± 13.61 43.25 ± 14.71 − 13.75 0.004

The comparison of fatigue and quality of life before and after intervention in case and control group, CI:
confidence interval, n number. FACIT-fatigue scale was used to measure fatigue. KDQOL was used to
measure quality of life

(P < 0.005) (Table 3). There was no significant effect on physical health, mental
health composite, and emotional composite summary (Table 3).

Discussion

Fatigue is frequently reported by participants undergoing hemodialysis, often lead-

ing to lower quality of life. There is growing public concern about the clinical prac-
tice of improving fatigue and quality of life among participants undergoing hemo-
dialysis. Information about the effects of listening to the Holy Qur’an and receiving
a slow stroke back massage on fatigue and quality of life effectiveness is crucial
for providing more appropriate complementary and integrative interventions and
quality care. The study addressed a gap in the existing literature by examining the
effects of listening to the Holy Qur’an and receiving a slow stroke back massage
in the hemodialysis unit and finding a positive influence. To our knowledge, this is
the first study investigating the effectiveness of combining listening to Holy Qur’an
and slow stroke massage to fatigue and quality of life among patients undergoing
hemodialysis.
This study had an equal representation by male and female participants, which is
different from a previous study on veterans undergoing hemodialysis in the USA that
the majority of patients with CKD are male (Kurella Tamura et al., 2018). We found
70% of participants had hypertension, confirming the results of previous research in
Indonesia. Hypertension is prevalent among participants undergoing hemodialysis

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(Suhardjono. et al., 2019). Hypertension is closely related to CKD; it can be a result

or cause (Covic et al., 2017).
The average fatigue score in both the intervention and control groups indicated
severe fatigue, which is not surprising. Many studies have confirmed that partici-
pants undergoing hemodialysis had more fatigue than participants under other renal
replacement therapy (Joshwa et al., 2020). After three weeks of listening to the Holy
Qur’an and receiving a slow stroke back massage, the fatigue levels in the interven-
tion group decreased significantly and the effect size is strong (Table 2). The results
of the study are in accordance with previous studies that found that a slow stroke
back massage reduced fatigue in participants undergoing hemodialysis (Ahmadidar-
rehsima et al., 2018; Lazarus et al., 2020). While other studies combined slow stroke
massages with essential oil, the combination of listening to the Holy Qur’an, that
has been employed in our study, has shown similar benefits. Thus, combining the
two interventions has a stronger effect on improving fatigue.
Our study demonstrated that listening to the Holy Qur’an combined with a slow
stroke back massage twice a week leads to an improvement in participants’ fatigue
level. Some studies have reported that listening to sound can reduce fatigue (Alcân-
tara-Silva et al., 2018; Atkinson et al., 2020). Although, in their study, the inter-
vention is music therapy for participants undergoing radiotherapy (Alcântara-Silva
et al., 2018), such therapy can alleviate fatigue in participants with chronic illnesses.
A possible reason for a better fatigue scale is that listening to the Holy Qur’an cre-
ates a relaxation response in the body similar to when listening to music. A study
found that conscious listening to the Holy Qur’an increases the relative theta power
in most areas of the head, which means that the body relaxes (Vaghefi et al., 2015).
In the study, the average quality of life of the participants in both groups is poor
(Table 2). The findings confirm the results of previous studies such as Chuasuwan
et al. (2020) that the quality of life among participants undergoing hemodialysis is
lower than that of participants receiving other renal replacement therapy. Our study
demonstrated a strong improvement in the overall quality of life of the interven-
tion group after three weeks (Table 3). In previous studies conducted with differ-
ent participant groups, slow stroke back massage was found to increase quality of
life (Miladinia et al., 2016). Another study found that providing a massage to par-
ticipants undergoing hemodialysis can improve their quality of life (Döner & Taşcı,
2021). However, there are studies on massage that do not find such improvement
in quality of life (Bullen et al., 2018; Habibzadeh et al., 2020). While this study
matches the literature on slow stroke massage being effective for improving qual-
ity of life, the inclusion of listening to the Holy Qur’an contributes to an important
difference that results in a strong improvement in participants’ quality of life, par-
ticularly in the domain of pain, health perceptions in general, social function, and
energy. This may be due to the effect of listening to the Holy Qur’an. This result
is consistent with that of a previous trial demonstrating the significant effect of
combining listening to the Holy Qur’an and intradialytic exercises in quality of life
improvement (Frih et al., 2017).

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Study limitations

There are some limitations that need to be addressed. First, the experimental group
listened to the Holy Qur’an and had a back massage, thus it is difficult to determine
which intervention was responsible for the treatment effect. In addition, as the con-
trol group received no comparable interventions, the “Hawthorne effect” may have
occurred. Second, as the study was not a randomized controlled trial, other factors
may have been responsible for the treatment effects. Furthermore, we examined only
participants undergoing hemodialysis in a hemodialysis unit, and the results may not
be generalizable to other populations.

Conclusion

This study bridges a gap in the existing literature by examining the effectiveness of
listening to the Holy Qur’an and a slow stroke back massage in hemodialysis set-
tings. The combination of listening to the Holy Qur’an and massage is feasible for
use in participants undergoing hemodialysis because it causes no adverse reactions
and improves fatigue and quality of life. The participants’ self-reported improve-
ment in fatigue level, role limitation due to physical health, pain, social function,
and energy components delivers the hope that listening to Holy Qur’an and a slow
stroke back massage can be integrated into routine programs at the hemodialysis
units in Indonesia. We recommend including the procedures and theoretical princi-
ples of listening to the Holy Qur’an and a slow stroke back massage interventions in
health-care training and nursing care standard procedures, particularly in hemodi-
alysis nursing. It is necessary to conduct randomized controlled trials in the future
to determine whether the combination of listening to the Qur’an and back massage
is beneficial in improving quality of life and reducing fatigue in patients undergoing
hemodialysis.
Acknowledgements This study was part of a study funded by Institute of Research and Community
Development (LP3M), Universitas Muhammadiyah Yogyakarta. The authors thank the LP3M UMY.

Author contributions AK and ER made substantial contributions to conception and design, or acquisition
of data, or analysis and interpretation of data; AK and ER involved in drafting the manuscript or revising
it critically for important intellectual content; AK and ER gave the final approval of the version to be pub-
lished. AK and ER agreed to be accountable for all aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding This study received grant from the Institute of Research and Community Development (LP3M),
Universitas Muhammadiyah Yogyakarta, Indonesia, under the scheme of International Research Collabo-
ration (No 034/PEN-LP3M/II/2021).

Declarations

Conflict of interest No conflict of interest has been declared by the authors.

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