Effects Of A Combination Of Microscopic Handgrip And Nature's Voice On A Client's Blood Pressure With Hypertension

. Background: Hypertension is the number one cause of death in the world every year because it causes complex cardiovascular problems. Semarang City Department's 2023 health profile data shows the number of hypertension is 24,949. Practicing holding a handgrip is a non-pharmacological therapy for treating hypertension because it stabilizes blood pressure and heart rate. Many combination therapies are used, including combining handgrip exercises with sound waves. Natural sounds will stimulate the hypothalamus, resulting in a feeling of calm and have an effect on the blood pressure regulation mechanism. The aim of this study was to determine the effect of a combination of handgrip exercise and natural sounds on the blood pressure of clients with hypertension. This research method is a pre-experimental one group pre and post test design and sampling using purposive sampling technique. The population of this study were clients who were recorded as suffering from hypertension at the Sekaran Semarang Community Health Center. The research instrument uses a digital spygmomanometer and SOP for action. The research stages consist of preparation, implementation and processing of research data. The steps in the preparation stage are literature study, field survey, discussions with lecturers and experts, developing procedures for the combination of handgrip exercise and natural sounds, expert review, and socialization of the combination of handgrip exercise and natural sounds to clients and families. The implementation stage is carried out by collecting data on clients registered at the Sekaran Semarang Community Health Center, pre and post tests by measuring blood pressure using a spygmomanometer, implementing actions according to the prepared SOP, observing implementation using an observation sheet. In the data processing stage, a Paired Sample T-test was carried out to assess the effect of the combination of handgrip exercise and natural sounds on the blood pressure of clients with hypertension. The targeted output is publication in national journals indexed by Sinta and HAKI. The TKT target for this combination of handgrip exercise and natural sounds is level 2. The research results showed that 91.67% of respondents experienced an average reduction in systolic blood pressure of 10.69 mmHg and diastolic blood pressure of 6.11 mmHg. Based on the Paired Sample T-test, the results obtained were 0.000 for the systolic value and 0.001 for the diastolic value, both of which were smaller than the p value of 0.05, so it was concluded that there was an influence of the combination of handgrip exercise and natural sounds on the blood pressure of clients with hypertension. The results of this research can be input for related parties to implement a combination of handgrip exercise and natural sounds as non-pharmacological therapy for hypertension sufferers.


BACKGROUND
A family is a group of people who are related by marriage or birth, and have functions, one of which is health.A health case that is closely related to family function is hypertension.
The family has a role in the successful management of hypertension therapy, starting from daily diet, physical activity, and stress management.(1) (2) (3) Hypertension is the number one cause of death worldwide every year because it is a complex cardiovascular problem.(4) (5) Hypertension is known as the silent killer because sufferers are not aware that they suffer from hypertension.(6) Effects Of A Combination Of Microscopic Handgrip And Nature's Voice On A Client's Blood Pressure With Hypertension The World Health Organization (WHO) in 2023 stated that as many as 1.28 billion people worldwide, adults aged 30-79 years, experience hypertension, the majority (two thirds) live in low and middle income countries.(7) The prevalence of hypertension in the population in Central Java aged > 15 years in 2021 is 8,700,512 people or 30.4%.(8) Health profile data from the Semarang City Department in 2023 shows that the number of hypertension is 24,949.
(9) The percentage of hypertension which increases every year is a health problem that must be controlled to prevent continued complications that result in death.(10) Uncontrolled hypertension can cause long-term and potentially fatal complications, leading to decreased cognitive function and quality of life.(11) Pharmacological treatment for hypertension needs to be combined with non-pharmacological treatment.(12) (13) Handgrip training is one of the non-pharmacological therapies that is of interest for treating hypertension.
The form of exercise involves statically contracting the hand muscles without excessive movement of the muscles and joints.(10)  to combine the two therapies.This action aims to determine changes in elderly blood pressure before and after being given a combination of handgrip training and natural sound therapy, as well as increasing the role of the family and community in controlling hypertension rates.
Based on these problems, it is necessary to combine handgrip exercise and natural sounds as a solution to lower blood pressure in elderly people with hypertension.This research is in accordance with the research focus in the health sector, especially family nursing in the university's strategic plan.

LITERATURE REVIEW Family
A family is a group of two or more people who live together through marital ties and emotional closeness, each of whom identifies themselves as part of the family.(1) The function of family health care which consists of five main family tasks in family health care, including: 1) recognizing health problems that occur, 2) deciding on family actions regarding health, 3) providing care if someone is sick, 4) modifying conditions around the house, and 5) accessing health facilities.(21) If the health care function is carried out well, the level of family independence will increase and the family will be able to independently prevent and resolve problems, as well as improve health status independently.The family's ability to carry out the five family health care tasks illustrates the family's independence through coaching and guidance by professional nurses at the community health center or work area.(20)

Hypertension
Hypertension or high blood pressure is a chronic condition characterized by increased blood pressure on the walls of the arteries (22).Hypertension can be defined as persistent high blood pressure where the systolic pressure is above 140 mmHg and the diastolic pressure is above 90 mmHg.( 23)

Blood pressure
Blood pressure is the force of blood flow that the heart pumps against the walls of the arteries.(27) The normal increase in arterial pressure, namely up to 120 mmHg, is called systolic pressure which occurs when the heart contracts to pump blood and when the ventricles relax, the aortic pressure tends to decrease to 80 mmHg, which is called diastolic pressure.(28) Several factors can influence blood pressure, namely the pumping power of the heart, the amount of circulating blood, blood viscosity, elasticity of blood vessel walls, peripheral resistance, blood flow speed.Blood pressure measurements are carried out using a spygmomanometer.One of the spygmomanometers that is often used is a digital one with measurements according to Figure 1 below.( 23))

Figure 1 How to Measure Blood Pressure Practice Gripping Handgrips
The exercise of holding a handgrip (isometric handgrip) is an exercise that involves statically contracting the hand muscles without excessive movement of the muscles and joints.
This therapy is carried out using the resistance of a handgrip device.The effect of this exercise is to stimulate the ischemic stimulus mechanism and the tension causes muscle contractions in the blood vessels.This muscle tension activates nitric oxide in endothelial cells which is then transported to the muscles by diffusion.Nitric oxide then stimulates the production of guanylate cyclase which dilates blood vessels and relaxes smooth muscles.This exercise will improve blood circulation and reduce high blood pressure.(10) (11) Previous research suggests contraction (handgrip grip) using happyfit brand handgrips.The intervention was carried out for 7 days with 1 intervention per day.Each intervention carried out 2 contractions on each hand with a duration of 45 seconds.The movement to release the handgrip is carried out for 15 seconds between 2 hand contractions.Each exercise will be supervised by the author.Then blood pressure is measured after resting.(10) Clients are asked to position themselves as comfortably as possible..

Stages of Research
The design of this study is a pre-experimental one group pre and post test design between independent variables of a combination of handgrip exercise and natural sounds with variables bound to blood pressure.The stages of research consist of:

Research preparation stage
Research preparation starts from field surveys and research permits.

Research implementation stage
The implementation of the study was carried out by socializing the application of a combination of handgrip exercise and natural sounds to clients and families, determining the samples to be involved in the study with hypertension criteria with blood pressure >140/90 mmHg, subjects aged 36-55 years, can grip handgrips, did not experience hearing loss then TD measurements were carried out using a digital spigmomanometer as pretest data, the application of a combination of handgrip exercise and gamelan natural sounds was carried out for 30 minutes with 10 minutes of handgrip exercise followed by hearing 20 minutes of natural sounds in the respondent group, after that post test By remeasuring blood pressure 15 minutes post-therapy.Activities are carried out for 7 consecutive days.

Research data processing stage
Data processing is carried out after the research data is collected then data analysis is carried out using statistical tests.Based on inclusion criteria, researchers obtained 12 respondents .Table 3. showed that of the 12 respondents who participated in the study, the majority were women, namely 9 respondents (75%).Table 4 shows that of the 12 respondents involved in the study, the majority did not control nutritional intake according to the recommended hypertension diet, which was 9 respondents (75%).Table 6 shows that the blood pressure of respondents before treatment, the majority fell into the category of grade 1 hypertension, which was as many as 6 respondents (50%).

Characteristics of respondents based on the consumption of antihypertensive drugs
E-ISSN: 29621178-P-ISSN: 2962-0880, Page 63-78 Table 7. showed that the blood pressure of respondents after treatment, the majority fell into the category of grade 1 hypertension, which was as many as 5 respondents (41.67%).Table 9. showed that the diastolic TD of respondents after receiving treatment, the majority decreased by 11 respondents (91.67%).

C. Bivariate Results
The statistical test used to determine the effect of the combination of handgrip exercise and natural sounds in this study is the Paired sample T-test.This statistical test is used to determine the effect of the combination of handgrip exercise and natural sounds on lowering blood pressure both systolic and diastolic before and after treatment because based on the Shapiro-Wilk normality test all data are normally distributed.The Paired Sample T-test obtained a mean value of 6.11111, standard deviation of 4.51335, t table is 1.771, then the acceptance area of Ho is between -1.771 to 1.771.In this study the calculated t value is 4.690, then the calculated t value is > t table.The p value of the Paired Sample T-test result is 0.001 which is smaller than the error level (α) 0.05, so it can be concluded that the hypothesis of the effect of the implementation of a combination of handgrip exercise and natural sounds on reducing blood pressure in clients with hypertension in the Sekaran Health Center Target Area is accepted.

Characteristics of respondents by gender
The characteristics of respondents who participated in the study, the majority were women, namely as many as 9 respondents (75%).The incidence in men is generally higher than in women, but in middle age and later age, the incidence in women begins to increase.
caused by having to take drugs continuously.All respondents (100%) prefer therapy without drugs because they feel cheaper and safer.

B. Effect of Handgrip Exercise Combination on Blood Pressure Reduction in Clients
with Hypertension 1. Blood pressure of respondents before treatment The majority of respondents' blood pressure before the elderly exercise treatment was in the grade 1 hypertension category, namely 6 respondents (50%).Blood pressure naturally tends to increase with age (6).Increased blood pressure is influenced by various factors.Factors that cannot be controlled are heredity, gender, race and age, while factors that can be controlled include exercise, food, alcohol, stress, smoking and being overweight (7).
The degeneration process in the elderly causes changes and deterioration in the cardiovascular system.Changes that occur include reduced elasticity of blood vessels, heart valves become thick and stiff, the heart's ability to pump blood decreases by 1% every year after the age of 20 years (5).This situation is exacerbated by calcification as a result of longlasting fat deposition in the inner lining of blood vessels (8).The factors that played the most role in increasing blood pressure in respondents were food and activity.

Respondent's blood pressure after treatment
The majority of respondents' blood pressure after the elderly exercise treatment decreased into the grade 1 hypertension category, namely 5 respondents (41.67%).A total of 11 respondents (91.67%) experienced a decrease in systolic and diastolic blood pressure.There was 1 respondent with stable blood pressure before and after treatment.A decrease in blood pressure, both systolic and diastolic, occurred on the fourth and fifth days, however, because on the sixth day the respondent's eating pattern became increasingly uncontrolled, there was an increase in blood pressure again reaching pre-treatment levels.This is what caused the respondent's blood pressure to remain constant during the first exercise and the eighteenth exercise.

Reducing Blood Pressure in Elderly People with Hypertension
The results of statistical tests to determine the effect of the combination of handgrip exercise and natural sounds on reducing blood pressure are the Pired Sample T-test.The results obtained by the p value are 0.000 and 0.001, which is smaller than the error level (α) of 0.05.
So it can be concluded that the hypothesis that there is an influence of the combination of handgrip exercise and natural sounds on reducing blood pressure in hypertension sufferers in the Sekaran Community Health Center target area is accepted.
The decrease in respondents' blood pressure after receiving the combination of handgrip exercise and natural sound therapy was due to the isometric handgrip holding exercise, which is an exercise that contracts the hand muscles statically without excessive joint muscle movement.The effect of this exercise is to stimulate the ischemic stimulation mechanism and the tension causes muscle contractions in the blood vessels.This muscle tension activates nitric oxidants in endothelial cells which are then transported to the muscles by diffusion.Nitric oxide then stimulates the production of guanylate cylase which dilates blood vessels and relaxes smooth muscles.So this exercise will improve blood circulation and reduce high blood pressure.(28) Handgrip training is effective in reducing high blood pressure by improving oxidative stress and increasing resistant vessel endothelial function.Hypertension occurs due to impaired vasodilation in the blood vessels.One of the causes of impaired vasodilation is due to the endothelium lacking the availability of nitric oxide.Nitric Oxide is an Endothelial Derived Releasing Factor (EDRF) which has vasodilator properties to prevent Low Density Lipoprotein.(14) This exercise, when combined with therapy that utilizes sound waves, can optimize the post-exercise relaxation effect.Listening to music is the right choice to achieve a relaxed state so that it will reduce the stress and depression experienced.Music will stimulate the hypothalamus so that it will stimulate feelings of calm which will later influence the production of endocrine, cortisol and catecholamines in the blood pressure regulation mechanism.(19) This mechanism explains that natural sound music can reduce blood pressure or hypertension.This is also in line with research conducted by Noor Kholifah, Setyowati, Sri Karyati entitled "The Effect of Providing Natural Sound Music Therapy on Reducing Blood Pressure in Hypertension Sufferers in Pelang Mayong Village, Jepara".

C. Limitations
The number of samples obtained by researchers was relatively small for the size of experimental research.Researchers managed to get 17 respondents at the first meeting.Four respondents were included in the exclusion criteria because they were unable to follow the scheduled action routine during the 7 meetings in the study.The final sample size obtained by the researchers was only 12 respondents.Researchers also have not been able to control dietary factors that can influence blood pressure in this study.

Figure 3 .
Figure 3. Listening to Nature Sounds After Handgrip Exercise Researchers have conducted a study on the Effect of the Combination of Handgrip Exercise and Natural Sounds on the Blood Pressure of Clients with Hypertension in the Sekaran Health Center Target Area which was conducted on April 10 -May 20, 2023.

Table 5
. It showed that of the 12 respondents who participated in the study, all (100%) did not take antihypertensive drugs.B.

Table 10 . Decreased Systolic TD After Handgrip Exercise and Natural Sound Combination Treatment Paired Sample Test
The Paired Sample T-test obtained a mean value of 10.69444, standard deviation of 6.90697, t table is 1.771, then the reception area Ho is between -1.771 to 1.771.In this study the calculated t value is 5.364, then the calculated t value is > t table.The p value of the Paired Sample T-test result is 0.000 which is smaller than the error level (α) 0.05, so it can be concluded that the hypothesis of the effect of the implementation of a combination of handgrip exercise and natural sounds on reducing blood pressure in clients with hypertension in the Sekaran Health Center Target Area is accepted.2.Decrease in diastolic TD before and after treatment