Improvement of Psychological Responses, Spiritual Responses,

and Cortisol Levels after Receiving Modification Psychoeducation

in Lepers

Cucu Herawati

, Agus Suwandon

, Suhartono Taat Putra

, Suhartono

, Hastaning Sakti

Syaeful Bakhri

and

Tia Karlina

Public Health Program, Sekolah Tinggi Ilmu Kesehatan Cirebon, Cirebon, West Java, Indonesia

Faculty of Doctor of Health Medical, Universitas Diponegoro Semarang, Central Java, Indonesia

Faculty of Dental Medicine, Universitas Airlangga Surabaya, East Java, Indonesia

Faculty of Public Health, Universitas Diponegoro Semarang, Central Java, Indonesia

Faculty of Psychology, Universitas Diponegoro Semarang, Central Java, Indonesia

Faculty of Sharia and Islamic Economics IAIN Syekh Nurjati of Cirebon, West Java, Indonesia

sakti.hasta@gmail.com, sultan01aulia@yahoo.com, tiakarlina20@gmail.com

Keywords: Anxiety, Cortisol, Lepers, Spiritual, Stigma.

Abstract: Prevention of Leprosy Stigma Based on the Stigma Reduction Guidelines of the International Federation of

Anti-Leprosy Associations (ILEP) has not been fully implemented into the Government's program efforts.

Several previous studies have not had interventions that aim to increase anxiety and spiritual impact due to

the stigma of leprosy. This study aims to increase spirituality, stigma, anxiety, and cortisol in leprosy patients.

Modification of psychoeducation is a development of psychoeducational intervention with intervention topics

consisting of knowledge management, relaxation, and prayer. The intervention was given in 5 sessions. This

study used a quasi-experimental design. The number of samples is 35 respondents. To see if there is a

difference in the mean before and after the intervention between the MP (modified psychoeducation), P

(psychoeducational), and K (control) groups, data analysis used the dependent T-test and time-series test.

Based on the research results obtained p-values in the MP group for spiritual response (0.0005), stigma

(0.002), anxiety (0.0005), and cortisol (0.374). Spiritual response, stigma, and anxiety scores in the MP group

experienced continuous improvement, and cortisol levels in the MP group decreased more gently than in the

P and K groups. Psychoeducational modifications increased spiritual response, perception of stigma, anxiety

levels, and cortisol levels compared with psychoeducational intervention. Psychoeducational modification

can encourage the proliferation of T lymphocytes, especially cytotoxic T (Tc) which is needed for the body's

resistance to leprosy to destroy cells infected with intracellular bacteria that can affect the leprosy healing

process.

1 INTRODUCTION

In addition to causing mental health problems,

leprosy stigma can cause delays in treatment, care,

healing and increase the risk of disability among

patients. (Wong, 2004) Based on a study conducted

in Indonesia, it was found that 931 (35.5%) of 1,358

leprosy patients experienced a perceived stigma

among patients, and 18-50% found stigma in the

community. (B.L Ajibade, Okunlade, J.O, Olawale,

2013) 60% of lepers were found to experience a

limitation in their life activities. (Lusli et al., 2016)

Based on the Cirebon District Health Office, 233 new

cases of leprosy were found in 2016, 230 new cases

were found in 2017, and 217 new cases were found in

2018. Based on the Cirebon District Health Office,

233 new cases of leprosy were found in 2016, 230

new cases were found in 2017, and 217 new cases

were found in 2018. (Dinkes Kabupaten Cirebon,

2018)

Based on Guidelines to Reduce Stigma of the

International Federation of Anti Leprosy

Associations (ILEP), Leprosy stigma prevention has

not all been carried out in the efforts of the

Government program. Two resources that are widely

Herawati, C., Suwandon, A., Putra, S., Suhartono, ., Sakti, H., Bakhri, S. and Karlina, T.

Improvement of Psychological Responses, Spiritual Responses, and Cortisol Levels after Receiving Modiﬁcation Psychoeducation in Lepers.

DOI: 10.5220/0010810400003347

In Proceedings of the 2nd International Conference on Psychological Studies (ICPsyche 2021), pages 193-201

ISBN: 978-989-758-580-7

193

used by people suffering from mental and physical

diseases are psychotherapy and spirituality. (Pearce et

al., 2015) The cause of leprosy stigma is an error in

various perceptions about leprosy, education, and

knowledge. (Stuart, GW, and Sundeen, 2005) Then

the intervention can be done with psychoeducation.

Psychoeducation therapy can improve psychomotor

attitudes and abilities in caring for clients of social

isolation. (Wiyati, 2007) Some groups believe that

leprosy is a judgment from God or the gods, as the

fault or sin of that lepers. (Rafferty, 2005)

Respondents refer to religion and spirituality as ways

of seeking health and protection in a sincere way to

leprosy stigma. (Peters et al., 2013) Some previous

studies showed no intervention aimed at solving

emotional problems such as anxiety due to the impact

of leprosy stigma, and there was no attempt to

manage the spiritual impact of leprosy stigma.

Cirebon is a palace area still attached to a distinctive

religious tradition and culture and endemic leprosy

area. The novelty in this study is that there are

psychoeducational intervention modifications that

have an impact on improving spiritual responses,

perceptions of stigma, anxiety levels, and decreasing

cortisol levels, which can encourage the proliferation

of T lymphocytes, especially T cytotoxic (Tc), which

is needed for the body's resistance to leprosy to

destroy infected cells intracellular bacteria that cause

leprosy. The research question is whether

psychoeducational modification can improve

spiritual response, perceived stigma, anxiety levels,

and cortisol levels in patients with leprosy. Thus, this

study aims to improve spiritual response, perceived

stigma, anxiety level, and cortisol levels among lepers

after psychoeducation modification.

2 METHOD

This research is quantitative research with a Quasi-

Experimental type of research with a pretest-posttest

design with a control group. The study began with

identifying the population, namely people with

leprosy who were receiving treatment (MDT); based

on the latest report at the time of the research, in 2018,

there were 217 cases. The comparison of cases and

controls in this study was 1:1, so the number of

samples for the treatment group was 12 respondents,

and the control group was 12 respondents. The

number of samples from 3 groups was 35 leprosy

patients who completed the entire series of studies.

The sampling technique used is cluster sampling and

simple random sampling. Data were obtained through

interviews through questionnaires and examinations

in the laboratory.

The questionnaires used in this study include the

perceived stigma questionnaire using the explanatory

model interview catalogue (EMIC), the EMIC

consists of 15 question items with 4 answer options.

According to the Hamilton Rating Scale For Anxiety

(HRS-A), the anxiety level questionnaire consists of

14 symptoms, each group being further detailed with

more specific symptoms. Moreover, a spiritual

response questionnaire consists of 3 components of

spiritual response components: patience, gratitude,

and sincerity. The spiritual response questionnaire

consists of 13 question items with 4 answer options.

Psychoeducational modification is the

development of the psychoeducational intervention,

which is one of group psychotherapy, with the aim

not only to increase knowledge and manage emotions

but also to increase the spiritual response of lepers,

with the intervention topics consisting of knowledge

management, relaxation, and prayer. At the same

time, the psychoeducational intervention provided

was only knowledge management and relaxation. The

intervention was given in 5 sessions and each session

for 60-90 minutes. Those who provide intervention

are leprosy programmers, psychologists, and experts

in the field of Sufism. The variables in this study were

psychological responses, namely levels of anxiety

and stigma, spiritual responses, and cortisol levels.

Statistical test using dependent T-test and time-series

test. This study was registered in the Health Research

Ethics Commission of the Faculty of Medicine,

Diponegoro University, Dr. Kariadi Hospital

Semarang with Ethical Clearance number:

525/EC/FK-RSDK/VII/2018.

3 RESULT

Based on the characteristics of study subjects (n=35),

the mean age of the respondents was 37.03 years, and

the mean treatment duration was 7.77 months. Most

of the respondents had elementary school education

(37,1%), had married (48.6%), and had an income of

< UMR (77.1), had a type of leprosy of MB (94.3),

and were not disabled (60%).

Table 1 showed that based on the paired T-test

results, the spiritual response score before and after

the intervention in post-test 2 was obtained p-value in

group MP of 0.0005, and the p-value in group P was

0.043. It can be concluded that there was a significant

difference in the spiritual response score between

before and after the intervention. While group K was

obtained a p-value of 0.084, it can be concluded that

ICPsyche 2021 - International Conference on Psychological Studies

194

Table 1: Difference Test of Spiritual Response and Perceived Stigma Scores (Pre and Post) among the 3 Groups of Lepers.

Time of Assessmen

MP=12 P=11 K=12 P-Value

Spiritual Response

P value

(pre-test an

-test 1)

0.0005* 0.180* 0.010*

P value

(pre-test and post-test 2)

0.0005* 0.043* 0.084*

P-value (time series)

0.003**

Perceived Sti

P value

(pre-test and pos

-test 1)

0.062* 0.451* 0.137*

P value

(pre-test and pos

-test 2)

0.002* 0.009* 0.054*

P-value (time series)

0.0005**

0.013**

0.190**

* Paired T-test ** Uji Friedman (seriestime)

MP= Psychoeducation Modification P= Psychoeducation K= Control

Figure 1: Graph of the mean scores of spiritual response before and after the intervention in the three groups.

response score between before and after the

intervention. Based on the paired T-test results, the

perceived stigma score before and after the

intervention in post-test 2 was obtained p-value in

group MP of 0.002, and the p-value in group.

Figure 1 shows the mean scores of spiritual

response before and after the intervention in group

MP which continued to increase. The mean score of

spiritual response in group P showed an increase, but

the increase was still below the mean score of

spiritual response in group MP, whereas a mean score

of spiritual response in group K in post-test 2 showed

an increase although it only showed a slight increase.

Figure 2 shows the mean scores in group MP the

mean score of perceived stigma decreased steeper

than group P. In group P, the mean score of perceived

stigma decreased. However, the decrease was not as

sharp as in group MP, whereas the mean score of

perceived stigma in group K continued to increase.

Table 2 showed, based on the paired T-test results,

anxiety level score before and after the intervention

in post-test 2, was obtained p-value in group MP of

0.0005, and the p-value in group P was 0.043. It can

be concluded that there was a significant difference in

the anxiety level score between before and after the

intervention, while in group K was obtained p-value

of 0.084, it can be concluded that there was no

Improvement of Psychological Responses, Spiritual Responses, and Cortisol Levels after Receiving Modiﬁcation Psychoeducation in Lepers

195

Figure 2: Graph of the mean scores of perceived stigma before and after the intervention in the three groups.

Table 2: Difference Test Results of Anxiety Levels Scores and Cortisol Levels (Pre and Post) among the 3 Groups of Lepers.

Time of Assessment MP=12 P=11 K=12

Anxiety Levels

P value

(pre-test and post-test 1)

0.0005* 0.180* 0.010*

P value

(pre-test and post-test 2)

0.0005* 0.043* 0.084*

P-value (series time)

Pre-test and post-test 1

Pre-test and post-test 2

0.0005**

0.180**

0.043**

0,010**

0.084**

Cortisol Levels

P value

(pre-test and post-test 2)

0,374* 0,174* 0,103*

* Paired T-test **Paired T-test (seriestime)

MP= Psychoeducation Modification P= Psychoeducation K= Control

difference in anxiety level score between before and

after the intervention. Based on the paired T-test

results, cortisol levels score before and after the

intervention in post-test 2, p-value in group MP of

0.374, p-value in group P was 0.174, and p-value in

group K was 0.103. Thus, it can be concluded that

there was no significant difference in the cortisol

levels score between before and after the intervention.

Figure 3 showed the mean scores of anxiety levels

before and after the intervention in group MP which

continued to decrease. The mean score of anxiety

level in group P showed a decrease, although the

decrease was still above the mean score of anxiety

level in group MP.

Figure 4 shows the mean score of cortisol levels

before and after the intervention, wherein the cortisol

levels in group MP, group P, and group K showed a

decrease. The decrease in cortisol levels in group MP

was slighter compared to group P and group K.

ICPsyche 2021 - International Conference on Psychological Studies

196

Figure 3: Graph of the mean scores of anxiety level before and after the intervention in the three groups.

Figure 4: Graph of the mean scores of cortisol levels before and after the intervention in the three groups.

4 DISCUSSION

4.1 Spiritual Response

In group MP, there was a significant difference in the

score of spiritual response between before and after

the intervention, while in group K there was no

difference between before and after the intervention.

Figure 1 shows the graph of spiritual response scores

before and after the intervention in group MP, which

increased steeper than in group P; it means that lepers

in group MP were able to adapt more quickly to

increase their spiritual response than group P received

psychoeducation only. At the same time, group K

increased post-test 2 because religious people can

learn from life experiences, even though it takes

longer. According to Maramis (2011), humans can

cope with the effects of stressors, called adaptability.

However, if this ability fails, there will be a disorder,

so individuals need help to bring homeostasis back in

this situation (Putra ST, 2011).

Relaxation of remembrance and prayer can widen

the walls of blood vessels that shrink due to anxiety

or stress. When remembrance occurs, a short shrink

of the brain blood vessels due to chemical response,

the supply of blood flow to the brain tissue decreases,

the brain immediately responds to this condition by

entering oxygen through the lungs to the brain

accompanied by a widening of the diameter of blood

vessels. Consequently, the supply of oxygen and

glucose into the brain tissue increased rapidly

(Anggraieni, Psikologi, Islam, & Mada, n.d.). The

results of this study are in line with previous studies,

which stated that evaluation of prayer interventions

after 1 month showed a decrease in anxiety and

depression, and spiritual states increased compared to

baseline measures among depressed and anxious

patients (Boelens, Reeves, Replogle, & Koenig,

2012) Various studies proved that one's level of faith

Improvement of Psychological Responses, Spiritual Responses, and Cortisol Levels after Receiving Modiﬁcation Psychoeducation in Lepers

197

was closely related to good immunity, physical or

mental (Hawari, 2016).

When someone always says positive sentences,

positive sentences are believed to generate positive

thoughts and emotions. Positive emotions can

stimulate limbic work to produce endorphins,

resulting in feelings of happiness and comfort and

improving one's mood to energize a person (Patimah,

S, & Nuraeni, 2015) Prayer and dhikr enhance

personalities such as optimism, toughness,

independence, and prominent personalities (Utami,

2017) Studies show that many patients believe

spirituality plays an essential role in their lives. There

is a positive correlation between the patient's

spirituality and health, meaning that if the patient's

spiritual state improves, his health will also get better

(Jamshidi, Seif, & Vazinigheysar, 2014)

Psychoeducation modification should be integrated

into the leprosy prevention program as a holistic

service that includes spiritual biopsychosocial

aspects. Psychoeducation modification can increase

intelligence and spiritual feelings, which impact the

suffering of the leprosy patient's body so that it is very

supportive of the leprosy healing process. (Cucu

Herawati, 2019).

Figure 2 shows the mean scores of perceived

stigma before and after the intervention in group MP

and group P, decreasing. However, in group P, the

decrease was not as steep as in group MP. Thus, it

indicated that group MP could adapt to the perceived

stigma better than those given only psychoeducation,

while group K, which only received MDT therapy

alone, tended to experience an increase in perceived

stigma. Group MP and group P obtained a p-value of

<0.005. It was concluded that there was a significant

difference in the score of perceived stigma between

before and after the intervention, while in group K the

p-value was 0.054.

According to Susanto (2006), the knowledge of

lepers is highly dependent on the level of education,

where the higher the level of education will affect the

process or pattern of thinking about something. (Putri

& Utomo, 2016) Psychoeducation can increase

knowledge about diseases to reduce the associated

stigma. Higher knowledge about the disease can

change the inherently perceived stigma. (Shin &

Lukens, 2002) The results of this study are in line

with several previous studies which stated that

respondents in the psychoeducation group had lower

values of an internal stigma than the control group

among patients with schizophrenia (Ivezic1, 2017)

and spirituality significantly mediated the negative

relationship between HIV stigma and psychological

health. (Burr, Brennan-Ing, Karpiak, Dugan, &

Porter, 2015) The effect of psychological stigma on

people can feel fear or shame, which can cause

anxiety and depression (van Brakel, Voorend,

Ebenso, Cross, & Augustine, 2011).

4.2 Anxiety Level

The results showed significant differences in anxiety

level scores between before and after the intervention

in group

MP and group P, whereas in group K there was no

difference in anxiety level scores between before and

after the intervention. Figure 3 shows a graph of the

mean level of anxiety before and after the

intervention in group MP which received

psychoeducation plus prayer that continued to

decrease. The mean score of anxiety level in group K

in post-test 2 showed a decrease. However, the

decrease was still above the mean score of group MP

and group P. This is because religious people can

finally take lessons from life experiences; patients can

slowly adapt to decrease the anxiety level. However,

if anxiety is left alone, no intervention will interfere

with the body's immunity. According to the theory

that anxiety is a response to affect disorders'

emotions, individuals who experience anxiety to the

level of panic can experience increased heart work

and become easily exhausted. These conditions will

worsen the immune response. (Nursalam, 2011).

Psychoeducation modification intervention in this

study was a relaxation technique, where a relaxation

technique helps regulate the emotional and physical

of individuals regarding stress, anxiety, and

depression. Physiologically relaxation provides a

relaxed response, can reduce blood pressure, promote

regular pulse and breathing, and loosen the muscles,

make the mind calm so that someone can think more

rationally. Remembrance and prayer to God can be

the heart energy, motivate the heart, and become

methods of realizing mental health (Rajab, 2013).

Psychoeducation reduces anxiety, depression, and

stress in pulmonary tuberculosis patients (Suryani,

Hernawati, & Sriati, 2016); prayer interventions can

reduce anxiety levels in preoperative patients

(Rahmayati El, 2018). The relationship between

religious coping and anxiety shows the importance of

spiritual and religious elements in managing anxiety

in HIV-positive patients (Tarakeshwar N, Hansen N,

Kochman A, 2005; Tapper L, Rogers SA, Coleman

EM, 2001).

ICPsyche 2021 - International Conference on Psychological Studies

198

4.3 Cortisol Levels

This study proved that psychoeducation modification

could reduce cortisol levels among lepers. Figure 4

shows the graph of the mean score of cortisol levels

before and after the intervention, the decrease in

cortisol levels in group P was steeper compared to

group MP. If it is continued, it has the potential to

pass faster than the lower limit of the normal range of

cortisol levels, so that it had a faster suppression

effect compared to group MP; thus the MP effect was

better. Cortisol has a normal range of a lower and an

upper limit; if cortisol rises within the normal limit,

an increase can lead to proliferation. If cortisol falls

within the normal limit, there is still proliferation but

slower. However, if cortisol is outside or below

normal values, it will suppress the proliferation of

lymphocytes, resulting in suppressed body

endurance. According to Purba (2011), stress causes

a decrease in unicellular function, and leukocyte

proliferation and activation of the natural killer cell

(NK) cytotoxic will be disrupted. The presence of

high cortisol levels in serum can result in decreased

quality and quantity of lymphocytes and the reduction

of the thymus and the lymphoid system functions.

(Putra, 2011).

Cortisol levels before and after the intervention in

the three groups were in the normal category; this

tendency was due to several factors, including the

length of treatment related to the length of knowing

the status of the disease. The mean duration of

treatment among lepers in this study was 8 months,

then the emotional reaction to stressors or leprosy

they had was in the depression or receiving

categories. The treatment duration will affect patients'

understanding and perception factors with the

consequences of the disease they suffer, thus causing

the cortisol levels of the three groups to be within

normal limits. The results of this study are in line with

the results of previous studies, which stated that

cortisol levels could be an indicator of the occurrence

of deviant behavior. Based on the results of the study,

it was found that all subjects had normal cortisol

levels. (Kartika Rita, 2015).

Women who received psychoeducation had

reduced cortisol levels at 12 months compared with a

control group of breast cancer patients. After

psychoeducational intervention with relaxation

techniques, there was no significant difference

between the cortisol levels in breast cancer patients

groups. (Phillips, K. MS, et al. l, 2008) Cortisol

responses to stress and anxiety varied because cortisol

may increase in response to acute stress or decrease

with chronic stress. (Carvalho et al., 2014)

Spirituality interventions are not related to cortisol

levels and symptoms of depression in HIV patients.

(Carrico et al., 2006) An abnormal cortisol condition

provides information that a person's psychological

abnormalities occur, allowing destructive behavior

changes (Shirtcliff & Essex, 2008).

The main finding in this study is that there is a

psychoeducational modification intervention that has

an impact on improving spiritual responses,

perceptions of stigma, anxiety levels, and decreasing

cortisol levels, which can encourage the proliferation

of T lymphocytes, especially T cytotoxic (Tc), which

is necessary for the body's resistance to leprosy to

destroy cells infected with intracellular bacteria that

cause leprosy so that it can affect the accelerated

healing process of leprosy he suffers. So it is

considered necessary to apply psychoeducational

modification interventions into the leprosy control

service program as a holistic service that includes

spiritual biopsychosocial.

5 CONCLUSION

There was a significant difference in spiritual

response scores (p = 0.0005), perceived stigma scores

(p = 0.002), anxiety level scores (p = 0.0005) between

before and after the intervention in the MP group.

There was no difference in cortisol levels before and

after the intervention in the MP group; the value of p

= 0.374 was obtained. The decrease in cortisol levels

in the MP group was slighter than in the P and K

groups. Psychoeducational modification is more

effective in improving spiritual response, perception

of stigma, anxiety levels, and cortisol levels

compared to psychoeducational interventions so that

it can encourage the proliferation of T lymphocytes,

especially cytotoxic T (Tc), which is needed for the

body's resistance to leprosy to destroy cells infected

with intracellular bacteria. The cause of leprosy, so

that it can affect the healing process of leprosy he

suffers.

The benefits of the results of this research are for

the development of science as material for the

development of holistic services that include

biopsychosocial spirituality from the results of

previous research so that it can enrich Hashanah

regarding overcoming the stigma of leprosy in the

community. Moreover, the practical benefits of the

results of this study are expected to improve the

quality of health service efforts comprehensively by

adding psychoeducational modifications to the

leprosy control program.

Improvement of Psychological Responses, Spiritual Responses, and Cortisol Levels after Receiving Modiﬁcation Psychoeducation in Lepers

199

ACKNOWLEDGMENTS

The author would like to express gratitude to all

respondents who have participated and contributed to

this study. Acknowledgement also to STIKes Cirebon

for the financial support and the Cirebon District

Health Office for the permission to conduct the study.

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