PENUGASAN BLOK 4.

4 KESEHATAN MASYARAKAT
EVIDENCE BASED PUBLIC HEALTH (EBPH)

Disusun Oleh :
Hosea Jona Yuliada
18711157
Tutorial 9

Dosen Pembimbing :
dr. Nur Aisyah Jamil M.Sc

PENDIDIKAN DOKTER
FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM INDONESIA
YOGYAKARTA
2022
A. Kasus
Penggunaan Aromatherapy
Saat ini aromatherapy marak dijual di pasaran dengan berbagai bentuk.
Masyarakat beranggapan bahwa penggunaan aromatherapy ini memiliki efek
yang baik untuk berbagai masalah kesehatan. Perlu bukti ilmiah untuk
memastikan hubungan penggunaan aromatherapy ini dengan kesehatan.

B. Rumusan PICO

Population/Problem Masyarakat
Intervention Aromatherapy
Comparison -
Outcome Efek kesehatan
Tabel 1. Rumusan PICO

Pertanyaan PICO :
Apakah penggunaan aromatherapy memberikan efek kesehatan pada
masyarakat ?

C. Searching Method

Question Part Question Term Synonyms

Population/Problem Masyarakat Community People
Intervention “Aromatherapy” “Aromatherapy” “Aromatic”
Comparison - - -
Outcome Efek Kesehatan* Health effect* Health
impact*
Tabel 2. Sinonim kata

Key words :
(community OR people)
AND
(“aromatherapy”OR”aromatic”)
AND
 (helath effect*OR helath impact*)

Gambar 1. Menuliskan key words pada laman website https://pubmed.ncbi.nlm.nih.gov/advanced/

Gambar 2. Tampilan hasil pencarian

 Gambar 3. Pemilihan artikel jurnal

Gambar 4. Tampilan artikel jurnal yang terpilih

 D. Artikel Jurnal
FEATURE S

The Effect of Aromatherapy on Sleep Quality

and Fatigue Level of the Elderly
A Randomized Controlled Study
 Fa tm a G en ç, P h D , R N  S o n g ü l K a rad ağ , P h D , R N  N a za n K ılıç A k ça , P h D , R N
 Mehtap Tan, PhD, RN  Derya Cerit, MD

This randomized controlled experimental study was conducted to determine the effect of inhaled aromatherapy on
the sleep quality and fatigue level of the institutionalized elderly. The sample of the study consisted of a total of 59
Downloaded from http://journals.lww.com/hnpjournal by BhDMf5ePHKbH4TTImqenVDdo7Ixf7iD9iOtxgaVp6zeOXxasxIKHbZlnFDlXMj94 on 05/28/2020

elderly individuals (30 in the intervention group and 29 in the control group) who met the inclusion criteria and
agreed to participate in the study. Aromatherapy (lavender oil) inhalation was administered to individuals in the
intervention group half hour before their sleep every day for a month in accordance with aromatherapy protocol. No
administration was applied to the control group. The data were collected using the Elderly Description Form,
Pittsburgh Sleep Quality Index, and Fatigue Severity Scale. Forms were completed in the beginning of
administration and in the follow-up at the end of 4 weeks (baseline and last follow-up). In the study, it was
determined that aromatherapy administration improved sleep quality (P < .001) and decreased fatigue severity in
the elderly (P < .05). The study should be replicated in a different group. KEY WORDS: aromatherapy, elderly,
fatigue, nursing, sleep quality Holist Nurs Pract 2020;34(3):155–162

INTRODUCTION o f life n eg ativ e ly. 3 In a stu d y b y G ü m ü ş et a l, 4 it w a s

determined that the elderly were primarily diagnosed
Due to the aging of the world population, the gradual with poorer sleep patterns (60.6%), a reduction in
increase of the elderly population, and age-related social interaction (60.6%), and fatigue (54.5%).
physiological changes, a number of problems arise.1 Long-term sleep disorder may increase fatigue,
Aging brings challenges including chronic diseases, daytime sleepiness, depression, anxiety, irritability,
balance disorder, osteoporosis, urinary retention, and pain sensitivity and cause shivering,
urinary incontinence, orientation disability, fatigue, immunosuppression, reduced mental functions, and
and sleep disorders in the elderly.1,2 The elderly impaired general health and functional condition.5
frequently experience sleep problems due to chronic Thus, chronic sleep disorders and fatigue may become
diseases, pain, neurological and psychiatric disorders, a morbidity-related situation by decreasing the quality
which affect their general health condition and quality of life in the elderly. Older individuals need quality
sleep to maintain their optimum life quality and
protect their mental functions.6 Sleep quality
Author Affiliations: Department of Internal Diseases Nursing, Faculty of
H ea lth S c ie nce s, G iresu n U n ive rs ity, Turkey (D r G e n ç); D e p a rtm e n t o f
contributes to the individual feeling fit and ready for a
In terna l D isea ses N u rsing , Fac u lty o f H e alth S c ie nc es , Ç u k u rova U n ive rs ity, new day after waking.7
A d a na , Tu rkey (D r K a rad a ğ); D e p a rtm e n t o f In te rn a l D isea ses N u rs ing ,
F acu lty o f H ea lth S c ien ces , İz m ir B a k ırça y U n ive rs ity, İz m ir, Tu rkey (D r
Sleep problems may be treated by pharmacological
K ılıç A k ça ); D e p a rtm e n t o f In te rna l D ise as es N u rs in g , Fa c u lty o f N u rsin g , and nonpharmacological methods. Pharmacological
A ta tü rk U n ive rs ity, E rzu ru m , Tu rk ey (D r Ta n ); a n d O rd u A h m e t C e m a l treatments are usually based on the utilization of
M a ğd e n N u rsin g H o m e , O rd u , Tu rk ey (D r C e rit).
hypnotics (benzodiazepines: oxazepam, triazolam, and
The authors have disclosed that they have no significant relationships with,
or financial interest in, any commercial companies pertaining to this article. diazepam; and nonbenzodiazepines: zolpidem,
zaleplon, and ramelteon), melatonin receptor
C or re sp o n d en ce : S o n g ül K a ra d a ğ , P h D , R N , D e p a rtm e n t o f In te rn a l D is -
ease s N u rs ing , F ac ulty o f H e alth S c ie nce s, Ç u k u ro va U n ive rsity, 0 1 3 8 0 antagonists, and antidepressants.5 Pharmacological
Adana, Turkey (skaradag201778@gmail.com). treatments may cause various complications in the
DOI: 10.1097/HNP.0000000000000385 elderly. Therefore, it is important to investigate

155
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
156 HOLISTIC NURSING PRACTICE • MAY/JUNE 2020

alternative strategies for sleep management.8

Nonpharmacological approaches heal sleep problems
at the rate of 70% to 80% and could be used as a first
step of treatment especially in older individuals who
frequently experience drug interactions.9,10
Nonpharmacological methods for sleep problems
include a number of methods such as massage,
listening to music, progressive relaxation exercises,
phototherapy, and aromathearpy.9,11,12
Aromatherapy is a natural treatment in which
essential oils derived from plants are applied via
massage, friction, inhalation, compress, and bath. The
safest way of using essential oils is inhalation and
cutaneous administration.13 Lavender oil is among the
most commonly used essential oils. It has an
antiseptic, anti-inflammatory, pain-relieving, and
relaxing effect in general and prevents sleep FIGURE 1. Sample diagram.
problems.13-16
Insufficient and inadequate sleep is of particular
importance for the elderly in terms of a number of computer. According to the power analysis, α = 0.05
problems it causes. Nurses are members of the and β = 0.20, and the power of the study was
medical team who provide patient care continuously, calculated as 0.94.
determine problems first, administer medication, and
implement nonpharmacological treatment approaches Ethical aspect of the study
efficiently.
This randomized controlled trial was conducted to In order to conduct the study, an Ethics Committee
determine the effect of aromatherapy, applied to the A p p ro va l fro m th e E th ic s C o m m itte e o f A ta tü rk
elderly living in a nursing home via inhalation on the University Faculty of Health Sciences and a written
sleep quality and fatigue level. institutional permission, from the center where the
study was conducted, were obtained. Individuals who
were included in the study were informed about the
objective of the study and their informed consents,
METHODS both verbal and written, were received.

Study design and sample Data collection

This randomized controlled trial was conducted in a
n u rsin g h o m e (O rd u A h m e t C em al M a ğ d en N u rsin g
Home) located in a city center in Turkey. The
population of the study consisted of all elderly
individuals (65 years and older) (110) in the nursing
home. Thirty subjects did not meet inclusion criteria
and 21 subjects refused participation. The sample of
the study, on the other hand, consisted of a total of 59
individuals including 30 in the aromatherapy group
and 29 in the control group, and as a result of the
power analysis, it was concluded that the sample size
was adequate (Figure 1). Each older individual in
the sample group was given a number; the numbers
were entered into the computer and elder individuals
were separated into the aromatherapy and control
groups based on the randomization list on the
The data of the study were collected by using the
Elderly Description Questionnaire, Pittsburgh Sleep
Quality Index (PSQI), and Fatigue Severity Scale
(FSS) before starting the administration. The PSQI
and the FSS were completed again 1 month after the
administration.
The inclusion criteria of the study were as follows:
. Having inadequate sleep problem for at least 3
months
. PSQI score ≥ 5
. FSS score ≥ 5
. Full ability to smell
. Full ability to see
. Full ability to hear
. Being open to communication and cooperation
 The Effect of Aromatherapy on Sleep Quality and Fatigue Level of the Elderly
. Having no psychiatric history
. Agreeing to participate in the study
Exclusion criteria of the study were as follows:
. Using antidepressants, antihistamines,
diuretics, hypnotics, benzodiazepines, and
narcotic analgesics that affect the sleep
quality
. Being allergic to any odor
. Suffering from a respiratory disease such as
asthma and chronic obstructive pulmonary
disease
Termination criteria of the study were as follows:
. Developing an allergy or feeling unwell during
the procedure
. Withdrawing from the study
Group 1: 3% lavender oil was administered to
the aromatherapy group via inhalation. Two drops
of lavender oil were dripped on a×2 2-cm cotton
pad between 22.00 PM and 08.00 AM every night
for a month. The forms were also completed
before and after the administration.
Group 2: No aromatherapy was administered to
the control group. The forms were also completed
before and after the administration.
Elderly Description Questionnaire
Prepared by the investigators based on the literature
review,3,6,17 the questionnaire consists of 8 questions
including descriptive characteristics and sleep
features of the elderly.
Pittsburgh Sleep Quality Index—PSQI
The index was developed by Buysse et al18 and its
Turkish validity and reliability study was conducted
b y A ğ a rg ü n . 1 9 In th e stu d y, th e C ro n b a c h α va lu e o f
the index was found as 0.97. In the present study, on
the other hand, the Cronbach α value of the scale
was found as 0.82. The PSQI is a self-report scale of
19 items evaluating sleep quality and disorder. The
index consists of 7 subscales evaluating subjective
sleep quality, sleep latency, sleep duration, habitual
sleep efficiency, sleep disturbances, use of sleeping
medication, and daytime dysfunction.
Each item of the test is scored between 0 and 3 as
follows: 0 if none during the last month, 1 if less
than once a week, 2 if once or twice a week, and 3
if 3 or more times a week. In the questionnaire,
sleep quality is evaluated as very good (0), fairly
good (1), fairly bad (2), and very bad (3). Total
score varies between
157
0 and 21. A total score of 5 or higher indicates a
clinically poor sleep quality in a significant way.18,19
Fatigue Severity Scale—FSS
The FSS was developed by Krupp et al20 in 1988 for
measuring the fatigue severity in patients with multiple
sclerosis. The scale was adapted into Turkish by
Armutlu et al.21 The FSS was used to determine the
lev e l o f fatig u e in th e e ld e rly b y S oy u e r an d Ş e n o l. 2 2
The scale consists of 9 items and is a Likert-type scale.
Each question is scored between 1 (strongly disagree)
and 7 (strongly agree). The FSS score is the mean
value of 9 sections. A high score signifies an increased
fatigue severity. If the mean score in the FSS is 5 or
higher, it is evaluated as “fatigue is experienced.”20-22
Process
Control group
No aromatherapy was applied to the control group.
The Elderly Description Questionnaire, PSQI, and FSS
were administered by the researcher to the elderly in
the control group during the first follow-up. Their last
evaluations were made using the PSQI and the FSS
during the second follow-up 1 month later.
Study group
The Elderly Description Questionnaire, PSQI, and
FSS were administered by the researcher to the elderly
in this group during the first follow-up. Their last
evaluations were made by using the PSQI and the FSS
during the second follow-up 1 month later. As is seen in
Figure 2, the administration was conducted in
accordance with the administration protocol that was
designed by reviewing the literature. The administration
protocol was developed by reviewing the relevant
literature for lavender oil
inhalation.17,23,24 Lavender oil was administered after
being prepared by an expert aromatherapist. The
reason for choosing lavender oil in the aromatherapy
administration is that lavender oil is the least toxic oil
that is most frequently used for symptoms of sleep
problems, stress, anxiety, and fatigue in the
literature.17,23-28
During the administration, 2 drops of lavender oil
were dripped on a 2 ×2-cm cotton pad and placed on
a stand approximately 15 to 20 cm far from the nose
so that they could inhale it. The administration was
conducted between 22.00 PM and 08.00 AM by
considering the sleeping hours of the elderly. It was
continuously performed every day for a month. The
158 HOLISTIC NURSING PRACTICE • MAY/JUNE 2020
FIGURE 2. Aromatherapy practice guide.
researchers guided the elderly during all
administrations.
Aromatherapy administration
Lavender oil administered to the patients in the
aromatherapy group was supplied from essential oils
produced by the same company. The oils were kept in
dark-color glass bottles with (5 mL) drip caps. The
bottles were closed with safety caps that could only be
opened with a strong pressure so that the oils would
have no contact with air. The oils were kept under
proper conditions according to expert opinions.
During the study, routine treatments of patients in the
control and aromatherapy groups were not modified or
discontinued. Sleep and fatigue treatment was based
on aromatherapy according to the evidence-based
aromatherapy inhalation administration
guidance.17,23-28
Data assessment
The data acquired from the study were assessed using
the IBM SPSS Statistics 22.0 packaged software (IBM
Corp, Armonk, New York). While χ 2 and independent
Student’s t test were used to evaluate the distribution
of the data, independent Student’s t test to evaluate
PSQI and FSS scores obtained from the aromatherapy
and control groups and paired sample Student’s t test
to assess the differences before and after the
administration and Bonferroni in advanced analysis
were used. The value of P < .05 was accepted to be
statistically significant.
RESULTS
This study was completed with a total of 59 elderly
individuals including 30 in the aromatherapy group
and 29 in the control group. It was determined that
73.3% of the elderly individuals in the aromatherapy
group were male, 40.0% were primary school
graduates, 73.3% had at least one chronic disease,
96.6% woke up at least once at night, and 46.7% slept
in the daytime. Their average age was determined as
74.50 ± 6.62 and duration of staying in the institution
was 4.34 ± 3.77 years.
On the other hand, 86.2% of elderly individuals in
the control group were male, and 55.2% were primary
school graduates. In addition, it was determined that
75.9% had at least one chronic disease, 86.2% woke
up at least once at night, and 55.2% slept in the
daytime. Their average age was 72.00 ± 7.94 and
duration of staying in the institution was 2.78 ± 4.11
years. The aromatherapy and control groups were
similar in terms of these variables (P > .05). These
results showed that the groups had a homogeneous
distribution (Table 1).
It was determined that there was a significant
difference between PSQI and FSS pre-/posttest scores
 The Effect of Aromatherapy on Sleep Quality and Fatigue Level of the Elderly 159

TABLE 1. Descriptive and Disease Characteristics of Participants in the Aromatherapy and Control
Groups (n = 59)
Characteristics Aromatherapy Group (n = 30) Control Group (n = 29) Test P

Age, mean ± SD, y 74.50 ± 6.62 72.00 ± 7.94 1.315a

.194
Stay in institution, mean ± SD, y 4.34 ± 3.77 2.78 ± 4.11 1.518a
.134
Gender
Female 8 26.7 4 13.8 1.508b
Male 22 73.3 25 86.2 .219
Education status
Not literate 11 36.7 11 37.9 3.333b
Primary school 12 40.0 16 55.2
Middle school 7 23.3 2 6.9 .189
Chronic illness status
Yes 22 73.3 22 75.9 0.050b
No 8 26.7 7 24.1 .824
Waking at night
Yes 28 96.6 25 86.2 1.970b
No 1 3.4 4 13.8 .160
Daytime sleepiness
Yes 14 46.7 16 55.2 0.427b
No 16 53.3 13 44.8 .514

a
Independent t test.
b 2
χ analyses.

of the elderly in the aromatherapy group (PSQI: t =
5.370, P < .001; FSS: t = 2.443, P = .021).
Individuals’ sleep quality improved and fatigue
severity levels significantly decreased after the
aromatherapy administration (Table 2). It was
determined that there was no significant difference
between PSQI and FSS pre-/posttest scores of those in
the control group (PSQI: t = 0.189, P = .951; FSS:
t = 0.207, P = .838).
It was observed that there was a statistically
significant difference between the pretest and posttest
scores obtained by the elderly in the aromatherapy

TABLE 2. Pittsburgh Sleep Quality Index and Fatigue Severity Scale Subdimension Scores of the
Participants in the Aromatherapy and Control Groups
Aromatherapy Group (n = 30) Control Group (n = 29)
Scales Mean ± SD Mean ± SD Testa P

PSQI beginning 8.10 ± 3.13 8.17 ± 3.01 t = −0.478

.634
PSQI last follow-up 5.06 ± 2.51 8.00 ± 2.96 t = −3.669
.001
b
Test t = 6.474 t = 0.324
P < .0 0 1 .951
FSS beginning 4.66 ± 1.40 4.73 ± 1.22 t = −0.761
(2.32-6.41) (2.52-6.65) .450
FSS last follow-up 3.77 ± 0.68 4.66 ± 1.33 t = −2.531
(1.42-5.64) (1.93-6.56) .014
Testb t = 2.443 t = 0.207
P .021 .838

Abbreviations: FSS, Fatigue Severity Scale; PSQI, Pittsburgh Sleep Quality Index.
a
Paired sample t test.
b
Independent sample t test
160 HOLISTIC NURSING PRACTICE • MAY/JUNE 2020

group from the subscales of the PSQI (P < .05). It was
determined that there was a significant decrease in
elderly subjective sleep quality, sleep latency, sleep
duration, habitual sleep efficiency, sleep disturbances,
and daytime dysfunction, which are among the
subscales of the PSQI, after the aromatherapy
administration (P < .05). It was determined that there
was no statistically significant difference between the
pretest and posttest scores obtained by individuals in
the control group from the subscales of the PSQI
(P > .05) (Table 3).
DISCUSSION
Aromatherapy is one of the most frequently used
nursing practices in recent years because it has fewer
side effects than medication, provides the feeling of
well-being, and is low-cost.16 Studies on animals have
showed that some essential oils such as bergamot,
sweet orange, lemon, rose, cedar, and lavender have
sedative-soothing effects.28 Inhalation of hypnotic
essential oils is one of the effective and safe methods
in treatment of sleep disorders.13,28 There are many
studies indicating that lavender oil, one of the most
frequently used aromatherapy oils, is effective in the
solution of sleep and fatigue problems.24,29-34
However, there are a limited number of studies
investigating sleep and fatigue problems that are
frequently encountered in the elderly. This study
revealed the effect of aromatherapy, which was
administered to the elderly with lavender oil, on the
sleep quality and fatigue level.
In the present study, it was determined that
aromatherapy applied via inhalation to a sample of
elderly (59) nursing home residents who resided in the
nursing home for a month increased their sleep quality
and decreased their fatigue level. In their study, Joseph
and Joseph9 determined that aromatherapy applied to
the elderly via inhalation for 5 days enhanced sleep
quality.
In the study conducted by Ko 17 with 39 elderly
individuals in a nursing home, it was found that
lavender oil inhalation applied to the intervention
group before sleeping for 7 days increased sleep
quality. When examining the studies conducted in
different patient groups, it was determined that
aromatherapy applied to patients in the intensive care
unit with lavender oil enhanced sleep quality.29-32
Afshar et al33 conducted a study with 158 women in
the postpartum period and revealed that lavender oil
applied to the intervention group via inhalation for
8 weeks significantly increased the sleep quality of
women. These results support the results of the
present study. On the other hand, in the study
conducted by Lee24 with mothers in the postpartum
period, it was determined that aromatherapy applied
with lavender oil had no effect on sleep quality, sleep
duration, nighttime waking frequency, and sleep
satisfaction.
In this study, it was determined that aromatherapy
with lavender oil applied to the elderly decreased the

TABLE 3. PSQI Subscale Scores of the Participants in the Aromatherapy and Control Groups a
Aromatherapy Group (n = 30) Control Group (n = 29)
Beginning Last Follow-up Beginning Last Follow-up
PSQI Subscale Scores Mean ± SD Mean ± SD Testa P Mean ± SD Mean ± SD Testb P

Subjective sleep quality 0.76 ± 0.97 0.10 ± 0.30 3 .6 73 0.41 ± 0.62 0.24 ± 0.43 1.4 10
.00 1 .16 9
Sleep latency 2.10 ± 1.06 1.16 ± 0.79 4 .5 97 2.37 ± 0.90 2.34 ± 0.93 0.1 89
>.001 .85 1
Sleep duration 1.63 ± 0.96 1.16 ± 0.91 3 .1 20 1.72 ± 0.92 1.75 ± 0.95 −0.254
.00 4 .80 1
Habitual sleep efficiency 1.00 ± 1.17 0.60 ± 0.96 2 .3 50 0.93 ± 0.92 1.00 ± 100 −0.465
.02 6 .64 6
Sleep disturbance 1.26 ± 0.44 1.00 ± 0.37 2 .8 04 1.34 ± 0.48 1.44 ± 0.50 −1.00
.00 9 .32 6
Daytime dysfunction 1.23 ± 0.50 1.03 ± 0.18 2 .6 93 1.17 ± 0.38 1.13 ± 0.35 0.3 72
.01 2 .71 2

Abbreviation: PSQI, Pittsburgh Sleep Quality Index.

a
PSQI score differences: score taken from last follow-up subtracted from score taken from the baseline follow-up.
b
Paired sample t test.
 The Effect of Aromatherapy on Sleep Quality and Fatigue Level of the Elderly
fatigue severity. No study determining the effect of
aromatherapy on fatigue of the elderly was found;
on the other hand, the study conducted by Lee24 on
postpartum mothers indicated that aromatherapy
decreased the fatigue level. In the study conducted
by Muz and Tas¸cı34 with patients undergoing
hemodialysis, aromatherapy applied via inhalation
enhanced sleep quality and decreased fatigue
severity. In their study conducted with 60 nurses
working in shifts, Sihyun et al35 determined that
aromatherapy inhalation applied via lavender and
rose oil enhanced sleep quality and decreased
fatigue level.
Limitations of the study
In this study, short-term effects of lavender oil
inhalation were evaluated. Thus, it is possible to
state that lavender oil has short-term effects on sleep
quality and fatigue level. It is recommended studies
evaluating long-term effects of aromatherapy on the
elderly be conducted.
CONCLUSION
The effect of lavender oil inhalation, applied for
one month for 30 minutes before bedtime, on the
sleep quality and fatigue severity of the elderly
nursing home residents was evaluated:
. Sleep quality of elderly in the nursing
home increased.
. Fatigue severity of elderly in the nursing home
decreased.
The effect of lavender oil inhalation on sleep
quality and fatigue severity in the elderly in the
nursing home had not been investigated in Turkey
before, and in this study, it was observed to be
effective. Nurses who work in institutions can
utilize the noninvasive, inexpensive, safe, and easy-
to-apply aromatherapy administration for the
purpose of enhancing sleep quality and decreasing
fatigue severity of elderly within the scope of their
independent nursing roles because they evaluate the
general health of the
elderly.
In addition, it is recommended to conduct
double-blind randomized controlled studies on
this subject. The results of the studies and the
long-term effects can be evaluated within 6
months to
1 year.
161
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162 HOLISTIC NURSING PRACTICE • MAY/JUNE 2020
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E. Critical Appraisal

CASP Randomised Controlled Trial Standard Checklist:

11 questions to help you make sense of a randomised controlled trial (RCT)

Main issues for consideration: Several aspects need to be

considered when appraising a randomised controlled trial:

Is the basic study design

valid for a randomised controlled
trial? (Section A)

Was the study

methodologically sound?
(Section B)

What are the results? (Section

C)

Will the results help locally?

(Section D)

The 11 questions in the checklist are designed to help you think

about these aspects systematically.

How to use this appraisal tool: The first three questions (Section
A) are screening questions about the validity of the basic study
design and can be answered quickly. If, in light of your responses to
Section A, you think the study design is valid, continue to Section B
to assess whether the study was methodologically sound and if it is
worth continuing with the appraisal by answering the remaining
questions in Sections C and D.
Record ‘Yes’, ‘No’ or ‘Can’t tell’ in response to the questions.
Prompts below all but one of the questions highlight the issues it is
important to consider. Record the reasons for your answers in the
space provided. As CASP checklists were designed to be used as
educational/teaching tools in a workshop setting, we do not
recommend using a scoring system.

About CASP Checklists: The CASP RCT checklist was originally

based on JAMA Users’ guides to the medical literature 1994 (adapted
from Guyatt GH, Sackett DL and Cook DJ), and piloted with
healthcare practitioners. This version has been updated taking into
account the CONSORT 2010 guideline (http://www.consort-
statement.org/consort-2010, accessed 16 September 2020).

Citation: CASP recommends using the Harvard style, i.e., Critical

Appraisal Skills Programme (2021). CASP (insert name of checklist
i.e. Randomised Controlled Trial) Checklist. [online] Available at:
insert URL. Accessed: insert date accessed.

©CASP this work is licensed under the Creative Commons

Attribution – Non-Commercial- Share A like. To view a copy of this
licence, visit https://creativecommons.org/licenses/by-sa/4.0/

Critical Appraisal Skills Programme (CASP) www.casp-uk.net Part of OAP Ltd

Study and citation:
Genc F, Karadag S, Akca NK, Tan M, Cerit D. The Effect of Aromatherapy on
Sleep Quality and Fatigue Level of the Elderly A Randomized Controlled Study. Wolters
Kluwer Health: Holistic Nursing Practice. 2020;34(3):155-162.

Section A: Is the basic study design valid for a randomised controlled trial?

1. Did the study address a clearly Yes No Can’t tell

focused research question?
CONSIDER: 
 Was the study designed to
assess the outcomes of an
intervention? YES ->
 Is the research question
‘focused’ in terms of:
• Population studied
• Intervention given
• Comparator chosen
• Outcomes measured? YES ->

Pada bagian abstrak dijelaskan

bahwa penelitian ini dilakukan untuk
mengetahui efek dari inhalasi
aromaterapi pada kualitas tidur dan
tingkat kelelahan pada lansia. Bagian
abstrak juga menjelaskan populasi
pada penelitian ini adalah kelompok
lansia yang dibagi menjadi 2
kelompok variabel yaitu kelompok
intervensi (inhalasi aromaterapi) dan
kelompok kontrol (tanpa intervensi
apapun), penelitian ini tidak memiliki
pembanding, dan hasil pengambilan
data dengan menggunakan berbagai
macam teknik diukur menggunakan
perangkat lunak pengolah data statistic
dengan menunjukkan hasil bahwa
intervensi aromaterapi meningkatkan
kualitas tidur (nilai p value < 0.001)
dan menurunkan keparahan kelelahan
pada lansia (nilai p value < 0.05).

2. Was the assignment of participants Yes No Can’t tell

to interventions randomised?
CONSIDER: 
• How was randomisation carried
out? Was the method
appropriate? YES ->
 • Was randomisation sufficient to
eliminate systematic bias?
Can’t tell
• Was the allocation sequence
concealed from investigators
and participants? Can’t tell

Pengacakan partisipan dalam proses

pembagian 2 kelompok variabel
(intervensi aromaterapi dan kontrol)
dilakukan dengan cara setiap individu
lansia diberi nomor, lalu nomor
dimasukkan kedalam sistem komputer,
kemudian sistem komputer akan secara
otomatis membagi dan mengacak nomor
setiap individu lansia untuk dibagi
kedalam 2 kelompok variabel. Penelitian
ini tidak menjelaskan mengenai apakah
teknik mengacak yang digunakan akan
mengeliminasi kemungkinan adanya bias,
penelitian ini hanya menjelaskan bahwa
berdasarkan analisis kekuatan ukuran,
sampel pada penelitian ini adekuat.
Penelitian ini juga tidak menyebutkan
apakah urutan alokasi sampel
disembunyikan dari peneliti dan
partisipan.

3. Were all participants who entered Yes No Can’t tell

the study accounted for at its
conclusion? 
CONSIDER:
• Were losses to follow-up and
exclusions after randomisation
accounted for? NO ->
• Were participants analysed in
the study groups to which they
were randomised (intention-to-
treat analysis)? YES ->
• Was the study stopped early? If
so, what was the reason? NO ->

Seluruh partisipan yang telah

memenuhi kriteria inklusi dan ekslusi
serta bersedia mengikuti penelitian ini
berjumlah 59 orang lansia yang dibagi
dalam 2 kelompok variabel yaitu
kelompok intervensi aromaterapi dan
kelompok kontrol secara acak. Selama
penelitian berlangsung seluruh partisipan
mengikuti penelitian ini dari awal hingga
akhir sehingga tidak terdapat loss follow-
up dan eksklusi partisipan setelah data
hasil penelitian diolah, serta penilaian dan
pengolahan data setiap partisipan
dilakukan berdasarkan pembagian
kelompok variabel yang telah ditentukan
sebelumnya. Penelitian tidak berhenti
lebih cepat dari waktu yang telah
ditentukan dilakukan karena alasan
tertentu, walaupun peneliti telah
menentukan kriteria terminasi.
 Section B: Was the study methodologically sound?

4. Yes No Can’t tell

 Were the participants ‘blind’
to intervention they were 
given? NO ->
 Were the investigators ‘blind’ 
to the intervention they were
giving to participants? NO ->
 Were the people 
assessing/analysing outcome/s
‘blinded’? NO ->

Penelitian RCTs ini dilakukan

langsung oleh peneliti yang bersangkutan
tanpa ada ‘blind’ baik dari pihak peneliti
atau pihak partisipan dari kedua kelompok
variabel yang ada, Peneliti langsung yang
mengatur dan melakukan seluruh bentuk
administrasi pada setiap partisipan dari
awal hingga penelitian berakhir. Saran
dalam penelitian ini adalah agar penelitian
selanjutnya dapat menerapkan double-
blind randomized controlled studies pada
subjek penelitian ini.

5. Were the study groups similar at Yes No Can’t tell

the start of the randomised
controlled trial? 
CONSIDER:
 Were the baseline characteristics
of each study group (e.g. age, sex,
socio-economic group) clearly set
out? YES ->
 Were there any differences
between the study groups that
could affect the outcome/s? NO
 Karateristik dasar yang ditetapkan
berupa usia partisipan yang dikategorikan
sebagai lansia yaitu individu dengan usia
65 tahun atau lebih yang berada di panti
jompo tersebut. Kriteria inklusi, eksklusi
dan terminasi tetap diterapakan. Penelitian
ini juga menampilkan variasi karakter
lainnya dari partisipan yang terlibat.
6 Apart from the experimental Yes No Can’t tell
intervention, did each study group
receive the same level of care (that 
is, were they treated equally)?

CONSIDER:
 Was there a clearly defined study
protocol? YES ->
 If any additional interventions
were given (e.g. tests or
treatments), were they similar
between the study groups? NO ->
 Were the follow-up intervals the
same for each study group? YES
->

Protokol penelitian ini dijelaskan

dengan lengkap dan spesifik. Hal ini
dijelaskan pada bagian metode penelitian
mulai dari desain studi dan pengambilan
sampel, aspek etik, teknik pengumpulan
data, proses administrasi pada kedua
kelompok variabel (panduan pemberian
aromaterapi), dan teknik penilaian dan
pengolahan data penelitian. Termasuk
follow-up pada kedua kelompok variabel
dilakukan sama.

Selama penelitian ini berlangsung,

perlakuan yang diberikan kepada setiap
partisipan dari kelompok intervensi
aromaterapi dan kelompok kontrol tidak
terdapat modifikasi dan tidak terdapat
ketidakberlanjutan.
 Section C: What are the results?

7. Were the effects of intervention Yes No Can’t tell

reported comprehensively?

CONSIDER:
• Was a power calculation
undertaken? YES ->
• What outcomes were measured,
and were they clearly specified?
YES ->
• How were the results
expressed? For binary
outcomes, were relative and
absolute effects reported? YES
• Were the results reported for
each outcome in each study Penilaian dan pengolahan data dalam
group at each follow-up penelitian ini dilaoorkan secara spesifik
interval? YES -> dan lengkap untuk semua kelompok
• Was there any missing or variabel yang ada dengan menggunakan
incomplete data? NO software IBM SPSS Statistics 22.0.
• Was there differential drop-out Evaluasi distribusi data menggunakan χ2
between the study groups that dan independent Student’s t test untuk
could affect the results? NO mengevaluasi skor PSQI dan FSS pada
• Were potential sources of bias kedua kelompok penelitian sebelum dan
identified? NO sesudah intervensi serta mengevaluasi
• Which statistical tests were distribusi data. Bonferroni digunakan
used? -> dalam analisis lanjutan. Nilai P (p-value)
• Were p values reported? YES - < 0.05 diterima signifikan secara statistik.
>

Total sampel pada penelitian ini

berjumlah 59 orang lansia yang dibagi
dalam 2 kelompok variabel yaitu
kelompok intervensi aromaterapi 30 orang
lansia dan 29 orang lansia termasuk dalam
kelompok kontrol. Seluruh sampel
mengikuti penelitian ini dari awal hingga
 akhir sehingga tidak terdapat drop-out
serta tidak dilaporkan adanya bias.

Hasil penilaian dan perhitungan data

menunjukkan adanya perbedaan yang
signifikan pada skor pre-/postest PQSI
dan FSS kelompok lansia aromaterapi
(PSQI: t = 5.370, P < .001; FSS: t = 2.443,
P = .021). Kualitas tidur individu
meningkat dan tingkat keparahan
kelelahan menurun secara signifikan
setelah pemberian aromaterapi. Pada
kelompok lansia kontrol tidak terdapat
perbedaan yang signifikan pada skor
pre-/postest PSQI dan FSS (PSQI: t =
0.189, P = .951; FSS: t = 0.207, P = .838).

Subskala PSQI (P < 0.05) pada

kelompok lansia aromaterapi
menunjukkan adanya perbedaan yang
signifikan secara statistik antara skor
pretest dan postest sehingga dapat
ditentukan bahwa terdapat penurunan
yang signifikan dalam kualitas tidur
subjektif lansia, latensi tidur, durasi tidur,
efisiensi kebiasaan tidur, gangguan tidur,
dan disfungsi siang hari, setelah
pemberian aromaterapi. Tidak terdapat
perbedaan yang signifikan secara statistik
antara skor pretest dan postest dalam
kelompok lansia kontrol dari subskala
PQSI (P > 0.05).

8. Was the precision of the estimate Yes No Can’t tell

 of the intervention or treatment 
effect reported?

CONSIDER:
• Were confidence intervals (CIs)
reported? NO

9. Do the benefits of the experimental Yes No Can’t tell

intervention outweigh the harms
and costs? 

CONSIDER:
 What was the size of the
intervention or treatment effect?
 Were harms or unintended
effects reported for each study
group? NO ->
 Was a cost-effectiveness
analysis undertaken? (Cost-
effectiveness analysis allows a
Lokasi penelitian ini berada disalah
comparison to be made between
satu panti jompo di negara Turki dan
different interventions used in
penelitian serupa belum pernah dilakukan
the care of the same condition
di negara ini. Penelitian ini tidak
or problem.) NO ->
melaporkan secara spesifik mengenai efek
samping intervensi yang mungkin
ditimbulkan dan biaya yang dihabiskan.
Peneliti hanya menyampaikan bahwa
penggunaan aromaterapi murah, aman,
dan mudah diaplikasikan.

Section D: Will the results help locally?

10 Can the results be applied to Yes No Can’t tell

. your local population/in your
context? 
CONSIDER:
• Are the study participants
similar to the people in your
care? YES ->
• Would any differences
between your population and
the study participants alter the
outcomes reported in the
study? NO ->
• Are the outcomes important to
your population? YES
• Are there any outcomes you
would have wanted
information on that have not
 been studied or reported? NO
• Are there any limitations of
the study that would affect
your decision? NO

Partisipan dalam penelitian ini

memiliki karateristik dan masalah
kesehatan yang mungkin serupa dengan
masyarakat sekitar saya sehingga hasil
penelitian ini sangat penting bagi populasi
masyarakat disekitar saya yang memiliki
permasalahan kesehatan yang serupa.
Semua informasi yang ingin saya dapatkan
dijelaskan dalam laporan penelitian ini.

Terdapat keterbatasan dalam penelitian

ini yaitu dalam penelitian ini hanya
dilakukan studi untuk mengetahui efek
jangka pendek intervensi aromaterapi pada
lansia, sedangkan efek jangka panjang
intervensi aromaterapi pada lansia belum
dilakukan. Namun, keterbatasan ini tidak
membuat saya ragu untuk mencoba
menerapkan intervensi ini.

11 Would the experimental Yes No Can’t tell

. intervention provide greater
value to the people in your care 
than any of the existing
interventions?

CONSIDER:
 What resources are needed to
introduce this intervention
taking into account time,
finances, and skills
 development or training
needs? ->
 Are you able to disinvest
resources in one or more
existing interventions in order
to be able to re-invest in the Intervensi inhalasi aromaterapi lavender
new intervention? YES ->
dapat dilakukan oleh perawat dalam
lingkup peran keperawatan independen
mereka karena mereka mengevaluasi
kesehatan umum dari lansia. Tujuan
intervensi ini untuk meningkatkan kualitas
tidur dan mengurangi keparahan kelelahan
pada pasien lansia secara non-invasif (tidak
memerlukan keterampilan khusus), harga
aromaterapi yang relatif murah, dan mudah
diaplikasikan (tidak membutuhkan waktu
yang lama dalam intervensinya).
Mempertimbangkan kelebihan dan
kemudahan tersebut intervensi ini mungkin
untuk dapat dilakukan dalam ruang lingkup
yang lebih besar dan dilakukan secara
berulang kapan saja dan dimana saja.

APPRAISAL SUMMARY: Record key points from your critical appraisal in this
box. What is your conclusion about the paper? Would you use it to change your
practice or to recommend changes to care/interventions used by your organisation?
Could you judiciously implement this intervention without delay?

Setelah saya melakukan penilaian terhadap jenis studi Randomized Controlled

Trial meliputi berbagai macam aspek yang tertera dalam checklist critical appraisal
RCTs. Saya menyimpulkan bahwa artikel jurnal dengan sitasi sebagai berikut, Genc F,
Karadag S, Akca NK, Tan M, Cerit D. The Effect of Aromatherapy on Sleep Quality
and Fatigue Level of the Elderly A Randomized Controlled Study. Wolters Kluwer
Health: Holistic Nursing Practice. 2020;34(3):155-162. terpercaya, bernilai, dan
memiliki relevansi dengan konteks yang telah saya tentukan sebelumnya (rumusan
PICO). Hasil penelitian mengenai intervensi inhalasi aromaterapi lavender untuk
meningkatkan kualitas tidur dan menurunkan tingkat keparahan kelelahan pada lansia
ini suatu saat mungkin akan saya coba terapkan dan saya rekomendasikan untuk
dilakukan. Mengingat bagaimana kelebihan dan kemudahan dalam penerapan
intervensi ini ada kemungkinan intervensi ini akan sangat mudah untuk segera
diterapkan.