J Relig Health

DOI 10.1007/s10943-014-9997-x

ORIGINAL PAPER

The Effect of Holy Qur’an Recitation on Anxiety

in Hemodialysis Patients: A Randomized Clinical Trial

Hassan Babamohamadi • Nemat Sotodehasl • Harold G. Koenig •

Changiz Jahani • Raheb Ghorbani

Ó Springer Science+Business Media New York 2015

Abstract Kidney disease and its related psychological costs have significantly increased
in recent years. The aim of this study was to investigate the impact of Qur’an recitation on
anxiety in hemodialysis patients. Sixty hemodialysis patients were randomized to either
Qur’an recitation or a control group. Spielberger’s State-Trait Anxiety Inventory (STAI)
was completed by patients at baseline and 1 month afterward. The intervention involved
listening to the recitation of the Qur’an in traditional cantillation voice. The control group
received no intervention. The data were analyzed using Student’s t test and general linear
models. Recitation of the Qur’an was effective in reducing anxiety in the intervention
group, decreasing STAI score at baseline from 128.5 (SD = 13.0) to 82.1 (SD = 11.3),
compared to the control group which experienced no change in anxiety scores from
baseline to follow-up (118.3, SD = 14.5, vs. 120.1, SD = 14.4, respectively. Between-
subject comparison at follow-up, after adjusting for baseline differences, indicated a sig-
nificant reduction in anxiety in the intervention versus the control group (F = 15.5,

H. Babamohamadi
C. Jahani
Nursing Department, Nursing and Allied Health Faculty, Semnan University of Medical Sciences,
5 Kilometer of Damghan Road, PO Box 3513138111, Semnan, Iran

N. Sotodehasl (&)
Psychiatry Department, Nursing and Allied Health Faculty, Semnan University of Medical Sciences,
5 Kilometer of Damghan Road, PO Box 3513138111, Semnan, Iran
e-mail: Sotodeh1@yahoo.com

H. G. Koenig
Center for Spirituality, Theology, and Health, Duke University Medical Center, Busse Building, Suite
0505, Box 3400, Durham, NC 27710, USA

H. G. Koenig
King Abdulaziz University (KAU), Jeddah, Saudi Arabia

R. Ghorbani
Research Center for Social Determinants of Health, Community Medicine Department, Faculty of
Medicine, Semnan University of Medical Sciences, 5 Kilometer of Damghan Road,
PO Box 3513138111, Semnan, Iran

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p = 0.0002, Cohen’s d = 1.03). Listening to the Holy Qur’an being recited is an effective
intervention for anxiety in patients undergoing hemodialysis in Iran.

Keywords Holy Qur’an recitation
Music
Anxiety
Hemodialysis
Iran

Introduction

End-stage renal disease (ESRD) is a major public health problem throughout the world,
which imposes a heavy economic burden on communities (Rahimi et al. 2008). In this
disease, the kidneys are not able to perform metabolic functions and cannot maintain fluid
and electrolyte balance in the body, leading to uremia. People with this disease initially
undergo medical treatment but often eventually require dialysis (Asgari and Soleimani
2013; Smeltzer et al. 2010). Hemodialysis is the most common treatment method for
ESRD worldwide and in Iran (Mahadavi Mazdeh et al. 2006). The number of kidney
patients in Iran has expanded dramatically in recent years, increasing by 15 % per year
(Sajjadi et al. 2008). Psychological problems, especially anxiety disorders, are prevalent in
these patients (Finkelstein et al. 2002; Biris et al. 2002; Kimmel 2002). According to
Navidian et al. (2006), dialysis is a stressful process and results in numerous social and
psychological problems. Finkelstein and Finkelstein (2000) reported that 25 % of
hemodialysis patients had psychological problems; of those, 48.5 % were suffering from
depression and 38.1 % from anxiety. Nazemian et al. (2008) also reported that 51.4 % of
dialysis patients were suffered from anxiety and that 49.7 % of these patients had hidden
anxiety. Likewise, in a study of patients with chronic renal failure, Drayer (2006) found
that anxiety disorder was present in 14.6 %.
To address this anxiety, in addition to drugs and psychotherapy, alternative therapies
have been used such as aromatherapy, relaxation, Hatha yoga exercises, and music therapy
(Imanishi et al. 2009; McCaffrey et al. 2009; Fitzgerald et al. 2007). Such methods are
increasingly common in medical and health-care centers due to cost-effectiveness, sim-
plicity, and limited side effects. Previous studies have emphasized the use of music as a
complementary therapy, especially for chronic diseases (Vahabi 2003; Ostadkelayeh et al.
2005; Smolen et al. 2002; Aragon et al. 2002; Chang and Chen 2005; Sendelbach et al.
2006). One type of ‘‘music therapy’’ is the sound of the words when the Holy Qur’an is
recited. To Muslims, this sound is deeply spiritual and is described as one of the greatest
miracles of the Qur’an (Majidi 2004).
The Holy Qur’an describes the purposes and obligations of Muslims throughout its
chapters and verses, which seek to educate and transform readers through recitation. The
Qur’an refers to itself as a book of healing: ‘‘We have sent down in the Qur’an that which
is healing and a mercy to those who believe’’ (17:82).
Prophet Mohammad (P) stressed the importance of reading the Qur’an aloud (Qur’an
recitation) versus silently: ‘‘The comparison between a silent reader and a recitor (Qari) is
like a bottle of perfume when it is closed and when it is opened.’’ Recitation of Qur’an by
the sick person or for the sick person has shown to have a direct healing effect on the sick
person (Kamali 2005). El-Kadi reported that listening to the recitation of Holy Qur’an was
associated with lower blood pressure, slower heart rate, and smooth muscle relaxation in
Muslim Arabs, non-Arab Muslims, and even in non-Muslims (El-Kadi 1985).

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Several studies have found that listening to music may be an effective and safe inter-
vention for complications caused by variety of diseases and can reduce stress, irritability,
and feelings of loneliness and improve mood (Guétin et al. 2009; Karimi et al. 2012; Kim
et al. 2006; Mirbagher Ajorpaz et al. 2012; Nanbakhsh et al. 2009; Sheibani Tazraji et al.
2010; Zare et al. 2009). For example, Mirbagher Ajorpaz et al. (2012) found a reduction in
anxiety and average systolic blood pressure in an intervention group that listened to music,
compared with those in the control group. Nanbakhsh et al. (2009) also found that listening
to relaxing music could reduce pain and anxiety in pregnant women at the time of delivery.
Likewise, Vahabi (2003) reported that listening to music reduced anxiety in patients who
had been admitted to the intensive care unit. Among hemodialysis patients in particular,
Kim et al. (2006) found that music therapy was helpful in reducing anxiety.
Although several studies have found positive effects of music therapy on psychological
disorders, other studies have questioned the effects of music on patients’ anxiety (Gaberson
1995). For example, Gaberson and colleagues found no significant relationship between
listening to music and anxiety in patients undergoing elective surgery (Gaberson 1995).
Likewise, Zimmerman and associates found that listening to music by patients undergoing
coronary artery bypass surgery did not significantly decrease their anxiety in patients
(Zimmerman et al. 1996). Finally, Cruz and colleagues reported that music had no effect
on reducing anxiety in older patients undergoing cataract surgery (Cruise et al. 1997).
Several studies from Iran (reported in Persian journals) have reported that reciting the
Qur’an, which may be considered a form of music as it is read aloud by the reader, was
effective in reducing anxiety in a variety of settings (Majidi 2004; Heidari and Shahbazi
2013; Akbari et al. 2012).

Objective

Many of the studies reviewed above focused on the effect of instrumental music (sound) on
anxiety and did not pay much attention to the words of the music. Given the limited
number of studies that have examined the effects of reciting the Holy Qur’an on the anxiety
of hemodialysis patients, we sought to examine the effect of the Qur’an recitation on
reducing anxiety in this patient population. We hypothesized that hearing the words and
content of the Qur’an, along with the sound created by its recitation in the traditional
cantillation voice by a Shateri reader, would have a therapeutic effect on anxiety.

Methods

Sixty hemodialysis patients admitted to the hemodialysis ward at Shahid Mahalati Hospital
in Tabriz, Iran, were enrolled into the study if they met the following inclusion criteria:
willingness to listen to the Qur’an recitation, consent to participate in the study, aged
18–65 years, history of at least 6 months of hemodialysis, fully conscious, hemodynami-
cally stable, not taking benzodiazepines or antidepressant drugs, and not having any acute
psychological complications. Exclusion criteria were mental retardation, hearing impair-
ment, experiencing a traumatic event in the past 6 months, history of mental illness or
psychiatric hospitalization, and physical illness severe enough to prohibit the patient from
participating. Eligible subjects were then randomized (by a coin toss) to either the Qur’an
recitation group or the control group.

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Two questionnaires were administered at baseline. The first was a demographic ques-
tionnaire that asked about age, gender, marital status, presence of children in the home,
financial status, quality of sleep, education level, and duration of hemodialysis. The second
questionnaire was the Spielberger State-Trait Anxiety Inventory (STAI), a widely used
measure of anxiety symptoms. The first section of the questionnaire (20 items) measures
‘‘state’’ anxiety, and the second section (20 items) assesses ‘‘trait’’ anxiety (Kim et al.
2006; Roohy et al. 2005). Each question was rated on a four-point Likert scale from ‘‘very
low’’ to ‘‘high,’’ and summing up individual item scores in each section produces a pos-
sible score range from 20 (low anxiety) to 80 (high anxiety). Scores from 20 to 39 for each
section indicate mild anxiety, 40–59 indicate moderate anxiety, and 60–80 reflect severe
anxiety (Behdani et al. 2000). This tool is easy to use and takes less than 5 min to
administer (Bassampour 2005). The internal reliability (Cronbach’s alpha) of the Persian
version of the state and trait anxiety subscales has been reported as 0.91 and 0.90,
respectively, in a group of 600 medical patients, and 0.94 and 0.90 in a second group of
130 medical patients (Mahram 1994). In a third study, Cronbach’s alpha was 0.91 on both
state and trait scales (Abolhasani 2007). A license to use the STAI in this study was
purchased from Mind Garden, Inc. (http://www.mindgarden.com/products/staisad.htm).
The STAI was completed at two time points. First, it was administered at baseline
before the start of a dialysis treatment and then a second time 1 month later. The inter-
vention group (n = 30) listened to a recitation of the Qur’an using an established protocol
(Guétin et al. 2009; Zare et al. 2009), whereas the control group (n = 30) received no
intervention. Surah Yasin from the Holy Qur’an was recited by a Shateri reader. This surah
was selected following consultation with theological experts on the Holy Qur’an. Surah
Yasin is the 36th surah of the Qur’an and is considered the ‘‘heart’’ of the Qur’an in many
narratives. Shateri is a reader (Qari) of the Holy Qur’an who reads with a relaxing and
calming voice. This is the most common way that people in Iran listen to the Qur’an being
recited and would be familiar to dialysis patients living and raised in this part of the world.
Participants listened to these verses three times a week for 1 month, each time for
20 min (5 min before dialysis and continued until 15 min after the start of dialysis). The
verses were played via MP3 players with headphones. After 1 month, those in the inter-
vention and control groups completed the STAI a second time. This trial was registered in
the IRCT (registration number 201312108665N2) and was approved by the university
ethics committee (No. 92/388666, 2014/01/07).

Statistical Analyses

Descriptive statistics were used to summarize characteristics of the sample at baseline.

Student’s t test and Chi-square statistic were used to compare sample characteristics
between intervention and control groups at baseline. Student’s t test was also used to
examine between-subject differences between STAI subscale scores and total score at
baseline and follow-up. A repeated measures general linear model (mixed factorial
ANOVA) was constructed with time 1 and time 2 STAI scores on the left side of the model
and group (intervention vs. control) and baseline covariates (p \ 0.20) on the right side of
the model. The partial eta-square for group (effect size) from the model was converted to
Cohen’s d (for comparison with past and future studies). The significance level was set at
p \ 0.05 for the primary endpoint (comparison of total STAI score between subjects) and
for other comparisons as well given the exploratory nature of this study. Statistical analyses
were performed using SAS (version 9.3; SAS Institute Inc., Cary, North Carolina).

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Results

Table 1 describes the characteristics of the overall sample and the characteristics by
treatment group. Of the overall sample (n = 60), 43 % were female and average age was
53 years. Financial state for the majority was poor (52 %), and over three-quarters (77 %)
had not obtained a high school diploma. Most were married and had children in the home
(90 %). Average length on hemodialysis was 20 months. Sleep quality was poor in most
participants (88 %). The intervention and control groups were equivalent on all charac-
teristics, although there was a slight tendency for those in the Qur’an recitation group (vs.
controls) to be female (50 % vs. 33 %, p = 0.19), younger (51 vs. 55 years, p = 0.12), and
less likely to have children (83 % vs. 97 %, p = 0.09). All participants were religious
Muslims (more than 98 % of population of Iran is Muslim).
Significant differences in overall STAI scores between intervention and control groups
were present at baseline (overall STAI score 128.5 vs. 118.3, respectively) and on follow-
up (82.1 vs. 120.1) (Table 2). The Qur’an recitation group experienced a reduction in
overall anxiety score of 46.4 points, compared to an increase of 1.8 points in the control
group (Fig. 1). Between-subject differences were present at follow-up, independent of
baseline anxiety scores, gender, age, and presence of children in the home (Table 3). For
the primary endpoint, those in the Qur’an recitation group experienced a significant decline
in anxiety scores on the STAI compared to controls (F = 15.5, p = 0.0002, Cohen’s
d = 1.03).

Discussion

We found that listening to the recitation of the Holy Qur’an had a positive effect on
lowering the level of anxiety in patients undergoing hemodialysis in Tabriz, Iran. Com-
pared to the control group, the effect was statistically significant with an effect size of 1.02.
A Cohen’s d of 1.02 is considered clinically significant, as an effect size of 0.80 or higher
is considered a large effect (Cohen 1988).

Table 1 Baseline characteristics of overall sample, Qur’an recitation, and control groups
Total sample Qur’an recitation Controls p value
(n = 60) (n = 30) (n = 30)

Demographics
Gender, female (%, N)a 42.7 (25) 50.0 (15) 33.3 (10) 0.19
Age, years (mean, SD) 53.0 (11.5) 50.7 (12.9) 55.3 (9.6) 0.12
Financial state, poor (%, N) 51.7 (31) 46.7 (14) 56.7 (17) 0.44
Education, \diploma (%, N) 76.7 (46) 76.7 (23) 76.7 (23) 1.00
Social characteristics
Marital status, married (%, N) 90.0 (54) 90.0 (27) 90.0 (27) 1.00
Children, yes (%, N) 90.0 (54) 83.3 (25) 96.7 (29) 0.09
Health characteristics
Months on dialysis (mean, SD) 19.9 (13.6) 20.3 (13.6) 19.6 (13.7) 0.84
Sleep quality, poor (%, N) 88.3 (53) 90.0 (27) 86.7 (26) 0.69
a
Column % (N)

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Table 2 Means (SD) of anxiety scores (STAI) by treatment group

Anxiety Qur’an recitation Controls Difference p
Mean (SD) Mean (SD) Mean (95 % CI)

State
Baseline 64.1 (7.3) 59.6 (7.1) -4.5 (-8.2 to -0.7) 0.02
1 month 41.2 (6.3) 60.5 (7.1) 19.3 (15.9 to 22.8) \0.0001
Trait
Baseline 64.5 (6.2) 58.7 (8.1) -5.8 (-9.5 to -2.1) 0.003
1 month 40.9 (5.5) 59.6 (8.0) 18.7 (15.1 to 22.2) \0.0001
STAI
Baseline 128.5 (13.0) 118.3 (14.5) -10.3 (-17.4 to -3.2) 0.005
1 month 82.1 (11.3) 120.1 (14.4) 38.0 (31.3 to 44.7) \0.0001

Means compared using Student’s t test

STAI State-Trait Anxiety Inventory combined score
SD standard deviation
CI confidence intervals

Qur'an Recitation
Controls
140

120
Anxiety (STAI)

100

80

60
0 1
Time (months)

Fig. 1 Effect of Qur’an recitation vs. controls on anxiety (STAI). STAI State-Trait Anxiety Inventory total
score (mean, standard deviation)

Despite advances in the treatment of patients with end-stage renal disease, many suffer
from a high level of anxiety that can negatively impact their treatment (Navidian et al.
2006). Several studies have now reported beneficial effects from listening to recitation of
meaningful verses from the Qur’an, including a reduction in anxiety (Heidari and Shahbazi
2013; Akbari et al. 2012; Zarani 2004; Ansari Jaberi et al. 2005; Sadeghi 2011). For
example, Majidi found that reciting the Qur’an had a significant effect on both state and
trait anxiety of patients undergoing coronary angiography (with differences between
intervention and controls significant at p = 0.0001) (Majidi 2004). Heidari and Shahbazi

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Table 3 Effect of Qur’an recitation on anxiety from baseline to 1 month later (between subjects)
F value p Effect size (Cohen’s d)

State anxiety 15.4 0.0002 1.03

Trait anxiety 13.2 0.0006 0.95
STAI total 15.5 0.0002 1.03
F values from general linear models (GLM)
Analyses controlled for baseline age, gender, and presence of children in the home
STAI State-Trait Anxiety Inventory

(2013), studying patients undergoing elective endoscopy, compared anxiety levels of those
listening to Qur’an recitation, receiving music therapy, and a control group, finding that
mean anxiety scores were reduced significantly more in the Qur’an recitation group
compared to the other groups. Finally, (Akbari et al. 2012) examined the effects of lis-
tening to Qur’an recitation on anxiety level of inmates at the Kermanshah Central Prison,
finding again a reduction in anxiety among those in the intervention group.
How might listening to recitation of the Qur’an decrease level of anxiety? Anxiety
states are often the result of an imbalance is catecholamine secretion from the adrenal
glands. Research has shown that music releases anti-anxiety substances in the body that
may reduce anxiety level (Moreno 1985). The relaxing qualities of listening to Qur’an
recitation may be a result of the sound and lyrics of the Qur’an verses in Arabic and its
structure, in addition to the meaning of the words. The effect of listening to the intrinsic
sounds that occur with recitation of the Qur’an can be easily felt by Muslims, but not easily
explained. The ‘‘music’’ is hidden in the structure and lies in the combination of words
within the sentences (Marefat 2012). From a psychological point of view, the effect of
listening to a relaxing voice can be explained by positive reinforcement and generation of a
pleasant and enjoyable stimulus, just as it has been shown that music may protect the mind
from pain (Nanbakhsh et al. 2009).
Music therapy strengthens mental health by creating harmony and maintaining order
and discipline which is found in musical notes and also in the words (Choi 2008). Studies
have found the effects of music as a nursing intervention on patients’ physical and mental
conditions which can reduce costs and maintain treatment effects (Henry 1995; Schorr
1993). To help explain the effects of Qur’an recitation on the anxiety of patients under-
going dialysis, we note the positive effect that music (sounds like those generated by a
Shateri reader reciting the Qur’an) has on preoperative anxiety, anxiety in intensive
medical environments, anxiety prior to diagnostic and invasive medical therapies, vital
signs during invasive procedures, vital signs in infants, respiration rates in those on
mechanical ventilators, and duration of endotracheal tube intubation after major surgeries
(Vahabi 2003; Ostadkelayeh et al. 2005; Smolen et al. 2002; Aragon et al. 2002; Chang
and Chen 2005).

Conclusion

We found that listening to the recitation of the Qur’an compared to controls resulted in a
large reduction in anxiety among patients on hemodialysis, independent of age, gender, and
family status. Given the increasing tendency of physicians, nurses, and patients to use non-
drug therapies for alleviating pain and reducing anxiety and the influence that the Holy

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Qur’an has in Iran, we recommend that further studies be done to examine the effects of
listening to Qur’an recitation on anxiety and other psychological disorders as well. This is
a complementary therapy that is widely available and less expensive than many other
treatments for anxiety and could be used alongside other therapies to achieve improved
results, particularly in patients undergoing hemodialysis.

Acknowledgments The present study was the part of a thesis by an MSc student of Critical Care Nursing.
The authors wish to thank all of the participants in the present study. Their willingness to share their
experiences and insights made this study possible. The authors also extend our gratitude to Semnan Uni-
versity of Medical Sciences for financial support.

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