International Journal of Nursing Studies 52 (2015) 509–518

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International Journal of Nursing Studies

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The effects of acupressure on depression, anxiety and stress in

patients with hemodialysis: A randomized controlled trial
Nant Thin Thin Hmwe a,*, Pathmawathi Subramanian a, Li Ping Tan b,
Wan Kuan Chong c
a
Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
b
Nephrology Division, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
c
Faculty of Medicine & Health Sciences, University Tunku Abdul Rahman, Sungai Long, Cheras, Malaysia

A R T I C L E I N F O A B S T R A C T

Article history: Background: Patients with end stage renal disease on hemodialysis are affected by
Received 13 June 2014 physiological and psychological stressors, which contribute to poor quality of life and
Received in revised form 15 October 2014 negative clinical outcomes. Depression, anxiety, and stress are highly prevalent in this
Accepted 2 November 2014
population. Effective interventional strategies are required to manage these psychological
symptoms. Acupressure has been believed to be one of the complementary therapies that
Keywords:
could promote psychological wellbeing.
Acupressure
Objective: The aim of this study was to evaluate the effects of acupressure on depression,
Renal dialysis
Hemodialysis anxiety, stress, and general psychological distress in patients with hemodialysis.
Anxiety Design: Open-label randomized controlled trial.
Depression Setting: Three hemodialysis centers.
Psychological Participants: A total of 108 patients with hemodialysis were randomly recruited into the
Stress acupressure group (n = 54) and the control group (n = 54).
Method: The intervention was carried out from January to March 2014. The acupressure
group received routine hemodialysis treatment plus 15 min acupressure applied three
times a week for four weeks. The control group received only usual care with routine
hemodialysis treatment. The outcome measurements were the Depression, Anxiety
Stress Scales (DASS-21), and general psychological distress using the General Health
Questionnaire (GHQ-28). Statistical analysis was performed using Wilcoxon signed-rank
test to compare DASS scales and GHQ-28 scores before and after acupressure
intervention.
Results: The acupressure group had significantly lower DASS scores and GHQ scores
compared to the control group, signifying improvements in depression, anxiety, stress and
general psychological distress. The sub-score of the GHQ-28 for social dysfunction,
however, were similar in both groups.
Conclusion: Findings from this study indicates that acupressure therapy delivered three
times a week for four weeks was able to significantly reduce depression, anxiety,
stress, and general psychological distress in patients with hemodialysis. This positive
finding suggests that acupressure may have a role in promoting psychological wellbeing
of patients. Promoting psychological wellness will improve patients’ quality of life,

* Corresponding author. Tel.: +603 79493646.

E-mail addresses: aprial.thin@gmail.com (N.T.T. Hmwe), pathmawathi@um.edu.my (P. Subramanian), liping_t@um.edu.my (L.P. Tan),
chongwk@utar.edu.my (W.K. Chong).

http://dx.doi.org/10.1016/j.ijnurstu.2014.11.002
0020-7489/ß 2014 Elsevier Ltd. All rights reserved.
510 N.T.T. Hmwe et al. / International Journal of Nursing Studies 52 (2015) 509–518
and reduce negative outcomes associated with psychological illnesses and distress
experienced by patients with hemodialysis.
What is already known about the topic?
 Symptoms of depression and anxiety are highly preva-
lent in patients with hemodialysis.
 Patients with hemodialysis often experience physiologi-
cal and psychological stressors affecting their wellbeing
and quality of life.
 Previous literature suggests that acupressure may
reduce depression, anxiety, and stress.
What this paper adds
 Acupressure intervention applied during hemodialysis
was shown to be effective for reducing depression, anxiety,
and stress and for improving psychological well-being.
 Acupressure could be a potential adjuvant treatment for
other approaches of psychotherapy.
1. Background
Hemodialysis is a lifelong treatment that significantly
affects the patients physically and mentally (Wang and
Chen, 2012). Adherence to hemodialysis treatment
requires the patients to adapt to a number of restrictions
such as fluid and diet control, painful fistula cannulation on
dialysis days, financial burdens, and frequent hospital
admission due to comorbid diseases. All these conditions
contribute to psychological illnesses and distress (Ger-
ogianni and Babatsikou, 2013).
Psychological illnesses are highly prevalent comorbid-
ities among hemodialysis population. The most commonly
reported psychological problems were depression and
anxiety, which are independent risk factors for suicidal
behavior, and strongly associated with a poor quality of life
in patients with hemodialysis (Feroze et al., 2012; Chen et
al., 2010; Wang and Chen, 2012). The prevalence of
depression in patients with end state renal failure ranges
from 19% to 60% (Wang and Chen, 2012). Moreover,
evidence shows that 12% to 52% of patients with
hemodialysis have substantial anxiety (Murtagh et al.,
2007), many of whom experience anxiety during individ-
ual dialysis treatment. Causes of anxiety that patients
mentioned include the mere act of going for routine
hemodialysis treatment, having their fistula cannulated by
new dialysis staff, and hearing the alarm sounds of the
dialysis machine (Feroze et al., 2012). Stress was also
identified as a significant factor affecting quality of life in
the dialysis population (Gerogianni and Babatsikou, 2013).
Unfortunately, despite the high prevalence, psycholog-
ical symptoms often go unrecognized and untreated.
Johnson and Dwyer (2008) reported a high prevalence of
ß 2014 Elsevier Ltd. All rights reserved.
untreated depression, with over 70% of patients with
depression and anxiety being unaware of their symptoms
and they did not acknowledge the need for proper therapy.
Most of the dialysis facilities do not routinely screen for
mental health problems, thus making them even less likely
to be detected. Untreated psychiatric illnesses contribute
to increased mortality, reduced quality of life and an
increased risk of suicide (Johnson and Dwyer, 2008). To
prevent these detrimental consequences, early diagnosis
and treatment for psychological symptoms are urgently
needed.
The treatment for psychological illnesses should use
pharmacological therapy as well as non-pharmacological
therapies such as social support network, cognitive
behavioral therapy and involvement in exercise program
(Wang and Chen, 2012). Acupressure is one of the popular
complementary therapies which is believed to improve
psychological and general health. Acupressure, a technique
practised in traditional Chinese medicine, is a method of
stimulating ‘acupuncture points’ or ‘acupoints’ by applying
pressure using hand, fingers or thumb (Tsay, 2004).
Stimulation of acupoints is believed to generate and
smooth the flow of energy (Qi), enhancing blood flow,
dispelling blood congestion and vitalizing organs (Freeman
and Lawlis, 2001), thereby improving general health.
Manual stimulation of acupuncture points has been shown
to increase the production of serotonin and endorphin as
well as improve the regulation of serum cortisol (Lane,
2009). Changes in these hormones may reduce anxiety,
induce relaxation and directly influence the pathologic
mechanism leading to depression. Therefore, acupressure
has been recommended as an adjuvant treatment to other
approaches of psychotherapy (Lane, 2009).
Acupressure applied manually using the fingertip is a
non-invasive and cost-effective intervention which does
not require any equipment. It is less likely to cause adverse
effects compared to needle acupuncture. Nurses can learn
acupressure easily and apply it in clinical practice to
promote patients’ comfort and reduce distress. However,
good evidence on the effectiveness of acupressure on
psycho-social aspects of health is limited (Robinson et al.,
2011). Studies investigating the effects of acupressure on
depression in patients with hemodialysis (Cho and Tsay,
2004; Tsay et al., 2004) has not given sound evidence, thus
further study is needed. To the authors’ knowledge, studies
evaluating the effects of acupressure on anxiety and stress
have not been previously conducted in patients with
hemodialysis. The purpose of this study was to evaluate
the effects of acupressure on depression, anxiety, stress,
and general psychological distress in a cohort of patients
with hemodialysis in Malaysia.
 N.T.T. Hmwe et al. / International Journal of Nursing Studies 52 (2015) 509–518
2. Methods
2.1. Study design
This study design was an open-label randomized
controlled trial. A total of 108 patients from three
hemodialysis centers were randomly assigned into the
intervention group (n = 54) and the control group (n = 54),
respectively. Random sequence allocation was performed
using a computer random number generator. The
intervention group received acupressure during hemo-
dialysis treatment three times per week over four weeks.
The control group on the other hand received the usual
care with routine hemodialysis treatment. Baseline data
were collected before starting acupressure intervention
and the outcome data were collected after intervention.
Blinding and allocation concealment were not applied in
this study.
2.2. Settings and population
The study settings involved three hemodialysis centers
(Centers A, B and C) located in Selangor state, Malaysia.
These centers are well-established under the supervision
of nephrologists from University Malaya Medical Center.
The hemodialysis treatment modalities and the character-
istics of the patients in all three centers were very much
alike. Patients undergoing hemodialysis treatments in the
morning and afternoon shifts were recruited. Inclusion
criteria were: (i) patients who received hemodialysis three
times a week, (ii) patients who had four complete limbs,
and (iii) patients who had intact cognitive functions to
respond to questionnaires. Patients with below knee or
below elbow amputation and those with impaired cogni-
tive functions were excluded. Patients with intact cogni-
tive functions were identified based on the general
assessment from senior staff nurses working at the
respective hemodialysis centers and verified by a nephrol-
ogist.
2.3. Acupressure intervention
The acupressure intervention was performed by the
primary investigator with experience in general nursing
and hemodialysis. The primary investigator had received
training on the basic concepts and techniques of acupres-
sure from a Chinese medicine physician for two weeks. The
practice sessions for acupressure were performed on
healthy subjects, under the supervision of the Chinese
medicine physician. The implementation of acupressure
intervention commenced in January 2014 and ended in
March 2014; January for Center A, February for Center B
and March for Center C. The acupressure intervention was
carried out by the primary investigator alone throughout
Centres A, B and C.
An acupressure protocol was developed based on the
review of literature and consultation with a Chinese
medicine specialist who supervised this study. The
acupressure technique was adopted from Tsay and Chen
(2003) and Shariati et al. (2012). The selection of acupoints
for depression, anxiety, and stress was based on the
511
Fig. 1. Selection of acupoints.
concepts of Chinese medicine. The protocol was reviewed
by two other Chinese medicine specialists from local
universities. The structured protocol was finalized with
100% agreement from the reviewers. The reviewers rated
every item of the protocol as either ‘‘relevant’’ or ‘‘very
relevant’’.
The principles of the protocol are as follows:
 Acupressure is performed by applying consistent finger-
tip pressure on selected acupoints with rotational
movements.
 The acupoints selected (Fig. 1) to reduce the level of
depression, anxiety, stress, and general psychological
distress are:
(i) Yin Tang (GV 29)—located at the midway between the
medial ends of the eyebrow.
(ii) Shenmen (HT 7)—located at the ulnar end of the
transverse crease of the wrist, in the small depression
between the pisiform and ulna bones. For this point,
acupressure is applied only on the non-fistula hand.
(iii) Taixi (KI 3)—located at the midway between the tip of
the medial malleolus and the attachment of the
Achilles tendon, level with the tip of the medial
malleolus. For this point, acupressure is applied on
both legs.
 The precision of acupressure is confirmed if the subjects
felt sore, numb, heavy, distended, and/or warm at the
point of application.
 The duration of each acupressure session is limited to
15 min; comprising 3 min of initial light massage to relax
the patients and 12 min of acupressure applied on GV 29,
HT 7 on the non-fistula hand, and KI 3 on the left and
right legs, i.e. 3 min of application for each acupoint
(altogether 4 acupoints).
 The course of intervention is three sessions per week for
four consecutive weeks.
2.4. Outcome measurements and tools
The outcome measurements for this study were
depression, anxiety, stress, and general psychological
distress. The measurement tools used were the Depression
Anxiety Stress Scales-21 (DASS-21) and the General Health
Questionnaire-28 (GHQ-28). The DASS-21 specifically
512 N.T.T. Hmwe et al. / International Journal of Nursing Studies 52 (2015) 509–518
measures depression, anxiety, and stress, whereas the
GHQ-28 measures the overall psychological status. These
two instruments were used to evaluate whether the result
indicated by the DASS-21 corresponded with the GHQ-28.
English, Malay and Chinese versions of the DASS-21 and
the GHQ-28 were used following the patients’ preference.
Most of the patients (n = 54, 50%) used the Chinese version,
29.6% (n = 32) used the English version and only 20.4%
(n = 22) used the Malay version.
2.4.1. Depression Anxiety Stress Scales-21 (DASS-21)
The DASS-21 consists of 21 items, with 7 items in each
scale measuring the respective current symptoms of
depression, anxiety, and stress. The DASS-21 uses a four-
point scale to rate the severity, which ranges from 0 (‘‘not
apply to me at all’’) to 3 (‘‘applied to me very much, or most
of the time’’). To obtain the total score and the scores for
depression, anxiety, and stress, the individual score from
the respective items were added up and multiplied by 2, as
recommended by Lovibond and Lovibond (1995) who
developed the tool. Scores for the DASS-21 are multiplied
by 2 to make them comparable to the corresponding
original DASS-42, the DASS norms and the published
studies (Lovibond and Lovibond, 1995).
The English version of DASS-21 is a well-validated tool
which showed very good comparative fit index (CFI = 0.93),
with Cronbach’s alpha 0.90, 0.95 and 0.93, respectively for
depression, anxiety, and stress scales, and 0.97 for the total
score (Crawford and Henry, 2003). The Malay version of
the DASS-21 was well translated with high psychometric
properties (Musa et al., 2007), with good factor loading
values for 17 out of 21 items (0.31-0.75) and Cronbach’s
alpha 0.75, 0.74, and 0.79 for depression, anxiety, and
stress in a clinical sample among diabetic patients (Ramily
et al., 2010). The Chinese version of the DASS-21 was also
reported to be a well-adapted measurement tool for cross-
culture research among the Chinese-speaking population
(adjusted goodness of fit = 0.86) (Taouk et al., 2001). In the
current study, all three versions of DASS have shown
internal consistency reliability. Cronbach’s alpha values for
the Malay version are 0.92 for the total score, 0.86, 0.75 and
0.72 for depression, anxiety, and stress scores, respectively,
whereas the Chinese version indicates 0.91 for the total
score and 0.78, 0.75 and 0.77 for depression, anxiety, and
stress scores, respectively. Cronbach’s alpha values for the
English version are 0.86 for the total score, and 0.70,
0.71 and 0.70 for depression, anxiety, and stress scores,
respectively,—slightly lower than the other two versions.
2.4.2. General Health Questionnaire-28 (GHQ-28)
The GHQ-28 is a good screening tool to assess
psychological wellbeing and detect psychological distress,
which is suitable for use as outcome measurement in
clinical trials. The GHQ-28 includes four subscales, namely,
somatic symptoms, anxiety/insomnia, social dysfunction
and severe depression. Each subscale has seven items with
four responses. The scoring method used a Likert scale,
which ranges from 0 to 3 for each item, with a total score of
0 to 84. A score less than 24 indicates wellness while more
than 24 indicates distress. The English version of the GHQ-
28 has Cronbach’s alpha ranging from 0.82-0.93, and the
sensitivity and specificity of the scale were 0.79, and 0.87
(Goldberg and Williams, 1988; Tonge et al., 2006). In the
current study, all three versions of the GHQ-28 have
internal consistency reliability with Cronbach’s alpha of
0.89 for the English version, 0.91 for the Malay version and
0.87 for the Chinese version, respectively.
2.5. Sample size estimation
The sample size estimation should be based on the
primary outcome data from previous study, however, the
outcome measurement tools used in the current study
were not the same as previous studies on acupressure
intervention. Therefore, sample size was estimated using
the data set from Centre A, where acupressure was
applied to the first group of patients in January. In Center
A, a total of 34 patients participated in the study; 17
patients in the acupressure group and the control groups,
respectively. The mean difference in depression scores of
the DASS-21 before and after intervention was 3.4 with
standard deviation 6.0 for the acupressure group. The
formula for two-tailed comparison groups was used as
follows:
 2
2 za=2 þ Z b S2
h¼
ðm1  m2 Þ2
Z a=2 ¼ 1:96; Z b ¼ 0:84
m1  m2 ¼ 3:4; S¼6
Based on the above data, 48 subjects in each group
were needed to be able to reject the null hypothesis, with a
power of 80% and Type I error 0.5. Taking into consider-
ation potential drop-outs, 54 patients in each group
totaling108 patients were recruited. These patients from
Centre A were included in the final analysis.
2.6. Data collection procedure
A pre-test data collection was carried out before
starting acupressure intervention. This included demo-
graphic and background information, depression, anxiety,
and stress scales using the DASS-21, and general
psychological distress using the GHQ-28. At the initial
contact, the purpose and nature of the study were
explained to the nurse managers of the respective
hemodialysis centers. Patients who met the inclusion
criteria were directly approached and invited to partici-
pate in the study. Patients who agreed to participate were
asked to sign a written consent form. Questionnaires were
subsequently administered by the primary investigator
and the staff nurses from the respective hemodialysis
centers. Patients responded to the questionnaires during
hemodialysis treatment. After the collection of pre-test
data, patients were assigned into the intervention and the
control groups, following the random numbers generated
by the computer random number generator. Random
allocation of patients was performed by the primary
investigator.
Acupressure intervention was given after pre-test data
collection and random allocation of patients into the
 N.T.T. Hmwe et al. / International Journal of Nursing Studies 52 (2015) 509–518
acupressure and control groups. Acupressure was given by
the primary investigator following the protocol estab-
lished. Performance of acupressure intervention was
randomly monitored by the Chinese medicine specialist
involved in this study (supervisor), to ensure that the
intervention was performed according to the protocol.
Prior to the start of each acupressure treatment, each
patient’s general condition and vital signs were assessed
and recorded in the acupressure treatment record.
All patients were closely monitored for the occurrence
of adverse effects (if any) during the intervention
period.
At the end of the four weeks of acupressure intervention,
outcome data were collected by the primary investigator
and staff nurses from the respective hemodialysis centers
with the same instruments used in the pre-test.
2.7. Data analysis
Data analysis was performed using IBM SPSS statistical
software version 21. The data were explored and assessed
for missing values, outliers, extreme values and normal
distribution. Descriptive statistics with mean and standard
deviation (SD) for continuous variables and frequency for
categorical variables were analyzed for the baseline data.
The data for age, the DASS scores and the GHQ-28 scores
were not normally distributed, thus non-parametric tests
were used to analyze these variables. A p value less than
0.05 was set as significant. The intention-to-treat analysis
was used.
At the baseline, the differences in demographic data,
duration (years) of undergoing hemodialysis treatment,
and the presence of comorbid diseases between the
intervention and the control groups were tested using
the Chi-square test. The differences in age, the DASS
total scores, the GHQ-28 total scores and the sub-scores
between the two groups were tested using the Mann–
Whitney U test. The Wilcoxon signed-rank test was used
to compare the differences in the total scores and the
sub scores of the DASS-21 and the GHQ-28 before
and after acupressure intervention in each group
(within group). Repeated-measures ANOVA adjusted
for age and gender was used to test the actual treatment
effects of acupressure on the DASS-21 and the GHQ-28
scores.
2.8. Ethical considerations
This study was conducted under the approval of the
Medical Ethics Committee, University Malaya Medical
Centre (MEC Ref. No. 1030.6). Permission was also
obtained from the administrators of the hemodialysis
centers. Potential participants were given explanations on
the purpose of the study, and on the acupressure
techniques. Patients were informed that they could
withdraw from the study at any time before the comple-
tion of the intervention. Patients who agreed to participate
in this study were asked to sign a consent form.
Confidentiality of participants’ information was assured
and the data were accessed only by the investigators
involved in the study.
513
3. Results
3.1. Response rate
A total of 102 (94.5%) out of 108 patients completed the
study, with 6 (5.6%) declining to complete the study. In the
acupressure group, three patients discontinued their
participation in the final week. The reasons for the
discontinuation of the intervention were intra-dialytic
hypotension (n = 2) and hospital admission due to hypo-
glycemic coma (n = 1). Three patients who stopped the
intervention early responded to the post-test question-
naires, thus the baseline data and outcome data were
retained. However, in the control group, three patients did
not respond to the post-test questionnaires, thus the
outcome data were imputed from their baseline data (pre-
test data) with the assumption that there was no difference
in pre-test and post-test. The flow diagram for enrolment,
randomized allocation, follow up and final analysis is
shown in Fig. 2.
3.2. Baseline characteristics
The baseline characteristics of the participants are
shown in Table 1. The mean age of the participants was
58.08  11.4, with age ranging from 28 to 77; 57.2% (n = 62)
of them were male and 42.6% (n = 46) were female. The
majority of the participants were Chinese who made up 73.1%
(n = 79), 20.4% (n = 22) were Indian, and only 6.5% (n = 7) of
the participants were Malay. The most prevalent comorbid
disease among the participants was hypertension which
accounted for 78.7% (n = 85), and the second-most common
disease was diabetes at 51.9% (n = 56). None of the study
participants were diagnosed with any psychiatric disorders
nor were they undertaking any psychiatric treatment. There
was no significant difference in the baseline data between the
acupressure and the control group (p > 0.05).
The mean of the DASS scores at the baseline was
31.44  20.95. From a total of 108 participants, almost half of
them (48.1%, n = 52) had depression, of which 15.7% (n = 17)
had mild, 21.3% (n = 23) moderate, 2.8% (n = 3) severe and
9.3% (n = 10) extremely severe depression. More than half of
the patients (50.9%, n = 55) had varying degrees of anxiety
ranging from mild (12%, n = 13), moderate (21.3%, 23), severe
(8.3%, n = 9) to extremely severe (9.3%, n = 9). More than one
third of the patients (35.2%, n = 38) presented stress
symptoms, exhibiting mild (20.4%, n = 22), moderate
(10.2%, n = 11), severe (1.9%, n = 2) and extremely severe
stress (2.8%, n = 3), respectively. There was no significant
difference in the level of depression, anxiety, and stress
between the acupressure and the control groups at the
baseline (p > 0.05).
The mean of the GHQ-28 scores at the baseline was
25.33  12.56. 52.8% (n = 57) had GHQ scores lower than
24 and 47.2% (n = 51) had scores higher than 24, indicating
that almost half of the patients exhibit psychological distress.
The mean score for somatic symptoms was 7.06  3.81, with
insomnia/anxiety at 6.51  4.86, social dysfunction at
7.69  2.1, and severe depression at 4.17  4.34, respectively.
There was no difference in the GHQ total score and sub-scores
between the acupressure and the control groups (p > 0.05).
514 N.T.T. Hmwe et al. / International Journal of Nursing Studies 52 (2015) 509–518

Center A Center B Center C

Assessed for eligibility Assessed for eligibility Assessed for eligibility
N=94 N=60 N=87

Not meeting Not meeting Not meeting

Enrolment
inclusion inclusion inclusion
criteria (n= 12) criteria (n= 14) criteria (n= 15)

Refused to Refused to Refused to

participate participate participate
(n=48) (n=32) (n=12)

Recruited (n=34) Recruited (n=14) Recruited (n=60)

Randomized
Allocation

Acupressure Control Acupressure Control Acupressure Control

(n=17) (n=17) (n=7) (n=7) (n=30) (n=30)

Acupressure (n=54) Control (n=54)

Follow up Completed 4 weeks Completed follow

acupressure (n=51) up response (n=51)

Discontinued Loss for follow up

acupressure in the (n=3)
last week (n=3)

Analysis
Analysis (n=54) Analysis (n=54)
Intention to treat Intention to treat

Fig. 2. Flow of the study.

3.3. The effects of acupressure on depression, anxiety, and
stress
The mean DASS total score in the acupressure group was
34.37  22.61 before intervention and was reduced to
27.04  20.3 after intervention. However, in the control
group, the DASS total score before intervention was
28.52  18.91 and after intervention 29.22  20.04. The mean
DASS total score in the acupressure group was significantly
reduced after intervention (p < 0.001), whereas no significant
difference showed in the control group (p = 0.912). The sub-
scores for depression, anxiety, and stress in the acupressure
group were significantly reduced after intervention, but no
difference was found in the control group. The DASS total,
depression, anxiety, and stress scores (for both groups) before
and after intervention are presented in Table 2.
Additional analysis with repeated measures ANOVA
was conducted using age and gender as covariates, which
are common confounding variables. The result showed
significant reduction in the DASS total (p < 0.001),
depression (p = 0.04), anxiety (p = 0.035) and stress
(p < 0.001) scores after intervention.
3.4. The effects of acupressure on general psychological
distress
The mean GHQ total score in the acupressure group was
26.93  13.75 before intervention and was reduced to
18.96  11.9 after intervention (p < 0.001). In the control
group, the GHQ total score was 23.74  11.15 before
intervention, and remained similar at 23.96  12.45 after
intervention (p = 0.856). The GHQ-28 sub-scores for somatic
symptoms, insomnia/anxiety and severe depression in the
acupressure group were significantly reduced after interven-
tion, but no difference was shown in the control group. The
sub-score for social dysfunction was not reduced in both
groups. The GHQ-28 total score and sub-scores in both
groups before and after intervention are presented in Table 3.
 N.T.T. Hmwe et al. / International Journal of Nursing Studies 52 (2015) 509–518 515

Table 1
Baseline characteristics of the participants (n = 108).

Variables Total (n = 108) Acupressure (n = 54) Control (n = 54) p-Value

%(n) or M  SD %(n) or M  SD %(n) or M  SD

Age 58.06  11.4 56.96  11.91 59.15  10.87 0.481*

Gender
Male 57.4% (n = 62) 55.6% (n = 30) 59.3% (n = 32) 0.697
Female 42.6% (n = 46) 44.4% (n = 24) 40.7% (n = 22)
Marital status
Single 17.6% (n = 19) 14.8% (n = 8) 20.4% (n = 11) 0.335
Married 69.4% (n = 75) 72.2% (n = 39) 66.7% (n = 36)
Divorce 4.6% (n = 5) 7.4% (n = 4) 1.9% (n = 1)
Widow/widower 8.3% (n = 9) 5.6% (n = 3) 11.1% (n = 6)

Ethnic
Malay 6.5% (n = 7) 5.6% (n = 3) 7.4% (n = 4) 0.803
Chinese 73.1% (n = 79) 75.9% (n = 41) 70.4% (n = 38)
Indian 20.4% (n = 22) 18.5% (n = 10) 22.2% (n = 12)

Education
Primary 52.8% (n = 57) 44.4% (n = 24) 61.1% (n = 33) 0.129
Secondary 37% (n = 40) 40.7% (n = 22) 33.3% (n = 18
Tertiary 10.2% (n = 11) 14.8% (n = 8) 5.6% (n = 3)

Employment
Yes 22.2% (n = 24) 22.2% (n = 12) 22.2% (n = 12) 1.0
No 77.8% (n = 84) 77.8% (n = 42) 77.8% (n = 42)

Duration of taking HD treatment

<1 Year 7.4% (n = 8) 11.1% (n = 6) 3.7% (n = 2) 0.106
1–3 Years 30.6% (n = 33) 35.2% (n = 19) 25.9% (n = 14)
3–5 Years 13.9% (n = 15) 16.7% (n = 9) 11.1% (n = 6)
>5 Year 48.1% (n = 52) 37% (n = 20) 59.3% (n = 32)
DASS total score 31.44  20.95 34.37  22.61 28.52  18.91 0.121*
GHQ total score 25.33  12.56 26.93  13.75 23.74  11.15 0.315*

HD; hemodialysis. Chi-square test was used for other variables.

* p-Value indicated by Mann–Whitney U test.

Repeated-measures ANOVA was conducted using age
and gender as covariates. The result indicated significant
reduction in the GHQ total score (p < 0.001) and sub-scores
for somatic symptoms (p = 0.001), insomnia/anxiety
(p < 0.001), and severe depression (p = 0.010) after inter-
vention.
3.5. Acupressure-related side effects
Acupressure-related side effects were observed during
acupressure intervention. The side effects occurred were
intra-dialytic hypotension (n = 11), dizziness (n = 6), palpi-
tation (n = 2) and headache (n = 1). Intra-dialytic hypoten-
sion occurred within half an hour after acupressure was
applied. Two patients discontinued acupressure in the final
week because hypotension occurred more often. The other
nine patients completed the four weeks of acupressure since
intra-dialytic hypotension occurred for only one or two
episodes during the initial two weeks, without any further
recurrence in the remaining weeks. The episodes of
dizziness occurred during acupressure and 15 min after
acupressure. One episode of palpitation occurred in two

Table 2
Depression, anxiety, and stress scores before and after acupressure intervention (n = 108).

Group Variables Before intervention After intervention p-Value

Mean  SD Mean  SD

Acupressure (n = 54) DASS total 34.37  22.61 27.04  20.3 <0.001

Depression 11.59  8.62 9.48  7.64 0.034
Anxiety 9.74  8.09 7.93  7.06 0.029
Stress 13.04  7.71 9.63  7.48 <0.001

Control (n = 54) DASS total 28.52  18.91 29.22  20.04 0.912

Depression 10.26  8.13 10.41  8.38 0.762
Anxiety 8.04  5.52 7.70  5.83 0.408
Stress 10.19  7.41 11.11  7.59 0.389

p-Value indicated by Wilcoxon signed rank test. 50% (n = 54) used the Chinese version, 30% (n = 32) of used the English version and 20% (n = 22) used the
Malay version of the DASS-21. Attrition: acupressure group = 3 (intra-dialytic hypotension = 2, hospital admission = 1). Control group = 3 (declined to
respond to post-test questionnaire). Intention to treat analysis was used; all recruited patients (n = 108) included in the analysis.
516 N.T.T. Hmwe et al. / International Journal of Nursing Studies 52 (2015) 509–518
Table 3
General psychological distress (GHQ-28 scores) before and after intervention (n = 108).
Group Variables
Acupressure (n = 54) GHQ total
Somatic symptoms
Insomnia/anxiety
Social dysfunction
Severe depression
Control (n = 54) GHQ total
Somatic symptoms
Insomnia/anxiety
Social dysfunction
Severe depression
p-Value indicated by Wilcoxon signed rank test. 50% (n = 54) used the Chinese version, 30% (n = 32) used the English version and 20% (n = 22) used the Malay
version of the GHQ-28. Attrition: acupressure group = 3 (intra-dialytic hypotension = 2, hospital admission = 1). Control group = 3 (declined to respond to
post-test questionnaire). Intention to treat analysis was used; all recruited patients (n = 108) included in the analysis.
patients, respectively while acupressure was being applied.
Headache occurred in one patient during the application of
acupressure. It resolved within a few minutes and did not
require the cessation of the acupressure intervention.
4. Discussion
Baseline data showed a high prevalence of depression,
anxiety, stress and general psychological distress. Nearly
50% of the study participants were shown to have
depression, anxiety and psychological distress, and
35.2% presented stress symptoms. This suggests that
clinicians and nurses should pay attention toward the
development of effective interventional models for en-
hancing psychological wellness.
Results from this study indicated that acupressure
significantly reduced depression scores. This finding is
congruent with the findings from previous studies con-
ducted on patients with hemodialysis (Cho and Tsay, 2004;
Tsay et al., 2004), although the acupoints applied and the
measurement tools used to measure depression in the
current study differ from the previous studies. Acupressure
was also found to reduce depression in patients with
chronic obstructive pulmonary disease (Wu et al., 2007),
and in the elderly in nursing homes who were suffering
from chronic knee pain (Tse and Au, 2010). Since the
positive findings of acupressure in reducing depression are
consistent across the studies, it is suggested that acupres-
sure is an effective complementary therapy to reduce
depression.
Acupressure also significantly reduced anxiety, a result
that is consistent with previous studies conducted among
patients with chronic obstructive pulmonary disease on
mechanical ventilation (Tsay et al., 2005). Even though
previous studies have been conducted in a different setting
and on a different patient population, the same positive
results can suggest that acupressure is effective in reducing
anxiety. Similarly, acupressure was also found to reduce
surgery-related anxiety in women with post-cesarean
section (Chen et al., 2005) and in elderly patients before
receiving extracorporeal shock wave lithotripsy (Mora et al.,
2007). However, two studies conducted among pre-opera-
Before intervention After intervention p-Value
Mean  SD Mean  SD
26.93  13.75 18.96  11.9 <0.001
7.63  4.03 4.72  3.08 <0.001
7.22  5.43 3.87  4.11 <0.001
7.91  3.12 7.56  3.11 0.353
4.35  4.65 2.81  3.87 0.006
23.74  11.15 23.96  12.45 0.856
6.5  3.54 5.76  3.53 0.086
5.8  4.15 6.43  4.29 0.133
7.46  2.88 8.04  2.66 0.073
3.98  4.03 3.70  4.21 0.471
tive patients showed unclear findings that acupressure and
sham acupressure equally reduced anxiety (Agarwal et al.,
2005; Valiee et al., 2012). Selection of acupoints, the method
applied and the dose of acupressure (frequency and
duration) might vary the treatment effect. In the current
study, acupressure applied consistently for 15 min over four
consecutive weeks might give an adequate therapeutic dose
of acupressure to reduce anxiety.
The finding of this study indicated a significant
reduction in stress in patients after receiving four weeks
of acupressure. In a previous study conducted among
college students, acupressure was compared with sham
acupressure and audio relaxation compact disc which
contained soothing background sounds and instructions to
relax body and mind (McFadden et al., 2012). The findings
indicated that stress response was reduced equally in all
three groups. However, the study failed to show the
superior effect of acupressure possibly due to the
inadequate dose of acupressure, which was given only
on one session. In a study conducted by Honda et al.
(2012), it was shown that four weeks of self-administered
acupressure was able to significantly lower the perceived
level of stress in college students, suggesting that the
duration and frequency of acupressure are important. The
results of the current study would support this.
This study also showed that acupressure was able to
significantly reduce general psychological distress with
the exception of domain measuring social dysfunction. The
GHQ total score and the sub-scores for somatic symptoms,
insomnia/anxiety and severe depression were significantly
lower after acupressure intervention. The reduction in
insomnia/anxiety score was highly significant. In previous
studies, acupressure had been found to improve sleep
quality in patients with hemodialysis (Nasiri et al., 2011;
Shariati et al., 2012; Tsay et al., 2004; Tsay and Chen, 2003).
Therefore, the finding of the current study suggested that
acupressure was effective in improving sleep quality in
patients with hemodialysis.
Improved sleep quality might contribute to psychologi-
cal and general wellbeing that might reduce the somatic
symptoms that appear in distressed patients. The reduction
in severe depression shown by the GHQ-28 sub-score was
 N.T.T. Hmwe et al. / International Journal of Nursing Studies 52 (2015) 509–518
congruent with the same result indicated by the DASS-21.
The result did not show any positive effect of acupressure on
social dysfunction, a domain that is affected by many socio-
economic factors. Providing social support combined with
acupressure might reduce the overall psychological illness
and distress in patients with hemodialysis.
The overall study findings indicated that acupressure
reduces depression, anxiety, stress, and psychological
distress in patients with hemodialysis. These positive
outcomes might be due to the regulation of neurotrans-
mitters and hormone functions by manual stimulation of
acupoints (Lane, 2009). Regulation of hormone functions
and nervous system functions by application of consistent
fingertip pressure on acupoints may improve sleep and
general health, which contributes to reduce psychological
symptoms. Therefore, acupressure can be suggested as an
adjuvant therapy for psychological illnesses.
In terms of safety issues, adverse effects observed
during acupressure intervention were intra-dialytic
hypotension, dizziness, palpitation, and headache. In a
study investigating the effect of acupressure on alertness
in the classroom among university students, the reported
common side effects of acupressure were muscle cramp,
muscle ache, headache and fatigue (Harris et al., 2005).
In the current study, intra-dialytic hypotension occurred
in 11 patients, with 2 of them discontinuing the
intervention because hypotensive episodes constantly
occurred. Hypotension is one of the complications that
could occur during hemodialysis, which might have been
aggravated by the application of acupressure, in the case
of this study. Acupressure applied on non-dialysis days
might reduce these undesirable effects. Thus, the occur-
rence of adverse effects in this study suggests that
acupressure applied during hemodialysis treatment may
not be the best time.
4.1. Limitations and recommendations for future study
This study has several limitations. First, blinding was
not employed because the primary investigator per-
formed acupressure and analyzed the data. Allocation
concealment of participants in the acupressure or the
control group and the blinding of outcome measurement
were not able to be applied due to logistic limitation to
employ assistants for allocation of participants and
collecting of the outcome data. Second, contamination of
acupressure intervention among patients in the control
group might occur because acupressure was performed
while all patients were undergoing hemodialysis treat-
ment. There was a possibility that the patients allocated
in the control group might learn to perform their own
acupressure. However, that would not be comparable to
the acupressure performed by the investigator, which
was consistently applied according the standardized
protocol.
Third, the sample size estimation was based on the
difference in depression score of the DASS 21 which was
observed in a small group of patients, instead of using an
effect size evidenced as clinically significant due to lack of
previous study. This would limit the precision of actual
sample size required. The fourth limitation was lack of
517
equivalence assessment between the English, Chinese,
Malay versions of questionnaires, and lack of validity
estimate for these scales in current study. Furthermore,
data collected for depression, anxiety, stress, and general
psychological distress were subjective responses. Thus, it
was hard to ensure the accuracy of information given by
the patients. Lastly, selected hemodialysis centers were
predominantly occupied by Chinese patients. The majority
of patients recruited for this study were Chinese (73.9%),
while one fifth (20.4%) of the patients were Indians, and
very few numbers were Malays (6.5%). Thus, the positive
results showed in this study might be affected by the
traditional belief on the treatment effects of acupressure
among Chinese patients.
Further study should be conducted in a diverse popula-
tion which includes equal proportions of ethnic groups to
ensure generalizability of the findings. A longitudinal study
is recommended to investigate the long-term effects of
acupressure on the psychological variables. Acupressure
intervention should be given on the non-dialysis day to
avoid contamination of the intervention in the control
group, and to minimize the occurrence of adverse effects.
4.2. Implications for clinical practice
The finding from the current study is not generalizable,
but it provides new knowledge about the promising effect
of acupressure on psychological variables. Despite the
limitations of the study, it has important nursing implica-
tions especially for dialysis nurses. Nurses are primary care
givers and at the forefront of dealing with patients, thus,
we stand at a pivotal position to comfort and relieve the
distressing symptoms experienced by patients. Acupres-
sure, a technique that can be learned easily by nurses, may
promote psychological wellbeing of patients. Nurse
practitioners would need to undergo basic training on
the concepts and techniques of acupressure application. It
would, therefore, be beneficial to consider the addition
of acupressure in the education programs for nursing
training.
5. Conclusion
The positive finding from this study suggests that
acupressure may have a role in promoting psychological
wellbeing of patients. Further studies with large-scale,
methodologically robust design are recommended in
order to produce strong evidence for application of
cost-effective acupressure intervention to promote
patients’ psychological wellbeing. The high prevalence
of depression, anxiety, and stress shown in this study
highlights the treatment gap currently present among
patients with hemodialysis. Psychological symptoms
which occur in patients with hemodialysis are affected
by many physiological and psycho-social factors, thus
acupressure intervention integrated with social support
and other approaches of psychotherapy might reveal even
greater effectiveness. Promoting psychological wellness
will increase patients’ quality of life and further reduce the
negative outcomes related to their psychological illnesses
and distress.
518 N.T.T. Hmwe et al. / International Journal of Nursing Studies 52 (2015) 509–518
Conflict of interest
The authors declare that there is no conflict of interest
in publishing this research article.
Funding
This research was funded by a Postgraduate Research
Grant (PPP) 2/2013 (P0041/2013B) from University of
Malaya, Malaysia.
Ethical approval
This study was conducted under the approval of the
Medical Ethics Committee (MEC), University of Malaya
Medical Centre (MEC Ref. No. 1030.6).
Acknowledgements
The authors thank to Mr Quet Hang Sah, for teaching
basic concepts and techniques of acupressure. We also
would like to thank Dr Te Kian Keong and Mr Han Aik Teng
for reviewing the acupressure protocol and Associate
professor Karuthan Chinna for providing expert guidance
in statistical analysis. We appreciate very much the helpful
support given by the nephrologists, nurse managers and
staff nurses from the respective hemodialysis centers and
all patients who participated in this study.
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