Effect of Health Education on Women’s Knowledge Level about Pap Smear’s Early Detection of Cervical Cancer Prevention

Introduction

Cervical cancer is a malignant tumor growing inside the neck of the uterine/cervix of the lowest part of the uterine which sticks on the branch at the top of the vagina. The cancer has surpassed heart disease as the top cause of death for Hispanics in the United States; therefore, it is even more critical to focus on early detection of cancer in this population.¹ Cervical cancer usually attacks elderly women between 35 to 55 years of age.² A very high percentage (80–90%) of cervical cancer cases originate from squamous, which can cause death among women.³

The prevalence of cervical cancer is high in the member states of the European Union (EU), with approximately 34,000 new cases of cervical cancer and 13,000 annual deaths.⁴ The prevalence of cervical cancer is particularly high. These conclusions are drawn based on the highest rates in Romania and Lithuania (13.7/100,000 and 10.0/100,000, respectively) and the lowest rate in Finland (1.1/100,000).¹

According to the Globocon data in 2018, new cases of cervical cancer in Indonesia reached 32,469 people. Tribun news reported that mortality due to cervical cancer has reached 18,279 per year. This means that approximately 50 Indonesian women died because of cervical cancer. The number has increased if one were to compare this to the Globocon data which states that in 2012, 26 Indonesian women died because of cervical. The latest Globocon data aligned with the research in Indonesia detected the occurrence of cervical cancer in 1 out of 1,000 women and an average of approximately 40 to 60 women died within a day.⁵

Public knowledge about the pap smear’s early detection and prevention of cervical cancer is still low and health promotion is required to improve their familiarity about the disease.⁶

Therefore, the socialization of pap smear’s early detection and prevention of cervical cancer is very necessary to change the behavior of the women in maintaining their health, especially their reproductive organs. Cervical cancer can mostly be prevented, namely, by avoiding risk factors, screening or early detection, and treating with human papillomavirus (HPV) vaccination to reduce mortality.³ Although the cervical cytology screening benefits a lot in the early diagnosis and treatment, cervical cancer outcomes vary significantly.⁷

In an effort to improve the health of the community, the program of the Department of Health, through health centers, is currently increasing the emphasis on promotion and preventive efforts. In this case, it is important to engage in the prevention of diseases such as cervical cancer, as it can be prevented with an early detection. Therefore, providing socialization and screening tests for timely detection is very important. One of the objectives of the prevention of cervical cancer is to decrease women’s mortality rate. For this purpose, information needs to be disseminated amongst them about the pap smear’s ability to detect and prevent cervical cancer.⁸ Pap smear is an examination of the state of the cells on the cervix (neck of the womb) and vagina. This examination is recommended to be done periodically for women who already had sexual intercourse, in addition to assessing the health of the female organs at the cellular level, and detecting cervical cancer at an early stage.⁹ In some countries, where detection of cervical cancer has been carried out early, there has been a decrease in the mortality of women. In the United States, women between 21 and 65 years do a pap smear thrice a year, and those between 30 and 65 years do a combination of pap smear and HIV every 5 years.¹⁰

Based on the assumption of researchers, one can be certain that most of women are not aware of the signs and symptoms of cervical cancer early, and the average woman who is visiting the hospital is often already up to the second stage and sometimes, the next stage. If a woman is aware about the purpose of pap smear, it is likely that she will know more about the early detection and prevention of cervical cancer.

Materials and Methods

Results

The distribution of respondents across age groups was as follows: 51 to 55 years (36.1%), 46 to 50 years (27.8%), 41 to 45 year (22.2%), and 35 to 40 years (13.3%). The majority of respondents, based on educational background, attended high school (58.3%), followed by college (25%), junior school (16.7%), and elementary school (0%). Variables were measured based on age, education, and occupation are outlined in Table  1.

Table 2 shows that respondents’ knowledge before health education in the age range of 35 to 40 years either did not exist, enough for four people (80%), and less for one person (1%). The substantial knowledge of respondents in the age range of 41 to 45 years was absent, most for two people (25%), and less for six people (75%). The knowledge of respondents in the age range of 46 to 50 years either did not exist, enough for six people (67.7%) and less than four people (33.3%). The knowledge of respondents in the age range of 51 to 55 years revealed the good knowledge of one person (7.1%), enough for five people (35.7%), and less for seven people (50%). However, after health education, the knowledge of respondents improved significantly. The knowledge of women in the age range of 35 to 40 years was good for five people (100%), enough and less for nobody. The knowledge of respondents in the age range of 41 to 45 years was good for five people (100%), enough and less for nobody. The knowledge of respondents in the age range 46 to 50 years was good for eight people (100%), enough and less for nobody. The knowledge of respondents in the age range of 51 to 55 years was good for eight people (80%), enough for two people (20%), and less for nobody.

Table 3 shows the respondents’ knowledge by education levels. The knowledge of respondents who attended junior school either did not exist, enough for two people (33.3%), and less for four people (67.7%). The knowledge of respondents who attended high school was good for one person (4.76%), enough for 11 people (52.4%), and less for nine people (42.9%). The knowledge of respondents who attended college either did not exist, enough for seven people (77.8%), and less for two people (22.2%). However, after health education, there was a change in the level of knowledge of respondents at the level of junior school attendants: good for six people (100%), enough and less for nobody. The knowledge of respondents at the high school was good for 21 people (100%), enough and less for nobody. The knowledge of respondents at the bachelor's level was good for nine people (100%).

Table 4 shows that knowledge, based on occupation before the health education, of housewife respondents was good for one person (5%), enough for ten people (50%), and less for nine people (45%). The knowledge of farmers in terms of good and enough was for nobody, and less for one person (100%). The knowledge of respondents as employees was nothing for good, enough for nine people (62.9%), and less for four people (30.8%). The knowledge of self-employed respondents in terms of good and enough was for nobody and less for two people (100%). However, after health education, the overall knowledge level of women turned out to be good, namely, knowledge of the female respondents as a housewives was good for 20 people (100%), enough and less for nobody. The knowledge of the respondent women as farmers was good for one person (100%), enough and less for nobody. The knowledge of respondents as employees was good for 13 people (100%), enough and less for nobody. The knowledge of respondents as self-employed was good for two people (100%), enough and less for nobody.

Based on Table 5, the results of the test using statistical analysis Wilcoxon Signed-rank test showed that p value < 0.05, where p value = 0.00. It can be concluded that there has been a significant influence of health education on the level of knowledge in women about pap smear’s early detection and prevention of cervical cancer.

Discussion and Conclusion

This study was conducted to prove the influence of health education on the level of women's knowledge about pap smear’s early detection of cervical cancer and prevention. The findings in this study revealed that there was a significant increase of knowledge level among women about pap smear’s ability to detect and prevent cervical cancer after intervention (p < 0.05). The expected results of health education change human behavior, maintain and improve the health, or target the promotion of health.¹¹ In this study, it was found that there was a significant influence on increasing the awareness of the women after the intervention with p-value 0.00 (< 0.05).

This study provided valuable information to the community, especially women. It was proven using a brochure with pictures that attracted attention, effectively conveying information, as we knew that in the present time, most people are comfortable using digital media because of its easy accessibility. Therefore, while meeting directly with communities using the brochure as a media tool, one could directly interact with a communicator if there were things that were misunderstood about the topic and more satisfaction could be derived by discussing things together. So, it was still effective to increase the knowledge of women about pap smear’s ability to detect and prevent cervical cancer.

Age is an important aspect in influencing knowledge. With the increase in age of a person, it will be easier to make a change in the physical and psychological aspects, as the psychological aspects help developing the level of thinking to be more mature and adult.¹⁶ Based on the results of research, the level of knowledge of female respondents in the range of 51 to 55 years was good for one person (7.1%), enough for five persons (35.7%), and less for seven people (50%). This result is in accordance with the one expressed by Wawan and Dewi, which also says that age plays an important role in influencing knowledge; the more the age of a person, the better is his or her knowledge.¹⁶

Education is guidance given to another person to understand a thing. One cannot deny that higher the education of a person, the more easily he or she receives information. On the contrary, if a person has a low level of education, it will inhibit the improvement of attitude of the person toward acceptance of the information and new values introduced.^17,18

This study was not in accordance with the theory expressed by Supardi. Siswanto and Susila revealed that higher level of education aids in an easier absorption of knowledge.^16,17 In this research, the knowledge of the women who attended high school was better compared with the women of undergraduate level, because before the health education intervention, it was found that the knowledge of female respondents at the high school level was good for one person (4.76%), sufficient knowledge for 11 people (52.4%), and less for nine people (42.9%). Knowledge of female respondents at the bachelor's level did not exist for good, enough for seven people (77.8%), and less for nine people (22.2%). It is because one receives information through gadgets, and it is known that the average Indonesian citizen uses the cellphone 5.5^18,19 hours per day and accesses the Internet for 4 to 7 hours per day (The Association of Internet Service Providers Indonesia).¹⁹ Therefore, it depends on how the person wants to obtain the information, which is freely available on the Internet.

According to Polite and Beck, work is an activity or activities performed by people to achieve livelihood. The work environment can transform a person into a more experienced and better informed individual, directly or indirectly. Job factors can also influence knowledge. A working person will have better knowledge compared to someone who does not work, because work entails deriving information from others.

Results of research on the 36 female respondents in MTMH, as indicated in Table 4, shows that women respondents' knowledge based on the point of view of occupation before the health education in terms of housewife was good for one person (5%), enough for TEN people (50%), and less for nine people (45%). The knowledge of respondent women as farmers was good and enough for no one, and less for one person (100%). The knowledge of respondents as employees either did not exist, enough for nine people (62.9%), and less for four people (30.8%). The knowledge of respondents as self-employed was good and enough for no one and less for two people (100%). However, after health education, the overall knowledge of women turns out to be good, namely, knowledge of respondents as housewives is good for 20 people (100%), enough and less nothing. The knowledge of women farmers was good for one person (100%), enough and less for no one. The knowledge of female respondents as employees was good for 13 people (100%), enough and less for no one. The knowledge of respondents as self-employed was good for two people (100%), enough and less for no one.

This study result is not in accordance with what was said by Notoadmojo, which says that job factors also influence humans knowledge, as discussed earlier in this article.²⁰ However, the results of this study showed a contradiction, because it was not forever that someone did not work or was less knowledgeable, and this study proved that women as housewives had good knowledge for one person (5%), enough for ten people (50%), and less for nine people (45%), compared with female respondents who worked and had no proper knowledge before the health education. This was because the housewife was able to set the time and there was also a willingness to find out something which, in turn, would result in knowledge increase. Especially in this digital era, all the information is easily accessible due to the availability of smartphone and the price is still affordable, making it easier for someone to find the information required.

From the results of the study, which had 36 respondents in MTMH, based on Table 3, the knowledge of women was good for three people (8.3%), enough for 12 people (33.3%), and less for 21 people (58.3%) before the health education. After health education, the number of women who were well knowledgeable rose to 30 people (83.3%), enough for two people (5.6%) and less for four people (11.1%). It can be said there was a significant influence in increasing the knowledge of women about pap smear’s ability to detect and prevent cervical cancer in MTMH as shown in Table 5. The results of the test using statistical analysis and Wilcoxon signed-ranks test showed that p value < 0.005 where p value = 0.00, so it can be concluded that there is significant influence provision of health education on the level of knowledge among women about pap smear’s ability to detect and prevent cervical cancer.

Some of the results of research conducted by previous researchers such as Erdin revealed that women’s knowledge about the benefits of the HPV vaccine became better after health education in Turkey.²¹ Health education spread by Chinwe and Abigail²² and Olubodun et al²³ mentioned that there was a change in the awareness level of secondary school teachers about knowledge, attitude, and practice of cervical cancer screening among secondary school teachers in Enugu state. The same was done by Ashtarian, who conducted research on the knowledge about cervical cancer and pap smear, and the factors that influence pap test screening among women, who possessed good knowledge about pap test screening and were willing to undergo screening.²⁴ Knowledge is one of the factors that change the pattern and attitude of a person’s behavior. The presence of health education can transform one’s knowledge into a better direction. According to previous research by Winangsit, health education can change family knowledge about caring for asthma patients. Health education can change behavior or improve someone’s knowledge about it.²⁵ The previous research by Simanullang showed there was significant effect of health education on women’s knowledge about cervical cancer at Bahorok village, North Sumatra.⁶

To conclude this study, there was a significant effect of health education in increasing the level of women's awareness about pap smear’s ability to detect and prevent cervical cancer, thereby reducing women’s mortality. Suggestions for further research are required to represent a greater number of respondents and a wider region.