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Journal of Drug Delivery and Therapeutics

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Relationship Between Mother's Level of Knowledge About Cervical Cancer in Performing Pap Smear Screening Tests in Kampung Rawa Panjang Bekasi in 2016

Marliana Nurprilinda¹*, Moskwadina Gultom²

¹ Department of Anatomic Pathology, Faculty of Medicine, Universitas Kristen Indonesia, Jakarta

² Departement of Anatomy and Histology Faculty of Medicine, Universitas Kristen Indonesia, Jakarta

INTRODUCTION

Cervical cancer is a primary malignant tumour originating from epithelial metaplasia in the squamocolumnar junction area, namely the transitional area of the vaginal mucosa and cervical canal mucosa. As many as 90% of cervical cancer originates from the squamous cells that line the cervix, and the remaining 10% comes from the mucus-producing gland cells in the cervical canal leading to the uterus. Cervical cancer usually affects women aged 35-55 years.

Cervical cancer ranks seventh globally in terms of incidence (6th in the least developed countries) and 8th as a cause of death (contributing 3.2% mortality) ^{1; 2}. The number of new women with cervical cancer ranges from 90-100 cases per 100,000 populations, and every year there are 40 thousand cases of cervical cancer ³. Cervical and breast cancer are cancers with the highest prevalence in Indonesia in 2013, namely cervical cancer by 0.8% and breast cancer by 0.5% ⁴.

The incidence of cervical cancer in Indonesia continues to increase, and the majority of sufferers are only detected at an advanced stage. The incidence of cervical cancer will significantly affect the lives of sufferers and their families and greatly affect the government's health financing sector. Therefore, increasing efforts to treat cervical cancer, especially in prevention and early detection, is needed by every party involved.

It can be prevented and detected earlier if women have good knowledge and awareness of early detection. One method of early detection of cervical cancer commonly used is the Pap smear, which examines cells taken from the cervix and then examined under a microscope. The Pap smear is a safe and inexpensive test used for many years to detect abnormalities in the cervix cells ⁵. This test is easy to do, quick, and painless, and can be done any time, except when menstruation, as well as being proper as a screening examination and tracking of cell changes leading to malignancy at an early stage so that pre-cancerous abnormalities can be detected and their treatment will be cheaper and more manageable.

Cervical cancer screening programs with Pap smears have been carried out in many developed countries and have succeeded in reducing the incidence of cervical cancer in these developed countries. Although screening programs have been running well in the United States, it is estimated that 30% of cervical cancer cases occur in women who have never had a Pap smear. Screening programs in developing countries are not routine or not even implemented. Women in developing countries have a Pap smear, which is only about 5% of the total female population, and almost 60% of cervical cancer cases in developing countries occur in women who have never had a Pap smear ⁶.

Many things influence a woman not to do a Pap smear, one of which is high or low knowledge about cervical cancer. It is necessary to conduct a research study to determine the relationship between the level of knowledge about cervical cancer in conducting Pap smear screening tests. Therefore, the research was conducted with the title "Is there a relationship between the mother's level of knowledge about cervical cancer in carrying out Pap smear screening tests in Kampung Rawa Panjang Bekasi?" This study aimed to determine the mother's level of knowledge about cervical cancer in carrying out a Pap smear screening test in Kampung Rawa Panjang, Bekasi.

LITERATURE REVIEW

Cancer is a general term for a large group of diseases that can affect any part of the body. Other terms used are malignant tumour and neoplasm. One of the defining features of cancer is the abnormal growth of new cells that grow beyond normal limits and can then invade adjacent parts of the body and spread to other organs ⁷. Cancer is a term for a disease in which cells divide abnormally without control and can invade surrounding tissues. Cervical cancer is a primary malignant tumour originating from epithelial metaplasia in the squamocolumnar junction area, namely the transitional area of the vaginal mucosa and cervical canal mucosa. Cervical cancer occurs in the cervix or cervix, an area in the female reproductive organs that is the entrance to the uterus, located between the uterus (uterus) and the vaginal opening ¹. According to The International Federation of Gynecology and Obstetrics (FIGO) ⁸, Stages of cervical cancer are stages 0, 1, 2, 3, and 4.

In the world, cancer is the second leading cause of death after cardiovascular disease. Approximately 7.5 million people die from cancer, and more than 70% of deaths occur in poor and developing countries ^{9; 10}. The highest types of cancer in women in the world are breast cancer (38 per 100,000 women) and cervical cancer (16 per 100,000 women) ². In Indonesia, the prevalence of cancer is 14 per 1,000 population and is the seventh leading cause of death (5.7%) of all causes of death ¹¹. The highest type of cancer in hospitalized patients throughout Indonesia in 2010 was breast cancer (28.7%), followed by cervical cancer (12.8%). Cervical cancer ranks seventh globally in terms of incidence (6th in the least developed countries) and 8th as a cause of death (contributing 3.2% mortality) ². The number of new women with cervical cancer ranges from 90-100 cases per 100,000 population, and every year there are 40 thousand cases of cervical cancer ¹². Based on research from Dharmais Cancer Hospital, cervical and breast cancer were cancers with the highest prevalence in Indonesia in 2013, namely cervical cancer at 0.8% and breast cancer at 0.5% ⁴.

Protozoal, fungal and bacterial infections are not potentially oncogenic, so recent studies have focused on viruses as an important cause. Not all viruses are said to cause cancer, but at least there are approximately 150 million types of viruses that are thought to play a role in the incidence of cancer in humans, and a third of them are DNA viruses. In the process of carcinogenesis, the viral nucleic acid can be integrated into the genes and DNA of the host cell, causing cell mutations ¹³. The primary cause of cervical cancer is a chronic infection of the cervix by one or more oncogenic types of HPV (Human Papilloma Virus) viruses at high risk of causing cervical cancer, which is transmitted through sexual intercourse (sexually transmitted disease). Women are usually infected with this virus in their teens to thirties, although cancer itself will not appear until 10-20 years later. HPV is a member of the Papovirida family, with a diameter of 55 m. This virus has a naked isohedral capsule with 72 capsomeres and contains double-stranded circular DNA. Its molecular weight is 5 x 106 Daltons—known several papillomavirus species, namely human species, rabbits, cattle and others. Currently, about 70 types of HPV have been identified, and there may be many more in the future. Each type has specific characteristics of epithelial damage and changes in the morphology of the resulting lesions. Approximately 23 types of HPV can cause infection in the external genitalia of women or men, which include HPV types 6,11,16, 18, 30, 31, 33, 34, 35, 39, 40, 42, 45, 51- 58, of which HPV types 16 and 18 are found in about 70% of cases. HPV type 16 is generally found in western countries such as Europe, USA and others, while type 18 is mostly found in Asia ¹⁴.

Although there is a close relationship between HPV and cervical cancer, there is no evidence supporting HPV is the sole cause. Malignant changes from normal epithelium require other factors, various observations, namely: support this) The development of an HPV infection to become cervical cancer is slow and takes a long time; b) Epidemiological surveys show that the prevalence of HPV infection is 10-30%, while the risk of women getting cervical cancer is less than 1%; c) Cancer is monoclonal, meaning that it develops from a single cell. Therefore, only one or a few of the HPV-infected epithelial cells can escape the control of average cell growth.

There are several risk factors for cervical cancer ¹⁵, namely: a) Early age of intercourse and multiple sexual partners, b) Smoking; c) Immunosuppression; d) History of vaginal discharge due to infection; e) diet; f) Oral contraceptives (birth control pills); g) Parity; h) Young age at first pregnancy; i) Family history of cervical cancer, and k) Socio-economic and educational level. Cervical cancer develops when abnormal cells in the cervix divide uncontrollably. It is caused by a virus called Human Papilloma Virus (HPV). Currently, there are 120 known types of HPV. 30 to 40 types of HPV are known to attack the genital area.

Various research efforts have resulted in much knowledge about cancer. Today, WHO states that one-third of all cancers are preventable, one third can be cured, and one-third of patients can be relieved of pain by using drugs. Preventing cancer is essential in cancer prevention activities because it can positively impact raising healthy and productive human resources and improving their socio-economic conditions. Cancer prevention is defined as identifying the factors that cause cancer in humans and rendering these causes ineffective in any way possible. Prevention of this cancer can be primary or secondary.

Primary prevention refers to activities/steps that everyone can take to avoid factors that can cause cancer to grow, including ^16; 17: a) Delaying sexual intercourse until the age of 20 years and having only one partner; b) Use of barrier contraception; c) Consumption of healthy foods that can reduce the risk of cancer; d) Quit smoking, and e) HPV vaccination; Is an empty cell that resembles HPV without viral DNA, so when this vaccine is inserted into the body it will form antibodies. This vaccine is recommended for girls aged 11-12 years; it is also recommended for girls and women aged 13-26 years who have not been vaccinated or completed the vaccine series. Administered IM 3 times, i.e. at the 0, first, and sixth months of 0.5 ml each ¹⁸.

At the same time, secondary prevention is a more commonly used term by health workers interested in cancer prevention research. Its application to the identification of population groups at high risk for cancer by screening specific populations ^{19; 20;22}. Given that cervical cancer is still in the top 2 ranks in Indonesia, efforts need to overcome or reduce its incidence. The concept of cervical cancer pathogenesis has an essential meaning in cervical cancer screening. Theoretically, a cancer screening program must be practical and economical.

Cervical cancer recognizes a pre-cancerous stage that can be found by cytological screening with a relatively inexpensive, painless, accurate Pap smear. Besides being done with the help of colposcopy, this stage can be treated with conservative means such as cryotherapy, cauterization or laser light. Health systems are different worldwide, but screening planning must be in line with other health services and collaboration between programs. Ideally, the screening program is part of a cancer health service developed within the health care structure. Of all countries where cervical cancer screening programs have been implemented for more than 20 years, the incidence of cervical cancer and the mortality rate of cervical cancer can decrease by 50-60% ²³.

According to human resources and existing infrastructure capabilities, management of pre-cancerous lesions is adjusted to health care facilities. Screening or early detection programs can be carried out at the primary service level with limited facilities and infrastructure. In screening with Pap smear test, abnormal findings are recommended for diagnostic confirmation by colposcopy. Surgery, radio- and chemotherapy in cervical cancer patients can increase metabolic stress so that it can cause a decrease in intake and the risk of malnutrition in patients. Research shows that as many as 40% of gynaecological cancer patients are malnourished, and cachexia is found in about 50-80% of cancer patients ²⁴. Thus, patients need to receive adequate nutritional management, starting from screening, determining the diagnosis, and general and specific management. If the patient can pass a series of therapies and is declared cancer-free, the patient still needs to receive education and nutritional therapy to prevent recurrence and improve the patient's quality of life. Cachexia syndrome requires multidimensional management that involves optimal nutrition, pharmacology, and physical activity. Optimal nutrition for cachexia patients needs to be done individually according to the patient's condition.

Cancer patients who experience anorexia require multimodal therapy, which includes the administration of drugs according to the patient's condition in the field: a) Progestins - According to a meta-analysis study MA is beneficial in increasing appetite and increasing body weight in cancer cachexia, but has no effect in increasing appetite. Muscle mass and quality of life of patients. The optimal dose for using MA is 480–800 mg/day. Use begins with a small dose and is increased gradually if for two weeks does not provide optimal effect; b) Corticosteroids - Corticosteroids are the most widely used organic substances. Various studies have shown that the administration of corticosteroids in cachexia patients can improve the patient's appetite and quality of life; and c) Cyproheptadine - Cyproheptadine is a 5-HT3 receptor antagonist, which can improve appetite and increase body weight in patients with carcinoid tumours. Side effects that often arise are drowsiness and dizziness. Generally used in pediatric patients with cancer cachexia and is not recommended in adult patients.

A cytological examination of the cervix and portion to see the early signs of cervical malignancy (pre-cancerous) characterized by changes in the cervical epithelial layer. The Pap smear is a safe and inexpensive test used to detect cervical cancer for many years. George Papanicolaou first discovered this test, hence the name Pap smear ²⁵. It is recommended that every woman begin screening three years after being sexually active for the first time. Women 30 years of age or older with three average Pap smear results have the test every 2-3 years, except for high-risk women who have to have the test every year. In addition, women who have had a total hysterectomy are not recommended to have a Pap smear test again. However, women who have had a hysterectomy without cervical removal still need to have a Pap test or other screening as recommended above ³⁰. Pap smears can be done in hospitals, private clinics, specialists in obstetrics and gynaecology, and trained midwives. Pap smears are not done during menstruation. The best time to do a Pap smear is 10-20 days after the first day of your last menstrual period. In patients with severe inflammation, the examination is postponed until the completion of treatment. Two days before the test, patients were prohibited from using tampons, lubricants, washing, or vaginal medications. It is because the drug can affect the results of the examination. The woman is also prohibited from having sexual relations for 48 hours before the Pap smear examination ²⁶.

Pap smear examination is done to detect pre-cancerous changes in the cervix. About half of all women diagnosed with cervical cancer have never had a Pap smear or had the last test more than five years earlier ²⁷. Knowledge results from "knowing", which occurs after people have sensed particular objects. Sensing occurs through the five human senses, namely the senses of sight, hearing, smell, taste and touch. For the most part, human knowledge is obtained from the eyes and ears. There are several levels of knowledge, namely ²⁸: a) Know - Tofu is defined as binding a material that has been previously studied. Included in this knowledge level is recalling something specific from the material studied or stimuli that have been received. Therefore, knowing is the lowest level of knowledge; b) Understanding (comprehension) - Understanding is an ability to explain known objects and interpret the material correctly. People who already understand the object or material must be able to explain, mention examples, conclude, predict, and so on the object being studied; c) Application - Application is defined as the ability to use the material that has been studied in actual situations or conditions; d) Analysis (analysis) - Analysis can describe the material or an object into components but still within an organizational structure and still have a relationship. This analytical ability can be seen from the use of verbs, such as describing (make a chart), distinguishing, and group; e) Synthesis - Synthesis refers to an ability to put or connect parts in a new whole form. In other words, synthesis is an ability to compile, plan, summarize, adapt, and so on to an existing theory or formulation; and f) Evaluation - This evaluation is related to the ability to justify or evaluate a material or object. The assessments are based on a self-determined criterion or using existing criteria. For example, you can compare well-nourished children, respond to the occurrence of diarrhoea in one place, interpret why mothers do not want to participate in family planning.

RESEARCH METHOD

This study is an analytic study with data collected using a cross-sectional approach. This research was conducted in Kampung Rawa Panjang, located in Bekasi City. Submission of titles begins in the first week of September 2016. Furthermore, proposal writing was carried out in October 2016 from the third week to the fourth week. Data collection and processing was carried out from December 2016 to January 2017. The population in a study is a collection of objects that can be used as research sources in the form of objects, humans or events that occur as objects or research targets. The population is the total number of all elements analyzed or studied. The population can be organisms, people, objects, events, or reports. The populations in this study were married mothers in Kampung Rawa Panjang, Bekasi. Sampling is a process of selecting some of the population elements that are statistically sufficient so that by studying the sample, understanding its characteristics will be known about the state of the population. Due to the study population of fewer than 100 people, the entire population was used as sampling. The data collection technique used in this research is an interview, which is a method of collecting data through one-sided question and answer, which is done systematically and based on research objectives. Interviews were conducted using a list of questions and were a direct method of obtaining data. Besides, a literature study collects data and information by carrying out library activities through books, journals, and previous research related to the research being carried out. Then, the questionnaire also became a research instrument. After the respondents filled in all the questionnaires, the next step was data processing. The data is processed using the SPSS 24.0 program, and the data will be presented in tabular form. Data processing is done through editing, coding, entry, cleaning, and concluding. Data analysis was carried out by univariate analysis to display the distribution of the frequency and percentage of each variable in the form of a table and bivariate analysis to see whether or not there was a statistically significant relationship between the independent and dependent variables with the Chi-square test using the SPSS version 24 program, 0. If the value of p = <0.05, then there is a relationship, and if the value of p = 0.05, then there is no relationship.

RESULT AND DISCUSSION

Respondents in this study were married women aged 25-50 years living in Kampung Rawa Panjang Bekasi with 77 people.

Table 1: Characteristics of respondents based on last education

Based on the table above, the data obtained: Respondents who did not go to school were 2.6%, did not finish elementary school as much as 9%, graduated from elementary school 6.5%, graduated from junior high school 26%, graduated from high school 27.3%, and S1 as many as 28, 6% of all respondents.

Table 2: Characteristics of respondents based on family income

Based on the table above, the data obtained are: Respondents with income below Rp. 1,000,000, - are 29.9%, between Rp. 1,000,000, - to Rp. 3,000,000, - are 29.9%, and above Rp. 3,000,000, - is as much as 40.3% of the total respondents.

Table 3: Characteristics of respondents by occupation

Based on the table above, the data obtained: Respondents who work as civil servants are 5.2%, entrepreneurs are 9.1%, homemakers are 63.6%, labourers are 1.3%, and those who have jobs other than those already mentioned as much as 20.8% of the total respondents.

Table 4: Characteristics of respondents based on the history of childbirth

Based on the table above, data is obtained: 31.2% of respondents have given birth once, 35.1% have given birth twice, 22.1% have given birth three times, 5.2% have given birth four times, 3.9% have given birth. 5x, and 2.6% of the total respondents had given birth 6x.

Table 5: Average results of respondents' questionnaire scores about cervical cancer

Table 6: Number and percentage of respondents on each value of the questionnaire answers about cervical cancer

Table 7: Characteristics of respondents based on knowledge about cervical cancer

Based on the table above, the data obtained: 51.9% of respondents have poor knowledge about cervical cancer, and another 48.1% already have good knowledge. Respondents who know that cervical cancer is a malignant disease that attacks the uterus are 62.3%, think cervical cancer is a dangerous disease that attacks the female reproductive organs are 29.9% and do not know what cervical cancer is 7,8% of all respondents.

Respondents who think that cervical cancer is found mainly in women aged 15-34 years are 18.2%, who know that cervical cancer is most common in women 35-54 years are 9.1%, and those who think that it is found the most in women aged >55 years is as much as 72.7% of the total number of respondents.

Respondents who think that bacteria cause cervical cancer are as many as 20.8%, who think that cysts cause cervical cancer as many as 14.3%, and those who know that viruses cause cervical cancer are 64.9% of the total respondents.

Respondents who do not know whether women who have never had sexual intercourse can or cannot get cervical cancer are as many as 24.7%, who think that women who have never had sexual intercourse can get cervical cancer are as many as 57.1%, and who know that women who have never had sexual intercourse cannot get cervical cancer as much as 18.2% of the total respondents. 

Respondents who think that there are three levels of malignancy of cervical cancer are 44.2%, those who think that there are five levels of malignancy of cervical cancer are 13%%, and those who know that there are four levels of malignancy of cervical cancer are 42.9% of the total respondents.

Respondents who do not know whether women who use oral contraceptives have a greater risk of cervical cancer or not are 51.9%, who think that women who use oral contraceptives do not have a greater risk of cervical cancer are 22.1%, and who know that women who use oral contraceptives have a greater risk of cervical cancer are 26% of the total respondents.

Respondents who do not know whether healthy and clean lifestyle habits can prevent cervical cancer or not are as much as 10%, who think that healthy and clean lifestyle habits cannot prevent cervical cancer are as many as 10.4%, and who know that lifestyle habits healthy and clean can prevent cervical cancer is as much as 76.6% of all respondents.

Respondents who think that changing partners cannot increase the risk of cervical cancer are as much as 5.2%. Who think that changing partners can increase the risk of cervical cancer because touching with sufferers is a form of cervical cancer transmission is 27.3%. Those who know that having multiple partners can increase the risk of cervical cancer because the chances of contracting HPV are getting bigger are 67.5% of the total respondents.

Respondents who think that smoking cannot increase the risk of cervical cancer are 20.8%, those who know that smoking can increase the risk of cervical cancer because it contains substances harmful to health are 40.3%, and those who know that smoking can increase the risk of cervical cancer because of the nicotine content in it is as much as 39% of all respondents. 

Respondents who did not know whether the use of vaginal cleansers containing antiseptics could prevent cervical cancer or not were 31.2%. Who knew that the use of vaginal cleansers containing antiseptics could not prevent cervical cancer were as many as 24.7%, and who considered that using Vaginal cleansers containing antiseptics could prevent cervical cancer as much as 44.2% of all respondents.

Respondents who thought that cervical cancer was transmitted through food contaminated with the virus were 18.2%, who thought cervical cancer was transmitted through saliva, 2.6%, and knew that cervical cancer was transmitted through sexual intercourse—39% of all respondents.

Respondents who think that the initial symptom of cervical cancer is abdominal pain are 36.4%, who think that the initial symptom of cervical cancer is bleeding when urinating is 16.9%, and who know that the initial symptom of cervical cancer is vaginal discharge is as much as 46.8% of the total respondents.

Respondents who think that the advanced symptom of cervical cancer is vaginal discharge are 10.4%, who think that the advanced symptom of cervical cancer is excessive bleeding during menstruation is 66.2%, and who know that the advanced symptom of cervical cancer is weight loss drastic is as much as 46.8% of the total respondents.

Respondents who consider that the risk factor for cervical cancer is the number of births that someone has carried out is 26%, who considers that the risk factor for cervical cancer is malnutrition is 55.8%, and who knows that the risk factor for cervical cancer is old age pregnancy is as much as 18.2% of the total respondents.

Respondents who think that if there is a family who has cancer, it will not affect the risk of cervical cancer in each of them are 58.4%. Who knows that if a family has cancer, the risk of cervical cancer in us will increase five times is as much as 2.6%. Who knows that if a family has cancer, then the cervical cancer risk in us will increase 2x as much as 39% of the total respondents. 

Respondents who think that avoiding cigarette smoke is a form of cervical cancer prevention are 6.5%, who think that eating nutritious food is a form of cervical cancer prevention are 32.5%, and who know that vaccination is a form of cervical cancer prevention are 61 % of the total number of respondents.

Respondents who think that the name of the germ that causes cervical cancer is Streptococcus pneumonia is 24.7%, who thinks that the name of the germ that causes cervical cancer is Pseudomonas aeruginosa is 13%, and who knows that the name of the germ that causes cervical cancer is Human Papilloma Virus is 62.3% of the total number of respondents.

Respondents who think that CT Scan is a form of early examination of cervical cancer are as many as 16.9%, who think that ultrasound is a form of early examination of cervical cancer are as many as 24.7%, and who know that Pap smear is a form of early examination of cervical cancer are as many as 58.4% of the total number of respondents.

Respondents who think that a physiotherapy is a form of cervical cancer treatment are as many as 22.1%, who think that immunization is a form of cervical cancer treatment are 16.9%, and who know that chemotherapy is a form of cervical cancer treatment are 61% of the total respondents. Respondents who do not know whether cervical cancer can be cured or not are 16.9%, who think that cervical cancer cannot be cured as much as 7.8%, and who know that cervical cancer can be cured are 75.3% of the total respondents.

Table 8: Average results of respondents' questionnaire scores about pap smears

Table 9: Number and percentage of respondents in each value of the answer to the questionnaire about pap smears

Table 10: Characteristics of respondents in doing Pap smear

Based on the table above, the data obtained: 66.2% of respondents do not agree with the Pap smear and its requirements, and another 26% agree with and will do the Pap smear. For more details, there is complete data on the frequency distribution of respondents' answers to the questionnaire regarding Pap smears which can be seen in the table below:

Respondents who strongly agree with the statement that pap smears can be done at any time are 40.3%, 44.2% agree, and 15.6% disagree.

Respondents who strongly agree with the statement that pap smears can be done by women who have never had sexual intercourse are 19.5%, those who agree are 50.6%, those who disagree are 24.7%, and those who strongly disagree the statement is as much as 5.2% of the total respondents.

Respondents who strongly agree with the statement that a pap smear should be done by someone who finds suspicious symptoms on his body, especially the reproductive organs, are 31.2%, who agree are 39%, who disagree are as many as 20.8% and those who strongly disagree. Agreeing with the statement is as much as 9.1% of all respondents.

Respondents who strongly agree with the statement that the Pap smear is a special cervical cancer examination are as many as 22.1%. Who agree are 49.4%, and those who disagree are as many as 18.2%. Those who strongly disagree with the statement are as many as 10.4% of all respondents.

Respondents who strongly agree with the statement that pap smears require a large amount of money to be carried out are 22.1%, those who agree are 23.4%, those who disagree are 48.1%, and those who strongly disagree with the statement are as much as 6.5% of the total respondents.

Respondents who strongly agree that pap smears can only be done in hospitals with complete facilities are 32.5%, those who agree are 39%, those who disagree are 19.5%, and those who strongly disagree with the statement 9.1% of the total respondents.

Respondents who disagreed with the statement that someone who had had sexual intercourse should have a Pap smear examination were 48.1%, and 49.1% of the total respondents who agreed with the statement

Respondents who strongly agree with the statement that before having a pap smear, they should not have sexual intercourse 24 hours before are 29.9%, those who agree are 41.6%, those who disagree are 20.8%, and those who strongly disagree the statement is as much as 7.8% of the total respondents.

Respondents who strongly agree that pap smears should be done every three years are 33.8%, those who agree are 50.6%, those who disagree are 37.7%, and those who strongly disagree with the statement are as many as 14.3% of all respondents.

Respondents who strongly agree that pregnant women may perform a Pap smear are 10.4%, 32.5% agree, 33.8% disagree, and strongly disagree with the statement. 23.4% of all respondents.

Respondents who strongly agree with the statement that a Pap smear does not need to be done by women who look healthy and have good sexual behaviour are 15.6%. Those who agree are as many as 20.8%, those who disagree are as many as 50.6%, and those who strongly agree. Disagree with the statement is as much as 13% of all respondents.

Respondents who strongly agree that a husband may forbid his wife to have a pap smear examination are 16.9%, those who agree are 11.7%, those who disagree are 42.9%, and those who strongly disagree with the statement. These are 28.6% of the total respondents.

Respondents who strongly agree with the statement that Pap smears are embarrassing because most examiners are men are 20.8%, those who agree are 26%, those who disagree are 33.8%, and those who strongly disagree with the statement are as much as 19.5% of the total respondents.

Respondents who strongly agree with the statement that the Pap smear as an early examination of cervical cancer does not need to be done because the results will only burden one's mind are 11.7%, those who agree are 32.5%, who disagree are 33.8%, and those who strongly disagree with the statement are as many as 22.1% of the total respondents.

Respondents who strongly agree with the statement that if you get a positive result on a Pap smear, it means you have to be careful and do a re-examination as many as 36.4%. Those who agree are as many as 29.9%, those who disagree are as many as 26%, and those who strongly disagree. Agreeing with the statement is as much as 7.8% of all respondents.

Table 11: The Relationship Between Knowledge Levels About Cervical Cancer In Performing Pap Smear Screening Tests

Table 12: Chi-square test results

Based on the table above, the p-value is 0.03. Because the p-value <0.05, it can be concluded that there is a relationship between the respondent's level of knowledge about cervical cancer in carrying out the Pap smear screening test.

The research results were conducted in Kampung Rawa Panjang Bekasi, respondents who have good knowledge about cervical cancer are 37 people (48.1%), and 40 people have poor knowledge (51.9%). These results indicate that some Kampung Rawa Panjang Bekasi women already know about cervical cancer.

Knowledge of cervical cancer can influence a person in carrying out a Pap smear screening test. With good knowledge, someone will take action based on his knowledge and apply it. In this case, a person will be more concerned about his health, so he will be willing to do self-examinations to avoid disease. On the other hand, the less knowledge a person has about cervical cancer, and the less likely someone will do early detection of cervical cancer using a Pap smear. The low level of public knowledge about cervical cancer can be caused by many factors, including lack of information, experience, and vigilance. To deal with this, relevant agencies such as puskesmas, assisted by local health cadres, introduce cervical cancer more, including definition, handling methods, modes of transmission, signs and symptoms, early detection using Pap smear examinations.

Based on the study results, it was stated that out of 77 respondents, 51 people (66.2%) of them did not agree to do Pap smears, and only 26 people (33.8%) agreed to do it. The results of the researcher's analysis, continuously decreasing every year due to lack of knowledge that influences a woman to take Pap smear examinations, in addition to other factors such as economic factors, feeling afraid of the results of the examination, shyness/reluctant to be examined by someone else. The opposite sex because most gynaecology specialists are male, a culture where society has a paradigm before it is known that the severe disease will not go to the doctor for treatment. 

There are still many respondents who have never had a Pap smear routinely with the provisions of at least once a year. It is following the theory of the American Cancer Society in 2009, which recommended that all women start screening three years after being sexually active for the first time. Retest every 2-3 years, except for high-risk women who have to have the test every year. This study is in line with previous research conducted which shows that the obtained data during 2009 as many as 297 (45.2%) of 658 people, in 2010 there was a decrease of 189 (36.3%) from 521 people and in January - April 2011 as many as 63 people who performs Pap smears ²⁹.

Based on the results of the analysis of the relationship between the level of knowledge about cervical cancer in conducting Pap smear screening tests from 77 respondents, it was found that 31 respondents had poor knowledge of cervical cancer and also did not agree to do Pap smears. So it can be concluded that there is a relationship between the mother's level of knowledge about cervical cancer in carrying out Pap smear examinations in Kampung Rawa Panjang Bekasi. Knowledge is an essential domain for forming one's actions (over behaviour). In this case, knowledge about Pap smears, and the more information obtained, the more knowledge will be obtained ³⁰. This study is in line with research which shows significant results between respondents' insufficient knowledge of cervical cancer and respondents for did not do pap smear examination with Fisher's exact test = 0.004 ^{31; 32}.

The researchers' results, the higher the level of knowledge of a person, the better for a change in the individual's behaviour. On the other hand, as in this study, the lower a person's knowledge about cervical cancer, the lower the interest in doing a Pap smear screening tests. The better a person's level of knowledge about cervical cancer, such as understanding, causes, treatment, and detection of cervical cancer by conducting regular Pap smear examinations, especially for married and sexually active women, the incidence of cervical cancer can be reduced. 

CONCLUSION

Respondents with good knowledge about cervical cancer are 37 people (48.1%), and those with poor knowledge are 40 people (51.9%). Respondents who disagreed with and did Pap smears were 51 people (66.3%) and 26 people (33.7%). There is a relationship between a person's level of knowledge about cervical cancer in carrying out a Pap smear screening test, as evidenced by the Chi-square test with a p-value below 0.05, which is 0.03. Thus, it is hoped that the community, especially women of childbearing age, can actively participate in counselling activities held by health workers, especially regarding reproductive health, to increase knowledge about various diseases that attack the reproductive organs, especially cervix cancer. In addition, the government and related health agencies should provide support by making policies to hold a mandatory Pap smear program for mothers, mothers of low-income families, women commercial sex workers with reduced costs. Then, health institutions are expected to be able to provide the latest references on reproductive health and are also expected to participate and play an active role by way of counselling or health promotion through health centres, family doctors, or local health cadres, especially about the importance of knowledge about cervical cancer and attitudes in carrying out Pap Smear examinations. Considering the health of WUS cannot be separated from the world of health.

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