Wardhani et al.

/ Path analysis on the Determinants of Pap Smear Utilization

Path analysis on the Determinants of Pap Smear Utilization for

Cervical Cancer Early Detection in Women of Reproductive Age
Gesit Kusuma Wardhani1), Ambar Mudigdo2), Isna Qadrijati3)

1)MastersProgram in Public Health, Universitas Sebelas Maret

2)Department of Onkologi, Dr. Moewardi Hospital, Surakarta
3)Faculty of Medicine, Universitas Sebelas Maret

ABSTRACT

Background: Cervical cancer is the fourth most common malignant cancer among women after
breast, colorectal, and lung cancers. Pap smear has been recognized as an effective strategy for
reducing the incidence and mortality rate of cervical cancer. This study aimed to investigate the
determinants of Pap smear utilization for cervical cancer early detection in women of reproductive
age using path analysis model.
Subjects and Method: This was an analytic observational study with a case-control design. The
study was conducted in Cilongok and Ajibarang Sub-districts, Banyumas, Central Java, from
January 3 to February 3, 2018. A total sample of 200 women reproductive age was selected for this
study by fixed disease sampling. The dependent variable was Pap smear utilization. The
independent variables were education level, attitude, perception on the quality health care, access
to the health center, family support, peer support, and health personnel support. The data were
collected by questionnaire and analyzed by path analysis.
Results: Pap smear utilization was positively and directly associated with education (b = 2.63;
95% CI= 1.77 to 3.48 p<0.001), perception on quality of health care (b= 1.04; 95% CI= 0.22 to 1.86;
p= 0.012), attitude (b= 1.48; 95% CI= 0.51 to 2.44 p= 0.003), access to health center (b=1.02; 95%
CI= 0.20 to 1.84 p= 0.015), family support (b= 1.29; 95% CI= -0.22 to 2.61; p= 0.029), and health
personnel support (b= 2.02; 95% CI= 0.60 to 3.45 p= 0.005). Pap smear utilization was indirectly
associated with peer support through perception on quality health care (b = 0.66; 95%= -0.01 to
1.33 p = 0.031).
Conclusion: Education, perception on quality of health care, attitude, access to health center,
family support, and health personnel support are directly associated with Pap smear utilization.

Keywords: Pap smear, cervical cancer, path analysis, education, attitude, perception, family
support, peer support, health personnel support

Correspondence:
Gesit Kusuma Wardhani. Masters Program in Public Health, Universitas Sebelas Maret. Jl. Ir.
Sutami No. 36 A, 57126, Surakarta, Central Java. Email: [email protected].

BACKGROUND In Indonesia, it is estimated that every

Up until now, cervical cancer is still a day, 40-45 new cases occur, 20-25 people
health problem of women in Indonesia in die, meaning that every 1 hour, it is
relation to the incidence and the death rate estimated that a woman died because of
caused by it which is very high. This disease cervical cancer. This is because a third of
is the fourth most common type of malig- cases of cancer including cervical cancer
nant cancer, following breast, colorectal come to health care at an advanced stage
and lung cancer. In developing countries where cancer cells have spread to other
cervical cancer is in the first place (Rasjidi, organs (Septadina, 2015).
2009). Considering the weight caused by
cervical cancer in terms of life expectancy,

e-ISSN: 2549-1172 359

Journal of Health Promotion and Behavior (2017), 2(4): 359-370
https://doi.org/10.26911/thejhpb.2017.02.04.08

the duration of suffering, and the high cost infrastructure or health facilities for the
of treatment, it is better if people pay community such as puskesmas, hospitals,
greater attention to the disease and posyandu, polindes, and so on); and
increase the preventive efforts that can be reinforcing factors (factors that reinforce
done (Bustan, 2007). According to Rasjidi the occurrence of behaviors such as the
(2009), if the disease is not immediately support of a husband or family, community
detected and treated, patients with cervical leaders, peers, religious leaders, health
cancer-without metastasis to the lymph workers, laws, regulations and so on).
nodes will only have 5 Year Survival Rate Based on preliminary study results
(5-YSR) or survive for 5 years. through interviews of 10 women who have a
One reason for the growing develop- partner in May 2017 in Cilongok sub-
ment of cervical cancer is caused by the low district, Banyumas regency, only 10% of
coverage of early detection of cervical women have had pap smear due to full
cancer, such as pap smears. Based on WHO support from their husbands, while others
data estimation in 2008, only 5% of women have never done pap smear examination
in developing countries, including Indo- with no reason to know and have never
nesia are receiving services, whereas effec- received information about cervical cancer
tive screening coverage is needed to reduce and papsmear. About 20% of them are
morbidity and mortality from cervical because of the cost limitation because they
cancer is 85% (Linadi, 2013). do not have BPJS card and have difficulty
According to Arum (2015), pap access to Pap smear examination.
smears can detect cervical cancer by finding Several efforts have been made by the
premalignant and malignant processes in local government of Banyumas Regency to
ectocervix and infections in endocervix with cope with the incidence of cervical cancer,
90% -95% specificity and 90% accuracy. one of them is through free pap smear
This is one of the advantages of Pap smear screening in collaboration with BPJS
tests compared to Visual Inspection with Kesehatan and some public health center in
Acetic Acid (IVA) with specificity of 64% - Banyumas Regency, but in fact this effort
98% and positive predictive value of 10% - has not been effective yet increase the
20% and accuracy of 85%. active role of women of childbearing age in
According to Rokhmawati (2011), Banyumas Regency in making preventive
behavior is still a barrier on Female Age efforts early detection of cervical cancer
Fertile to perform early detection of servical with pap smear method. The purpose of
cancer. The process of formation or change this study is to analyze the determinants of
of behavior can be influenced by various early detection of cervical cancer Pap smear
factors both from inside and outside of the method in women of childbearing age in
individuals. Banyumas Regency ".
Based on Lawrence Green (1980),
behavior is determined by three main SUBJECTS AND METHODS
factors namely; predisposing factors 1. Study Design
(factors that facilitate the occurrence of This was an analytic observational study
behaviors such as knowledge, attitude, with a case control design. The study was
perception, education level, socioeconomic conducted in Ajibarang and Cilongok
level); Possible factors (access to health districts, Banyumas regency, from January
services, availability of facilities and 3 to February 3, 2018.

360 e-ISSN: 2549-1172

 Wardhani et al./ Path analysis on the Determinants of Pap Smear Utilization

2. Population and Samples questionnaire. The measurement scale was

The target population of the study was continuous, but for the purpose of data
women of childbearing age. While the analysis, it was transformed into dichoto-
source population in this study was Women mous, coded 0 for poor access and 1 for
Age Fertile (WUS) in Ajibarang and good access.
Cilongok districts. A sample of 200 study Family support was defined as all the
subjects was selected by fixed disease attitudes and behaviors of the family in
sampling. giving encouragement and attention to the
3. Research Varibles subjects, both emotional, physical support,
The independent variable in this study was and information to perform pap smear
the perception of service quality, attitude, examination. The data were collected by
education, access of health service, family questionnaire. The measurement scale was
support, peer support, support of health continuous, but for the purpose of data
worker, while the dependent variable was analysis, it was transformed into dichoto-
the pap smear use. mous, coded 0 for weak support and 1 for
4. Operational definition of variables strong support.
The perception of service quality was Peer support was defined as the
defined as the response or opinion of the encouragement, information, and open and
subject to the quality of services provided positive nature provided by peers in both
by health personnel. The data were collect- emotional, real, and information support so
ed by the SERVQUAL questionnaire (15 that the subjects are willing to perform a
questions). The measurement scale was Pap smear examination. The data were
continuous, but for the purpose of data collected by questionnaire. The measure-
analysis, it was transformed into dichoto- ment scale was continuous, but for the
mous, coded 0 for poor and 1 was good. purpose of data analysis, it was transform-
Attitude was defined as the response ed into dichotomous, coded 0 for weak
or the closed response of the subject to the support and 1 for strong support.
examination of early detection of cervical Health personnel support was defined
cancer Pap smear method. The data were as encouragement, information, and posi-
collected by questionnaire (10 questions). tive attitude provided by health personnel,
The measurement scale was continuous, both emotionally, physically, and informa-
but for the purpose of data analysis, it was tion support so that the subject are willing
transformed into dichotomous, coded 0 for to perform the pap smear examination. The
negative and 1 was positive. measurement scale was continuous, but for
Education was defined as the highest the purpose of data analysis, it was trans-
level of formal education that has been formed into dichotomous, coded 0 for weak
taken. The data were collected by question- support and 1 for strong support.
naire. The measurement scale was catego- The use of Pap smear test was defined
rical, coded 0 for <Senior high school and 1 as a form of action performed by WUS in
for ≥Senior high school. the form of early detection of cervical
The definition of access to health cancer with Pap smear method within the
services was defined as access or distance last 1 year. The measuring tool was a
traveled by Fertile Age Women from home register book of Pap smear. The measure-
to health services to perform pap smear ment scale was categorical, coded 0 for
examination. The data were collected by never done the pap smear examination and

e-ISSN: 2549-1172 361

Journal of Health Promotion and Behavior (2017), 2(4): 359-370
https://doi.org/10.26911/thejhpb.2017.02.04.08

1 for have done a pap smear examination in was done by calculating the total-item
last 1 year. correlation and Cronbach alpha.
5. Data Collection 6. Data Analysis
The variables of perceptions of service The characteristics of sample perception
quality, attitude, family support, peer data on service quality, attitudes, educa-
support, health personnel support were tion, access to health services, family
measured by questionnaires. While the support, peer support, health personnel
variables of education, access to health support were described in n and%.
service and the use of Pap smear test were The bivariate analysis was done using Chi-
measured by checklists. square test.
The research instruments were The data were analyzed by using path
questionnaires and medical records. The analysis, with the following steps:
validity test in this study was conducted on a. Estimation
20 women of childbearing age in Cilongok b. Model specification
district. The face validity has been consult- c. Model fit
ed to prof. Dr. Ambar Mudigdo, dr., Sp. PA d. Model re-specification
(K) and Dr. Eti Poncorini Pamungkasari, 7. Research Ethics
dr., M.Pd. The research ethics included research
The reliability test in this study was approval, anonymity, and confidentiality.
conducted on 20 women of childbearing
age in Cilongok district. The reliability test RESULTS
1. Univariate analysis
Table 1. Sample characteristics
Variable n %
The perception of service quality
Good Perception 107 53.5
Bad perception 93 46.5
Attitude
Positive attitude 61 30.5
Negative attitude 139 69.5
Fertile Age Women Education
High 136 68
Low 64 32
Access to Health Services
Good access 108 54
Poor access 92 46
Family Support
Good support 14 7
Poor support 186 93
Peer Support
Good support 152 76
Poor support 48 24
Health personnel support
Good support 180 90
Poor support 20 10

362 e-ISSN: 2549-1172

 Wardhani et al./ Path analysis on the Determinants of Pap Smear Utilization

Table 2. Chi-square analysis of perceptions of service quality, attitudes,

education, access to health services, family support, peer support, support of
health workers with the use of pap smear tests
Pap smear use 95% CI
Variable Category No Yes OR Lower Upper p
n % n % Limit Limit
Perception of Poor 45 48.4% 48 51.6% 3.07 1.67 5.63 <0.001
service quality perception
Good 25 23.4% 82 76.6%
perseption
Attitude Negative 59 42.4% 80 57.6% 3.35 1.60 6.98 <0.001
Positive 11 18% 50 82%
Education Low 44 68.7% 20 31.3% 9.30 4.71 18.36 <0.001
High 26 19.1% 110 80.9%
Access Poor 46 50% 46 50% 3.50 1.90 6.44 <0.001
Good 24 22.2% 84 77.8%
Family Poor 69 37.1% 117 62.9% 7.66 0.98 59.88 0.023
support Good 1 7.1% 13 92.9%
Peer Support Poor 23 47.9% 25 52.1% 2.05 1.06 3.98 0.031
Good 47 30.9% 105 69.1%
Health Poor 15 75% 5 25% 6.81 2.36 19.69 <0.001
personnel Good 55 30.6% 125 69.4%
support

Table 2 presents bivariate analyzes of was a positive correlation between

perceptions of service quality, attitudes, perception of health service quality and Pap
education, access to health services, family smear use (OR = 3.07; 95% CI = 1.67 to
support, peer support, support of health 5.63; p <0.001).
workers with the use of Pap smears. There

Figure 1. The specification model of path analysis

e-ISSN: 2549-1172 363

Journal of Health Promotion and Behavior (2017), 2(4): 359-370
https://doi.org/10.26911/thejhpb.2017.02.04.08

Table 3. The result of path analysis determinant of pap smear use

CI 95 %
Independent
Dependent Variable b SE Lower Upper p
Variable
Limit Limit
Direct effect
Pap smear use  Attitude 1.48 0.49 0.51 2.44 0.003
Pap smear use  Education 2.63 0.43 1.77 3.48 <0.001
Pap smear use  Family support 2.64 1.21 0.26 5.02 0.029
Pap smear use  Access to health 1.02 0.41 0.20 1.84 0.015
service
Pap smear use  Health personnel 2.02 0.72 0.60 3.45 0.005
support
Pap smear use  The perception of 1.04 0.41 0.22 1.86 0.012
service quality
Indirect Effects
Health personnel support  Access to health 1.69 0.57 0.56 2.83 0.003
service
The perception of service  Family support 1.29 0.67 -0.02 2.61 0.055
quality
The perception of service  Peer support 0.66 0.34 -0.003 1.33 0.051
quality
N Observation = 200
Log likehood = -397.16

There was a positive relationship support of health workers and perceptions

between attitudes and the use of Pap of service quality with the use of pap
smears (OR = 3.35; 95% CI = 1.60 to 6.98; smears and increased logs to perform pap
p <0.001). There was a positive correlation smear examinations, and the relationship
between education and the use of Pap was statistically significant.
smears (OR = 9.30; 95% CI = 4.71 to 18.36; There was also an indirect relation-
p <0.001). ship between access to health services with
There was a positive relationship the use of pap smears through the variable
between access to health services and the support of health personnel and the
use of Pap smears (OR = 3.50; 95% CI = relationship was statistically significant.
1.90 to 6.44; p <0.001). There was also an indirect relationship
There was a positive relationship between family support and peer support
between family support and Pap smear use with the use of pap smears through the
(OR = 7.66; 95% CI = 0.93 to 59.88; p perceptual variables of health service
<0.001). quality and the relationship was statistically
There was a positive relationship significant.
between peer support and Pap smear use
(OR = 2.05; 95% CI = 1.06 to 3.98; p DISCUSSIONS
<0.001). There was a positive relationship 1. The relationshiop between per-
between the support of health personnel ception on the quality of health
and the use of Pap smears (OR = 6.81; 95% center and Pap Smear utilization
CI = 2.36 to 19.69; p <0.001). The result of this study showed that there
Table 3 shows that there was a direct was a relationship between perception on
correlation between attitudes, education, the quality of health center and Pap Smear
family support, access to health services, utilization. The better the quality of health

364 e-ISSN: 2549-1172

 Wardhani et al./ Path analysis on the Determinants of Pap Smear Utilization

services on Pap Smears, the greater the Pap Smear utilization. This study is consis-
willingness of women in reproductive age tent with a study by Ketut (2011) about the
(WRA) to perform the Pap Smear test. relationship between knowledge and
Research subjects stated that the quality of WRA’s attitudes on Pap Smear test in
health services in health center was already Sukawati II health center. The result of
good and proper, so WRA was satisfied the study showed that attitude was
with the services provided. The services strongly related to Pap Smear test.
include the expertise of health personnel, Sakanti (2007) also stated that all
health personnel response/responsiveness, women who perform early detection of
security guarantees of service, empathy of cervical cancer check-up have a positive
health personnel, hygiene, and comfortable attitude towards early detection of cervical
places and service equipments. cancer.
This study is consistent with a study Based on the result of this study, it
by Mursyida (2012), which stated that was known that most women in repro-
quality of service was closely related to ductive age were afraid of doing Pap
satisfaction, satisfaction was able to provide Smears tests because they were worried
a good foundation for behavior change and about the results of the tests that may
mothers' re-visit, as well as spreading the diagnosed them to have cervical cancer.
recommendation. There were also some mothers who feel
It can be concluded that if the quality embarrassed because the Pap Smear test
of health services was not guaranteed, then required them to show their genitals part to
it would affect the perception of the other people. Mothers assumed that Pap
recipients of health services and would be a Smear tests were not neccessary because
barrier to the mothers to perform a health the mothers did not have history of cancer.
service, including Pap Smer test. Mothers felt the need to do an early
This study is consistent with a study examination of cervical cancer if there were
by Candraningsih (2011) who stated that some symptoms of cervical cancer such as
several constraints to Pap Smear test were bleeding and vaginal discharge.
the mothers felt embarrassed and afraid to Most of the subjects of this study were
check their cervical reproductive organs to mothers who worked outside the house.
health personnels, and the lack of sources 16.5% of mothers who did not do Pap smears
of information and facilities or health test were working as laborers/farmers, entre-
services for Pap Smear test. Therefore, the preneurs, private employees, and civil
facility and quality of a health service was servants. Mothers assumed that they did not
considered very important for a health have free time to perform health services
service provider. If the quality of health except services that were considered import-
ant, such as pregnancy check or did the
services was good, then the perception of
treatment due to illness.
the recipient would be good as well,
Regarding the positive attitudes on Pap
therefore, it increased the willingness of
Smear utilization, 35% of mothers were
WRA to perform health services, especially
housewives, therefore, mothers have more
Pap Smear test.
time and opportunity to attend a health
2. The relationship between attitude center. This suggested that the type of
and Pap Smear utilization employment greatly affect the maternal
The result of this study showed that there attitudes to perform Pap Smear tests.
was a relationship between attitude and

e-ISSN: 2549-1172 365

Journal of Health Promotion and Behavior (2017), 2(4): 359-370
https://doi.org/10.26911/thejhpb.2017.02.04.08

Based on the description above, the Based on the researcher's observation,

researcher suggested that someone’s the distance of health service facility of Pap
attitude would affect the action to be smear test in Cilongok and Ajibarang has
performed. Attitude would give the person been reached by the community. The
a basis to behave in a particular way he/she mileage was not too far which was 3-5 km,
choose. Mothers who have negative the highway was not damaged, and there
attitudes tend to behave negatively, and were many available public transportations.
vice versa. This condition was very supportive for
3. The relationship between educa- WRA in doing Pap Smear test.
tion and Pap Smear utilization Another factor was the support of
According to Dewi (2010), education can health personnels, WRA with good access
affect someone’s behavior to formed life- and who initially intended to perform other
style, especially in motivating the attitude health services were educated and persua-
to participate and also in health develop- sive by health personnel, therefore, WRA
ment. Generally, the higher a person's was interested to conduct Pap Smear tests.
education, the easier it was to receive infor- This often happened in reality so that it can
mation. The result of this study showed that increase the coverage of Pap Smear test.
there was a significant relationship The distance of health facilities that
between education and Pap Smear utiliza- provide affordable Pap smear test services
tion. The result of this study was in accord- for WRA would increase the utilization of
ance with Green (1980) who stated that Pap smear test, because the distance limit
education greatly affected on health beha- the ability and willingness of women to seek
vior. This was also in line with Handoko services, especially if the availability of
(2011) who stated that human's behavior transportation was limited, difficult
was determined by his/her thinking ability. communication, and if there was no place
The higher the level of education and for services in that area.
consciously also perform actions to fulfill This study is consistent with a study
the desires and needs. by Susanti (2012) which stated that there
Based on the results, it can be was a significant relationship between the
concluded that highly educated people availability of health services and behavior-
would have wider knowledge than the low- al test of early detection of cervical cancer.
educated people, therefore, they would This study is consistent with a study by
have a better attitude towards the import- Rohmawati (2011) which stated that there
ance of early detection of cervical cancer, in was a significant relationship between the
this case was the method of Pap Smear. reachable distance to the service of early
4. The relationship between access to detection of cervical cancer (health center)
health services and Pap Smear with the behavior of early detection of
utilization cervical cancer.
The result of this study showed that there Green (1980) stated that the distance
was a direct relationship between access to and the availability of transportations were
health services and Pap Smear utilization. the enabling factors of an accomplished
There was also an indirect relationship motivation. Basic Health Research (2010)
through positive relationship between reported that the ease of access and
access and Pap Smear utilization through utilization of health services were related to
health personnel. several determinants, one of them was the

366 e-ISSN: 2549-1172

 Wardhani et al./ Path analysis on the Determinants of Pap Smear Utilization

distance of residence to health service in the society that was suspected to be the
facilities, therefore, it can be concluded that cause of the mothers to not conduct Pap
access to health services has an important Smear test even though she has a good
effect on the occurrence of a health service. education and work. This indicated the
If the access was good, it would encourage existence of cultural values that have
the mothers to perform a health service, changed the perception and behavior of
especially Pap Smear test. mothers in making decisions. Mothers felt
5. The relationship between family that every decision taken should be based
support and Pap Smear utilization on the husband's decision. Mothers who
The result of this study showed that there did not get support from their husbands felt
was a significant relationship between that their husbands did not know about
family support and Pap Smear utilization. women's health issues. Similarly, mothers
Family support was related to Pap Smear who have a positive attitude would not do a
utilization through perception on quality of Pap Smear test if they did not get positive
health care. This study is consistent with a supports from their husband. As long as the
study by Purba (2011) which stated that an mother did not complain about certain
important factor in encouraging the symptoms, then the husbands would think
mothers to perform test of early detection that the mothers were healthy.
of cervical cancer was the closest people Based on the result of this study, the
which were husband and family. researcher can concluded that if the
This study is consistent with a study mothers have awareness and interest in the
by Kinanti (2012) which stated that there Pap Smear from themselves and get the
was a relationship between family support support from their husbands/families
and the implementation of Pap Smear on (emotional support, real support and infor-
reproductive age couple (RAC) in Pustang mation/knowledge support) it can signi-
Gading Housing Semarang in 2012. ficantly increase the maternal desire to
Family was a reinforcing factor that perform pap smear test.
can affect WRA behavior. More husband 6. The relationship between peer
mobility also help them to get information support and Pap Smear utilization
about cervical cancer and Pap Smear from The result of this study showed that there
their work environment. The support given was an indirect positive relationship
by the family or husbands was positive between peer groups and Pap Smear
response if the mothers invited discussion utilization. This study is consistent with a
on women's health issues, two of them was study by Sri Wahyuni (2013) which stated
cervical cancer and Pap Smear. Families that peer group support was related to the
who responded well would be followed by behavior of early detection of cervical
the provision of financial support for the cancer.
cost of a Pap smear test, and the husband/ From the questionnaires used in this
family expressed no objection when the study, it was showed that most of them
mothers asked to be taken to the Pap Smear assumed that WRA often did association
test. Most of the supportive husband would with peers, and in the forum WRA did a lot
have the initiative to motivate the mothers of ideas exchange with each other. WRA
to conduct Pap Smear test. claimed that they got many information
Based on the result of the study, it was and recommendations about health from
showed that there was patriarchal culture their friends, and most of WRA was

e-ISSN: 2549-1172 367

Journal of Health Promotion and Behavior (2017), 2(4): 359-370
https://doi.org/10.26911/thejhpb.2017.02.04.08

accompanied by their friends to do a cancer test. The result of this study was in
consultation to health personnels in order line with Rohmawati (2010), who stated
to get information about Pap Smear. The that in a population, the support from
invitation from peer simply affected the health personnel was related to maternal
maternal decision to conduct the test, behavior in Pap Smear test. Romadani
especially if the person who invited was a (2014) also stated that lack of support from
close friend, because usually the mother health personnel became a great factor on
believed in the stories of their peers. the delay of early detection of cervical
This study is consistent with a study cancer.
by Parapat (2016) which stated that many According to Bascommetro (2009),
mothers who eventually decided to do the when a person was important to mothers,
test after being told by the their friends who then the mothers tend to agree and did
invite them to conduct the test, therefore, what that person was saying or doing.
the mothers actually did Pap Smear test. These important people were often referred
Based on the results of this study, it to as reference groups, among others;
can be concluded that peer groups can teachers, religious scholars, customary
provided support and motivation to change chiefs (tribes), headman, and the like.
the perception of Pap Smear, the quality of Health personnel was a source of health
health care, and cervical cancer, therefore, information and in this case was Pap Smear
this can provide support for the mothers to test.
perform early detection of cervical cancer. This study is consistent with a study
The supports can be in the form of by Sakanti (2007) which stated that women
emotional support including an attentive who were suggested by health personnel to
expression, instrumental support including conduct health check up tend to have a
material support, and informational strong desire to conduct such tests.
support. To increase the coverage of the Pap
7. The relationship between health Smear service, it can also be done by
personnel and Pap Smear inviting the mothers to conduct Pap Smear
utilization test. Because based on the experience, the
The result of this study showed that there
majority of WRA were willing to conduct
was a relationship between health person-
Pap Smear test if they were invited by the
nel and Pap Smear utilization. The propor-
officer or health cadre.
tion of WRA who received good support
from health personnel (62.5%) was greater
REFERENCES
to perform Pap Smear than WRA who have
Ali M, Asrori M (2014). Metodologi dan
lack of support from health personnel
Aplikasi Riset Pendidikan. Jakarta :
(27.5%).
Bumi Aksara.
Based on the results of the study
Arum SP (2015). Stop Kanker Serviks. Yog-
above, it can be seen from the support of
yakarta: Notebook.
health personnel in research subjects' point
Bascommetro (2009). Konsep Perilaku
of view which was quite good, due to the
Kesehatan. http://www.bascommet-
active role of health personnel in providing
ro.com/2009/05/konsep-perilaku-
health education about Pap Smear test, and
kesehatan.html. Diakses 08 Januari
it helped the research subjects to know the
2018 jam 19.40WIB.
importance of early detection of cervical

368 e-ISSN: 2549-1172

 Wardhani et al./ Path analysis on the Determinants of Pap Smear Utilization

Bustan (2007). Epidemiologi Penyakit Ti- di Puskesmas Candiroto Kabupaten

dak Menular. Jakarta: Rineka Cipta. Temanggung. Jurnal Kesehatan
Candraningsih (2011). Hubungan Tingkat Masyarakat. Volume 4, Nomor 4.
Pengetahuan WUS Tentang Kanker Purba EM (2011). Faktor-Faktor yang
Serviks dengan Praktek Deteksi Dini Berhubungan dengan Pemeriksaan
Kanker Serviks di BPS Is Manyaran Pap smear pada Pasangan Usia subur
Semarang. Jurnal Penelitian. (PUS) di Puskesmas Belawan Kota
Depkes RI (2007). Pedoman Penemuan Medan Tahun 2011. Skripsi: FKMUI.
dan Penatalaksanaan Penyakit Kan- Rasjidi I (2008). Modalitas Deteksi Dini
ker. Jakarta. Kanker Serviks. Jakarta: Sagung Seto.
_____ (2009). Pencegahan Kanker Leher _____ (2009). Deteksi Dini Pencegahan
Rahim dan Kanker Payudara.Jakarta. Kanker pada Wanita. Jakarta: Sagung
Dewi (2010). Teori dan Pengukuran Seto.
Pengetahuan, Sikap dan Perilaku _____ (2009). Epidemiologi Kanker
Manusia. Yogyakarta : Nuha Medika. Serviks. Indonesian Journal of Can-
Handoko BS (2011). Manajemen Pema- cer, III, 103-108.
saran-Analisis Perilaku. Konsumen. Riskesdas (2010). Laporan Nasional Riset
Yogyakarta : BPFE. Kesehatan Dasar. Jakarta: Badan
Linadi KE (2013). Dukungan Suami Penelitian dan Pengembangan Dasar.
Mendorong Keikutsertaan Pap Smear Rohmawati I (2011). Faktor – Faktor yang
Pasangan Usia Subur (PUS) di Berhubungan dengan Perilaku Wanita
Perumahan Pucang Gading Se- Usia Subur dalam Deteksi Dini
marang. Jurnal Kesehatan Repro- Kanker Servik dengan Metode IVA
duksi, 4, 61-71. (Inspeksi Visual Dengan Asam Asetat)
Mursyida RF (2012). Kepuasan Ibu Hamil Di Wilayah Kerja Pusksesmas
Dan Persepsi Kualitas Pelayanan Ngawen I Kabupaten Gunung Kidul
Antenatal Care Di Puskesmas Tanjung Tahun 2011. Skripsi. Jakarta, FKMUI.
Kabupaten Sampang Madura. Media Sakanti A (2007). Faktor-faktor yang
Kesehatan Masyarakat Indonesia, Berhubungan dengan Perilaku Pe-
11(2). meriksaan Pap Smear pada Wanita
Murti B (2013). Desain dan Ukuran Sampel Usia Subur di Puskesmas Kecamatan
Untuk Penelitian Kuantitatif dan Makasar Tahun 2007. Jakarta, FKM
Kualitatif di Bidang Kesehatan. UI.
Yogyakarta: Gadjah Mada University Septadina IS (2015). Upaya Pencegahan
Press. Kanker Serviks Melalui Peningkatan
Ni Ketut M (2013). Hubungan karakteristik Pengetahuan Kesehatan Reproduksi
pengetahuan dan sikap wanita usia WanitaJurnal Pengabdian Sriwijaya,
subur dengan tindakan pemeriksaan 223.
pap semar di Puskesmas Sukawati II. Susanti I (2010). Hubungan usia pertama
Universitas udayana denpasar. Tesis. kali berhubungan seksual dan jumlah
FKM Universitas Udayana. pasangan seksual dengan kejadian
Parapat FT (2016). Faktor Faktor yang lesi pra-kanker leher rahim pada
Berhubungan dengan Perilaku De- wanita yang melakukan deteksi dini
teksi Dini Kanker Leher Rahim menggunakan metode inspeksi visual
Metode Inspeksi Visual Asam Asetat dengan asam asetat (IVA) di

e-ISSN: 2549-1172 369

Journal of Health Promotion and Behavior (2017), 2(4): 359-370
https://doi.org/10.26911/thejhpb.2017.02.04.08

Puskesmas cikampek, Pedes, dan tahun 2009–2010. Tesis. Jakarta.

Kota Baru Kabupaten Karawang

370 e-ISSN: 2549-1172