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Knowledge of cervical cancer, attitude and husband’s support of Pap smear among multiparous women which have Pap’s smear examination in Aviati clinic Padang Bulan Medan

Cervical cancer is a serious health problem and stated as the second cause of death of woman worldwide. Several studies have noted a higher incidence of cervical cancer with increasing parity. Early detection with Pap smear is proven to reduce mortality of patients. Knowledge, attitude and husband’s support contributed to theled womanto follow Pap smear examination. This study explores the knowledge of cervical cancer, attitude and husband’ s support of Pap smearin multiparous women that have Pap smear examination. This research is a quantitative study with cross sectional approach recruited 50 respondents as multiparous women that have Pap smear examination inAviati Clinic, Padang Bulan, Medan. The data were collected by self-reports using structured objectives by questionnaires. The result of this study showed that 66% respondents have high knowledge of cervical cancer and 76% respondents have ahigh attitude of Pap smear, but they almost have low husband’s support of Pap smear including information support (62%), emotional support (46%) and real support (50%). This study has revealed that multiparous women that had Pap smear examination generally had high knowledge about cervical cancer and positive attitude about Pap smear, even most of them had low husband’s support.


Introduction
Cervical cancer stated is the fourth most common cancer in women worldwide, with approximately 530,000 new cases each year, of which 445,000 occur in less developed regions. It is the second most common cancer in women [1] and reports in 2012 by the International Agency for Research on Cancer (IARC), the cancer death currently accounts for about 57% of cases and 65% of cancer deaths worldwide. [2] The estimated incidence of cervical cancer in Indonesia is 17 per 100,000 women. [3] Risk factors classically associated with cervical cancer are the early age of first intercourse, multiple sexual partners, and increasing parity, are sufficiently common that a high percentage of women should do Pap smear screening by these criteria. [4,5] Since the implementation of widespread screening with the Papanicolaou test, rates of cervical cancer in the United States have decreased from 14.2 per 100,000 in 1973 to 7.8 per 100,000 in1994. [6] Screening programs, unfortunately, are rudimentary or nonexistent in many parts of the world.Fewer than 5% of women in developing countries have ever had a Pap test. [7] One reason for the growing development of cervical cancer is caused by low coverage of cervical cancer detection, such as Pap smear in Indonesia. Based on WHO data estimates in 2008, there were only five percents of women in developing countries, including Indonesia who received services. [8] Uptake of screening include of Pap smearremains low in most regions compounded by the lack of basic knowledge women have regarding screening as an opportunity for the prevention of cervical cancer. [9] The variety level of knowledge about cervical cancer that has found in studies from over the world showed that it is needed for improvement in cervical cancer prevention education. [10] Many past studies revealed that the relationship between emotional support and informational support from the husbands or partners playing an important role to encourage the woman to practice Pap smear. [11,12] The purpose of this study is to examine the knowledge of cervical cancer, attitude and husband's support of Pap smear in multiparous women that have Pap smear examination.

Study Area
This study was conducted at a primary care clinic called Aviati Clinic Padang Bulan, located in Jamin Ginting Street 15 Medan North Sumatera in 2017.

2.2.1.Recruiting Methods.
Participants of this study were purposively selected and they were recruited by asked whether they knew other people who met the criteria and might be willing to participate in the research, then followed up on these contacts. Most of the respondents were recruited through friends and participant connection.

2.2.2.Respondents
Characteristics. This study has recruited 50 respondents which were multiparous women, married, aged above 18 years for the purpose of consented information and absent of intercourse at least for 3 days for the better screening of Pap smear.

Data Collection
The data were collected by self-reports using open-ended question and structured objectives by questionnaires consist of respondent's socio-demographic background, knowledge, attitude and husband's support which wereinformation support, emotional support,and real support.

Socio-Demographics Background
The breakdown number of the respondents in each character is as follows.

Knowledge
The level of knowledge of cervical cancer described from respondents' self-reports using open-ended question and structured objectives by questionnaires, consist of definition, etiology, symptoms, risk factor, and stadium of cervical cancer. Majority of the respondents (94%) knew about the term name of virus due to cervical cancer.Meanwhile, only 20% of the respondents knew about the symptom of the late stadium of cervical cancer. Most of the respondents (76%) choose correctly about definition and symptom of cervical cancer. Regarding the knowledge about the high risk of cervical cancer, themajority of respondents (88%) agreed that multipartner is the high risk to have cervical cancer, as well as they, knew about the stadium level of cervical cancer (84%). About 78% respondents choose correctly in the age range that cervical cancer mostly occurs. Only 66% of the respondents could identify the exception of cervical cancer risk factor. Meanwhile, only 44% choose correctly about the reason why cervical cancer can occur in smoker woman.
Inconsistent with this study, another study in Rhode Island,found that all participants in that study had a poor knowledge of cervical cancer and HPV, and greater lack of knowledge about the relationship between HPV and cervical cancer. [13] Another study in Philadelphiashowed womenaged 40 to 70 have decreased HPV and cervical cancer knowledge compared with women aged 19 to 26. [14]  This study found that respondent who had level education as the bachelor had the most high level of knowledge about cervical cancer (n=17). Some studies compared to level education and knowledge, as the study found that college graduates have greater knowledge of human papillomavirus and cervical cancer compared with high school graduates. [14] Furthermore, the study in Nigeria also found that increasing education was significantly associated with knowledge of cervical cancer. [

Attitude
In general, the respondents had a positive attitude by the average and high level towards Pap smear screening. This was because many of them found that Pap smear screening was very important to prevent them from suffering cervical cancer. Many of the respondents showed a positive attitude that disagreed about refused Pap smear examination and neither that it is troublesome and painful. Most of the respondents agreed that they were not comforted and should be embarrassed if Pap's smear examination was performed by the male doctors. Interestingly many of the respondents disagreed that the Pap's smear examination was low cost. Most of the respondents agreed that Pap smear examination was the screening to prevent cervical cancer and multiparity women and woman that has been intercourse should have Pap smear examination. Almost half of therespondents disagreed that using contraception IUD/ implant should have Pap smear examination, and it should be donein women over 60 years old, and at least once in a lifetime. The positive attitudes towards Pap smear screening werealso found in theprevious study in Malaysia [10], but inconsistent result reported byanother study in Semarang. [8]  This study also found that respondent who had level education as the bachelor had the highestlevel attitude about Pap smear. According to the many previous studies that found the high level of knowledge led to apositive attitude. [10]  Respondents that have Pap smear experienced gave the positive attitude of Pap smear examination as well as respondents which never had experience, although all of three respondents which have Pap smear experienced two times gave the high attitude of Pap smearexamination.Consistent with the study that found that respondents which have Pap smear experienced gave the positive attitude of Pap smearexamination as well as respondents which never had experience. [16] Age, ethnicity and previous Pap test experience were significant independent factors associated with preference for selfsampling. [17]

Husband's support
Husband's support consists of information support, emotional support, and real support. Surprisingly most of the respondents had low support from their husband. Some of them even came to the clinic to have pap's smear examination by themselves without accompanied by their husband although they had the specific reason for the absence of their husband.  It was not consistent with another studyinMandalayfoundthat thefactors which are influencing on intention to take Pap smear screening in married women, were high knowledge level and husband and family support, encouragement was significantly associated with their intention. [12] Study in Diyala City, Iraq revealed a very low rate of Pap smear practice and only the husbands' encouragement influenced their decision to undergo a Pap smear screening. [18] Otherwise, a study in Semarang showed that the respondent had high husband's support, and they also found that husband's support and respondents' knowledge had a significant relationship to Pap smearparticipation. [8] The finding of this study showed that most the respondents had low information support from the husband (62%). It was suggested that the respondent had low support in providing solutions to problems, giving advice, direction, advice or feedback. According to several studies, among men, the level of knowledge for cancer of the cervix and Pap smear was quite low. [10] Another study in Singapore found that Singaporean men displayed moderate knowledge of cervical cancer but poor knowledge of HPV. [19] According to this study that found generally, all the respondents had low husband's support, in fact, they keep doing Pap smear examination at clinic even without accompanied by their husband. Interestingly study in Malaysia found that the husband gives more freedom to their wives to choose andmaking a decision on their health due to prominent reason that women know best about their health. [10]

Conclusion
This study has revealed that multiparous women that had Pap smear examination had high knowledge about cervical cancer and positive attitude about Pap smear, even most of them had low husband's support. It is important to launch a sustainable health campaign program about cervical cancer and Pap smear widely through the multimedia, so more people are involved to care about cervical cancer and Pap smear examination as the screening, include of the husbands that need to be aware that women's health is also part of their responsibilities as they are equally responsible for their wives' sexual health.