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Indonesian Self-Risk Assessment for Cervical Cancer (SiNara): Instrument Development and Validation

*Devita Madiuw  -  Faculty of Health, Universitas Kristen Indonesia Maluku, Indonesia
Yanti Hermayanti  -  Department of Maternity Nursing, Faculty of Nursing, Universitas Padjadjaran, Indonesia
Tetti Solehati  -  Department of Maternity Nursing, Faculty of Nursing, Universitas Padjadjaran, Indonesia
Open Access Copyright (c) 2021 Nurse Media Journal of Nursing
Creative Commons License This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

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Abstract

Background: Women’s ignorance of cervical cancer risk factors has caused low participation in the screening of the disease. Women can independently assess cervical cancer risk factors in themselves through a risk assessment instrument. However, no instruments were found that assessed cervical cancer risk based on the characteristics of Indonesian women.

Purpose: This study aimed to develop and validate an Indonesian self-risk instrument for cervical cancer.

Methods: The instrument was developed based on scale development following the guidelines by DeVellis (2017). A cross-sectional study was implemented to validate the instrument. A total of 20 women were involved in the pre-testing, and as many as 200 women were included in the instrument testing. Based on the scale development guidelines, data collection was initiated with a literature review to determine the instrument construct and item pool. A total of 29 articles were used in the formulation of the item pool and resulted in 38 items for validity and reliability testing. Content validity ratio (CVR) and content validity index (CVI) were used to test the content validity of the instrument, which was reviewed by three experts. Exploratory factor analysis (EFA) with principal component analysis (PCA) method and Kuder-Richardson 20 (KR-20) were used to evaluate construct validity and internal consistency reliability, respectively.

Results: A total of 26 items met the content validity and 21 items met the construct validity evaluation, with five items being removed because they had a loading factor value of <0.4. After the validity were evaluated, the instrument was reduced from 38 items to 21 items. The internal consistency reliability with Kuder-Richardson 20 (KR-20) was 0.807.

Conclusion: The Indonesian self-risk assessment for cervical cancer (SiNara) instrument is of good validity and reliability. However, it needs to be tested in other settings using larger samples to measure its psychometric properties as well as its applicability and acceptability.
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Keywords: Cervical cancer; risk factors; self-risk assessment; women’s health

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  1. Abiodun, O., Fatungase, O., Olu-Abiodun, O., Idowu-Ajiboye, B., & Awosile, J. (2013). An assessment of women’s awareness and knowledge about cervical cancer and screening and the barriers to cervical screening in Ogun State, Nigeria. IOSR Journal of Dental and Medical Sciences, 10(3), 52–58. https://doi.org/10.9790/0853-1035258
  2. Acera, A., Manresa, J. M., Rodriguez, D., Rodriguez, A., Bonet, J. M., Trapero-bertran, M., Hidalgo, P., Sanchez, N., & de Sanjose, S. (2017). Increasing cervical cancer screening coverage : A randomised, community-based clinical trial. PLoS ONE, 0(0), 1–11. https://doi.org/10.1371/journal.pone.0170371
  3. Anthoine, E., Moret, L., Regnault, A., Sbille, V., & Hardouin, J.-B. (2014). Sample size used to validate a scale: a review of publications on newly-developed patient reported outcomes measures. Health and Quality of Life Outcomes, 12, 176. https://doi.org/10.1186/s12955-014-0176-2
  4. Arfailasufandi, R., Mudigdo, A., & Sudiyanto, A. (2016). The effect of obesity, oral contraceptive and passive smoking on the risk of cervical cancer. Journal of Epidemiology and Public Health, 4(3), 189–197. https://doi.org/10.26911/jepublichealth.2019.04.03.06
  5. Armadhani, R., Mudigdo, A., & Budihastuti, U. R. (2019). Path analysis on the determinants of pap smear uptake in women of reproductive age in Tegal, Central Java. Journal of Maternal and Child Health, 4(2), 77–86. https://doi.org/10.26911/thejmch.2019.04.02.03
  6. Bae, H., & Park, H. (2016). Sexual function, depression, and quality of life in patients with cervical cancer. Supportive Care in Cancer, 24(3), 1277–1283. https://doi.org/10.1007/s00520-015-2918-z
  7. Bassal, R., Schejter, E., Bachar, R., Perri, T., Jakobson-setton, A., Ben-david, L. H., Cohen, D., & Keinan-Boker, L. (2016). Risk factors for cervical cancer and CIN3 in Jewish women in Israel - two case control studies. Asian Pasific Journal of Cancer Prevention, 17(4), 2067–2073. https://doi.org/https://doi.org/10.7314/apjcp.2016.17.4.2067
  8. Bjelic-radisic, V., Jensen, P. T., & Kuljanic, K. (2012). Quality of life characteristics inpatients with cervical cancer. European Journal of Cancer, 48(16), 3009–3018. https://doi.org/10.1016/j.ejca.2012.05.011
  9. Bolarinwa, O. A. (2016). Principles and methods of validity and reliability testing of questionnaires used in social and health science researches. Nigerian Postgraduate Medical Journal, 22(4), 195–201. https://doi.org/10.4103/1117-1936.173959
  10. Borruto, F., & Ridder, M. De. (2012). HPV and Cervical Cancer Achievements in Prevention and Future Prospects. Springer Publishing Company, LLC
  11. Budiman, B., Hidayat, Y. M., & Harsono, A. B. (2019). Evaluasi program deteksi dini kanker serviks dengan metode see and treat di Kabupaten Karawang [Program evaluation of cervical cancer early detection using see and threat method in Karawang Subdistrict]. Obgynia, 2(1), 72–80. https://doi.org/10.24198/obgynia.v2n1.77
  12. Canadian Centre for Occupation Health and Safety. (2017). Risk assessment. https://www.ccohs.ca/oshanswers/hsprograms/risk_assessment.html
  13. Cancer Care Ontario. (2019). My cancerIQ. https://www.mycanceriq.ca/
  14. Chandrawati, R. (2016). Faktor risiko yang berpengaruh dengan kejadian kanker serviks di RSUD dr. H. Abdul Moeloek Provinsi Lampung [Risk factors affecting the incidents of cervical cancers in dr H Abdul Moeloek Hospital, Lampung Province]. Jurnal Kesehatan, 7(2), 282–287
  15. Chelimo, C., Wouldes, T. A., Cameron, L. D., & Elwood, J. M. (2013). Risk factors for and prevention of human papillomaviruses (HPV), genital warts and cervical cancer. Journal of Infection, 66(3), 207–217. https://doi.org/10.1016/j.jinf.2012.10.024
  16. Damayanti, I. P. (2013). Faktor-faktor yang berhubungan dengan kejadian kanker serviks di RSUD Arifin Achmad Pekanbaru tahun 2008-2010 [Factors related to cervical cancer’s incidents in Arifin Achmad Hospital Pekanbaru]. Jurnal Kesehatan Komunitas, 2(2), 88-93. https://doi.org/10.25311/keskom.Vol2.Iss2.51
  17. Darmayanti, D., Hapisah, & Kirana, R. (2015). Faktor-faktor yang berhubungan dengan kanker leher rahim di RSUD Ulin Banjarmasin [Factors related to cervical cancers in Ulin Banjarmasin Hospital]. Jurnal Kesehatan, 6(2), 172–177
  18. DeVellis, R. F. (2017). Scale development: Theory and applications (4th ed.). Sage Publications, Inc
  19. Dewi, I. G. A. A. N. (2017). Pendekatan faktor risiko dalam mendeteksi lesi prakanker leher rahim di Kota Denpasar [Risk factor approach in detecting pre-cervical cancer lesions in Denpasar]. Jurnal Infokes Apikes Citra Medika Surakarta, 7(2), 56–62. https://ejurnalinfokes.apikescm.ac.id/index.php/infokes/article/view/185
  20. Dewi, I. G. A. A. N., Sawitri, A. A. S., & Adiputra, I. N. (2013). Paparan asap rokok dan higiene diri merupakan faktor risiko lesi prakanker leher rahim di Kota Denpasar tahun 2012 [Cigarette smoke exposure and self-hygiene are the risk factors of pre-cervical cancer lesions in Denpasar in 2021]. Public Health and Preventive Medicine Archive, 1(1), 84–91
  21. Dewi, N. K., Rejeki, S., & Istiana, S. (2015). Hubungan lama penggunaan kontrasepsi oral pada wanita lebih dari 35 tahun dengan stadium kanker serviks di RSUD Kota Semarang [The relation between the duration of oral contraceptive use on women aged more than 35 years old and cervical cancer stadium in Semarang Regency Hospital]. Jurnal Kebidanan, 4(1), 31–38. https://doi.org/10.26714/jk.4.1.2015.31-38
  22. Dianti, N. R., & Isfandiari, M. A. (2015). Perbandingan risiko ca serviks berdasarkan personal hygiene pada wanita usia subur di Yayasan Kanker Wisnuwardhana Surabaya [The comparisons of cervical cancer risks according to personal hygienes of women at reproductive age in Yayasan Kanker Wisnuwardhana, Surabaya]. Promkes, 4(1), 82–91. https://doi.org/10.20473/jpk.V4.I1.2016.82-91
  23. Diapari, M., Tobing, L., Sahiratmadja, E., Dinda, M., Hernowo, B. S., & Susanto, H. (2014). Human papillomavirus genotypes profile in cervical cancer patients at Dr . Hasan Sadikin General Hospital, Bandung, Indonesia. Asian Pacific Journal of Cancer Prevention, 15(14), 5781–5785. https://doi.org/10.7314/APJCP.2014.15.14.5781
  24. Ezechi, O. C., Gab-okafor, C. V, Ostergren, P. O., & Pettersson, K. O. (2013). Willingness and acceptability of cervical cancer screening among HIV positive Nigerian women. BMC Public Health, 13(46). https://doi.org/10.1186/1471-2458-13-46
  25. Fitrisia, C. A., Khambri, D., Utama, B. I., & Muhammad, S. (2019). Analisis faktor-faktor yang berhubungan dengan kejadian lesi pra kanker serviks pada wanita pasangan usia subur di wilayah kerja Puskesmas Muara Bungo 1 [An analysis of pre-cervical cancer lesion relating factors in women on reproductive age in public health center of Muara Bungo 1]. Jurnal Kesehatan Andalas, 8(4), 33–43. https://doi.org/https://doi.org/10.25077/jka.v8i4.1147
  26. Fraenkel, J. R., Wallen, N. E., & Hyun, H. H. (2011). How to design and evaluate research in education (8th ed.). Mc Graw Hill
  27. Ghebre, R. G., Barrett, S., Osman, S., Adawe, A., Nguyen, H. T., Okuyemi, K. S., & Joseph, A. (2015). Cervical cancer: Barriers to screening in the Somali community in Minnesota. Journal of Immigrant and Minority Health, 17(3), 722–728. https://doi.org/ 10.1007/s10903-014-0080-1
  28. Gray, J. R., Grove, S. K., & Sutherland, S. (2013). The practice of nursing research: Appraisal, synthesis, and generation of evidence (7 ed.). Elsevier
  29. Hendryadi, H. (2017). Validitas isi: Tahap awal pengembangan kuesioner [Content validity: initial stages of questionairre development]. Jurnal Riset Manajemen dan Bisnis FE-UNIAT, 2(2), 169–178
  30. Hidayat, E., Hasibuan, D. H., & Fitriyanti, Y. (2014). Hubungan kejadian kanker serviks dengan jumlah paritas di RSUD Dr. Moewardi tahun 2013 [The relation between cervical cancer incidents and parity numbers in dr Moewardi Hospital in 2013]. JKKI: Jurnal Kedokteran dan Kesehatan Indonesia, 6(3), 128–136
  31. International Agency for Research on Cancer. (2018). Human papillomavirus and related diseases report. In: ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre), pp. 1–67. https://www.hpvcentre.net
  32. Jasa, N. E. (2016). Determinan yang berhubungan dengan kejadian kanker serviks pada wanita di poli kebidanan RSUD DR. H. Abdul Moelek Propinsi Lampung [The determinants of cervical cancer incidents on women in gynecological outpatient clinic at DR. H. Abdul Moeloek Hospital, Lampung Province]. Jurnal Kesehatan, 7(3), 445–454
  33. Khatun, S. F., Khatun, S., Hossain, A. K. M. F., & Nahar, K. (2018). Prolonged use of oral contraceptive pill, a co-factor for the development of cervical cancer. Bangabandhu Sheikh Mujib Medical University Journal, 11(3), 222–225. https://doi.org/10.3329/bsmmuj.v11i3.37279
  34. Kim, Y., Lambe, F. M., Soetikno, D., Wysong, M., Tergas, A. I., Rajbhandari, P., Ati, A., & Lu, E. (2013). Evaluation of a 5-year cervical cancer prevention project in Indonesia: Opportunities, issues, and challenges. The Journal of Obsterics and Gynaecology Research, 39(6), 1190–1199. https://doi.org/10.1111/jog.12052
  35. Kusumawati, Y., N Wiyasa, R., & Rahmawati, E. N. (2016). Pengetahuan, deteksi dini dan vaksinasi HPV sebagai faktor pencegah kanker serviks di Kabupaten Sukoharjo [Knowledge, early detection, and HPV vaccines as preventive factors of cervical cancers in Sukoharjo Subdistrict]. Jurnal Kesehatan Masyarakat, 11(2), 204–213. https://doi.org/10.15294 /kemas.v11i2.4208
  36. Lee, H. Y., & Lee, M. H. (2017). Barriers to cervical cancer screening and prevention in young korean immigrant women: Implications for intervention development. Journal of Transcultural Nursing, 28(4), 353–362. https://doi.org/10.1177/1043659616649670
  37. Lestariningsih, S., & Martini, M. (2013). Faktor-faktor yang berhubungan dengan terjadinya kanker serviks [Factors related to the incidents of cervical cancer]. Jurnal Kesehatan Metro Sai Wawai, 6(1), 16–22. https://doi.org/10.26630/jkm.v6i1.708
  38. Li, N., Franceschi, S., Howell-jones, R., Snijders, P. J. F., & Clifford, G. M. (2011). Human papillomavirus type distribution in 30,848 invasive cervical cancers worldwide: Variation by geographical region, histological type and year of publication. International Journal of Cancer, 128, 927–935. https://doi.org/10.1002/ijc.25396
  39. Linadi, K. E. (2013). Dukungan suami mendorong keikutsertaan pap smear pasangan usia subur (PUS) di perumahan Pucang Gading Semarang [Husband’s support to encourage pap smear participation of fertile couples in Pucang Gading Residence Semarang]. Jurnal Kesehatan Reproduksi, 4(2), 61-71. http://ejournal.litbang.kemkes.go.id/index.php/kespro/article/view/3904
  40. Lubis, A. U. N., Mutiara, E., & Ashar, T. (2015). Pengaruh media leaflet dan film terhadap pengetahuan tentang kanker serviks dan partispasi wanita dalam deteksi dini kanker serviks di Kampung Darek Kecamatan Padangsidempuan Selatan [The effect of leaflet and movies on the knowledge about cervical cancer and women’s participation of cervical cancer early detection in Darek village, South Padangsidempuan subdistrict]. Jurnal Ilmiah PANNMED, 11(3), 158–162
  41. Mingo, A. M., Panozzo, C. A., Diangi, Y. T., Smith, J. S., Steenhoff, A. P., Ramogola-masire, D., & Brewer, N. T. (2015). Cervical cancer awareness and screening in Botswana. International Journal of Gynecology Cancer, 22(4), 638–644. http://dx.doi.org/10.1097/IGC.0b013e318249470a
  42. Ministry of Health Republic Indonesia. (2019). Indonesia health profile data and information 2018. http://www.depkes.go.id/
  43. Mwaka, A. D., Orach, C. G., Were, E. M., Lyratzopoulos, G., Wabinga, H., & Roland, M. (2015). Awareness of cervical cancer risk factors and symptoms: Cross-sectional community survey in post-conflict northern Uganda. Health Expectations, 19, 854–867. https://doi.org/10.1111/hex.12382
  44. Natphopsuk, S., Settheetham-ishida, W., Sinawat, S., Pientong, C., Yuenyao, P., & Ishida, T. (2012). Risk factors for cervical cancer in Northeastern Thailand detailed analysed of sexual and smoking behavior. Asian Pasific Journal of Cancer Prevention, 13, 5489–5495. https://doi.org/10.7314/apjcp.2012.13.11.5489
  45. Nindrea, R. D. (2017). Prevalensi dan faktor yang mempengaruhi lesi pra kanker serviks pada wanita [Prevalence and factors affecting pre cervical cancer lesions on women]. Journal Endurance, 2(1), 53–61. https://doi.org/10.22216/jen.v2i1.1538
  46. Nurhasanah, & Afiyanti, Y. (2017). Factors affecting behaviors of cervical cancer screening using VIA (Visual Inspection with Acetic Acid) method on women in Srengseng Sawah Jakarta Indonesia. UI Proceedings on Health and Medicine, 2, 1–4. Universitas Indonesia. http://proceedings.ui.ac.id/index.php/uiphm/article/view/157/201
  47. Partiwi, N. M., Putra, I. W. G. A. E. P., & Karmaya, I. N. M. (2015). Hormonal contraceptive use and history of sexually transmitted infection as risk factors of the pre‑cancerous cervical lesions. Public Health and Preventive Medicine Archive, 3(2), 138–142. https://doi.org/10.15562/phpma.v3i2.105
  48. Pfaendler, K. S., Wenzel, L., Mechanic, M. B., & Penner, K. R. (2015). Cervical cancer survivorship: Long-term quality of life and social support. Clinical Therapeutics, 37(1), 39–48. https://doi.org/10.1016/j.clinthera.2014.11.013
  49. Prendiville, W. (2011). Risk of cancer in women with cervical precancer: Improving risk assessment and management protocols. Cytopathology, 22(3), 143–145. https://doi.org/10.1111/j.1365-2303.2011.00870.x
  50. Putri, A. R., Khaerunnisa, S., & Yuliati, I. (2019). Cervical cancer risk factors association in patients at the gynecologic-oncology clinic of Dr. Soetomo hospital Surabaya. Indian Journal of Cancer, 13(4), 104–109. https://doi.org/http://dx.doi.org/10.33371/ijoc.v13i4.610
  51. Rahmah, A. H., Winarto, E., & Trisniwati. (2017). Risiko kejadian kanker serviks pada wanita berdasarkan faktor keturunan di RSUD Gambiran Kota Kediri [Risks of cervical cancer incidents on women based on heredity in Gambiran Hospital, Kediri]. VisiKes Jurnal Kesehatan Masyarakat, 16(4), 128–132. http://publikasi.dinus.ac.id/index.php/visikes/article/view/2248
  52. Rasjidi, I. (2009). Epidemiologi kanker serviks [The epidemiology of cervical cancers]. Indonesian Journal of Cancer, 3(3), 103–108
  53. Rimmi, Deaver, U. J., & Srinivasan, P. (2016). A study to identify risk for cervical cancer among women residing in selected rural areas of Haryana. International Journal of Applied Research, 2(6), 591–593. https://doi.org/10.13140/RG.2.1.2801.4327
  54. Rio, S., & Suci, E. S. T. (2017). Persepsi tentang kanker serviks dan upaya prevensinya pada perempuan yang memiliki keluarga dengan riwayat kanker [Perceptions of cervical cancer and its prevention measures on women who have families with the history of cancer]. Jurnal Kesehatan Reproduksi, 4(3), 159–169. https://doi.org/10.22146/jkr.36511
  55. Schroy, P. C., Caron, S. E., Sherman, B. J., Heeren, T. C., & Battaglia, T. A. (2013). Risk assessment and clinical decision making for colorectal cancer screening. Health Expectations, 18(5), 1327–1338. https://doi.org/10.1111/hex.12110
  56. Silalahi, V., Lismidiati, W., & Hakimi, M. (2018). Efektivitas audiovisual dan booklet sebagai media edukasi untuk meningkatkan perilaku skrining IVA [The effectivity of audiovisual and booklet as educational media to increase IVA screening behaviors]. Jurnal Media Kesehatan Masyarakat Indonesia, 14(3), 304–315
  57. Soans, S. C., Valsaraj, B. P., & Lobo, D. J. (2012). A Study to identify the women at risk for cancer cervix and their compliance to a screening test after an individual awareness programme in a selected village of Udupi District, Karnataka. International Journal of Nursing Education, 4(1), 87–90
  58. Studts, C. R., Tarasenko, Y. N., & Schoenberg, N. E. (2013). Barriers to cervical cancer screening among middle-aged and older rural Appalachian women. Journal of Community Health, 38(3), 500–512. https://doi.org/10.1038/jid.2014.371
  59. Sudenga, S. L., Rositch, A. F., Otieno, W. A., & Smith, J. S. (2013). Brief report: Knowledge, attitudes, practices and perceived risk of cervical cancer among Kenyan women of cervical cancer among Kenyan women. International Journal of Gynecology Cancer, 23(5), 895–899. https://doi.org/10.1097/IGC.0b013e31828e425c
  60. Sundari, S., Palimbo, A., & Ella, E. (2017). Factor related to the incident of cervical cancer in obstetrics & gynecology departement at Ulin Hospital Banjarmasin. Dinamika Kesehatan: Jurnal Kebidanan dan Keperawatan, 8(2), 296–303
  61. Syatriani, S. (2011). Faktor risiko kanker serviks di rumah sakit umum pemerintah Dr. Wahidin Sudirohusodo Makassar, Sulawesi Selatan [Risk factors of cervical cancers in Dr Wahidin Sudirohusodo General Hospital, Makassar, South Sulawesi]. Jurnal Kesehatan Masyarakat Nasional, 5(6), 283–288
  62. Thakur, A., Gupta, B., Gupta, A., & Chauhan, R. (2015). Risk factors for cancer cervix among rural women of a Hilly State : A case-control study. Indian Journal of Public Health, 59(1), 10–13. https://doi.org/10.4103/0019-557X.152862
  63. Thapa, N., Maharjan, M., Xiong, Y., Jiang, D., Nguyen, T. P., Petrini, M. A., & Cai, H. (2018). Impact of cervical cancer on quality of life of women in Hubei, China. Scientific Reports, 8(1), 2–10. https://doi.org/10.1038/s41598-018-30506-6
  64. Trifitriana, M., Sanif, R., & Husin, S. (2017). Faktor risiko kanker serviks pada pasien rawat jalan dan rawat inap di departemen obstetri dan ginekologi RSUP Dr. Mohammad Hoesin Palembang [Risk factors of cervical cancers on inpatients and outpatients of the obstetric and gynechology department, Dr Mohammad Hoesin Palembang Hospital]. Biomedical Journal of Indonesia, 3(1), 11–19. https://core.ac.uk/download/pdf/267825365.pdf
  65. Umami, A., Rahardjo, S. S., & Murti, B. (2017). Path analysis on the biopsychosocial determinants and genital hygiene on cervical cancer at Dr. Moewardi hospital, Surakarta, Central Java. Journal of Epidemiology and Public Health, 3(2), 277–290. https://doi.org/10.26911/jepublichealth.2018.03.02.07
  66. University of Rochester Medical Center. (2020). Cervical cancer risk assessment. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=42&contentid=CervicalCancerRisk
  67. Valdez, A., Napoles, A. M., Stewart, S., & Garza, A. (2019). A randomized controlled trial of a cervical cancer education intervention for Latinas delivered through interactive, multimedia kiosks. Journal of Cancer Education, 33(1), 222–230. https://doi.org/10.1007/s13187-016-1102-6.A
  68. Van Erkelens, A., Sie, A. S., Manders, P., Visser, A., Duijm, L. E., Mann, R. M., ten Voorde, M., Kroeze, H., Prins, J. B., & Hoogerbrugge, N. (2017). Online self-test identifies women at high familial breast cancer risk in population-based breast cancer screening without inducing anxiety or distress. European Journal of Cancer, 78, 45–52. https://doi.org/10.1016/j.ejca.2017.03.014
  69. Walker, S., & Hamilton, F. W. (2017). Risk of cervical cancer in symptomatic women aged ≥ 40 in primary care: A case – control study using electronic records. European Journal Of Cancer Care, 26(3), e12706. https://doi.org/10.1111/ecc.12706
  70. Warta, N., Fajar, N. A., & Utama, F. (2015). Pengaruh persepsi terhadap partisipasi wanita usia subur dalam melakukan screening kanker serviks dengan metode Inspeksi Visual Asam Asetat (IVA) di Desa Talang Alur Kabupaten Ogan Ilir [The effect of perception on the participation of women on reproductive age to carry out cervical cancer screening using IVA method in Talang Alur village, Ogan Ilir subdistrict]. Jurnal Ilmu Kesehatan Masyarakat, 6(3), 178–185. https://doi.org/10.26553/jikm.2015.6.3.178-185
  71. World Health Organization. (2014). Comprehensive cervical cancer control: A guide to essential practice (2nd ed.). https://www.who.int/reproductivehealth/publications/cancers/cervical-cancer-guide/en/
  72. World Health Organization. (2020). WHO recommendations on self-care interventions: Human papillomavirus (HPV) self-sampling as part of cervical cancer screening. https://www.who.int/publications/i/item/WHO-SRH-2012
  73. Yuliani, V., Mose, J. C., & Susanto, H. (2019). Perbedaan faktor risiko dan perilaku deteksi dini kanker serviks pada wanita usia subur antara wilayah Parungkuda dengan Palabuhanratu [The difference on the risk factors and cervical cancer early detection behaviors between Parungkuda and Pelabuhanratu]. Jurnal Kebidanan, 5(2), 172–180. https://doi.org/10.33024/jkm.v5i2.1202
  74. Yuviska, I. A., & Amirus, K. (2015). Analisis faktor risiko terjadinya kanker serviks di rumah sakit umum daerah Dr. H. Abdul Moelek Provinsi Lampung [An analysis of cervical cancer risk factors in Dr H Abdul Moeloek Hospital, Lampung Province]. Jurnal Kesehatan Holistik, 9(1), 1–7

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