Determinant of The Act of VIA Test Taking in Puskesmas Ngagel Rejo Area

in Surabaya

Abstract
Cervical cancer is a death cause that can be prevented by the VIA test. Based on the
health profile of Surabaya, the VIA test visits declined. Research related to risk factors for
cervical cancer and VIA test is relatively rare, especially in Puskesmas Ngagel Rejo area, which
has low VIA test rates. The purpose of this study was to analyze the relationship between parity,
age of marriage, and VIA test behavior in Puskesmas Ngagel Rejo in Surabaya. It uses a cross
sectional design. The population was married women of fertile age in Puskesmas Ngagel Rejo
Surabaya area. Sampling was done by cluster sampling method. The required sample is 163
respondents. The statistical tests used were chi-square test, Prevalence Ratio (PR), and 95% CI.
It showed that parity and married age were related to the act of taking the VIA test in women of
fertile age in the Puskesmas Ngagel Rejo area in 2020 with parity p = 0.018 (PR = 2.354; 95%
CI: 1.146 - 4.832) and married age of marriage p = 0.002 (PR = 3.05; 95% CI: 0.160 - 0.668). It
was concluded that multiparous women and women who were married at ≤ 20 years of age had a
chance to undergo the VIA test. The risk factors of cervical cancer, VIA test, and the simple
nature of the VIA test need to be presented to the general audience, especially woman of fertile
age.

Introduction
(1). (2). (3). (4). (5). (6). (7). (8). (9). (10).
(11). (12).
(12). (13).
(14). Primary prevention can be done by educating the target group about high-risk
sexual behavior, while secondary prevention can be done by doing early detection (15).
Screening aims to detect precancerous changes that could progress to cancer if left untreated.
Some early detection methods are visual inspection with acetic acid (VIA), Papanicolaou smear
test (pap smear), cervicography, and HPV test (16). VIA test is an early detection method that
suits a developing country like Indonesia because of its cheap and straightforward process (18).
VIA test is simple, easy, affordable, painless, and the result can immediately be seen without
laboratory interpretation (19).
Puskesmas Ngagel Rejo is a public health center that offers a VIA test with a thorough
facility and competent medical personnel. According to Surabaya’s Health Profile in 2018, it is
known that the number of women who underwent the VIA test at Puskesmas Ngagel Rejo is still
low, around 810 out of 9.170 women in the Puskesmas Ngagel Rejo area (8.83%) (20).
This study used Lawrence Green’s theory (1980) cited in Harahap (2016), which states
that three factors form behavior. Those factors are predisposition factors, enabling factors, and
driving factors (21). The predisposition factor is a factor that comes internally from an
individual. Parity and age of marriage are included in this factor. According to Nordianti (2018),
the VIA test visit is associated with cervical cancer risk factors with a p-value of 0.008. Women
who had a risk factor of cervical cancer are 0.39% more conscious of undergoing VIA test visits
rather than women who aren’t at risk (22). According to Hakimah (2016), there is a correlation
between parity and the act of early detecting cervical cancer (23). But Sri Dewi Handayani’s
study stated otherwise. The said study stated that there is no correlation between parity and the
act of early detecting cervical cancer (24). Study-related to cervical cancer risk factors and VIA
test are relatively rare, especially in Puskesmas Ngagel Rejo area, which has a low number of
VIA test. This study was done to prove whether the risk factors of parity and age of marriage
affect the act of taking the VIA test. The purpose of this study was to analyze the correlation
between parity and age of marriage in the act of taking the VIA test in Puskesmas Ngagel Rejo
Surabaya.
Research Method
This study used an analytic observational design with a cross-sectional study. The
population in this study were all women of fertile age in the area of Puskesmas Ngagel Rejo
Surabaya, which is Ngagel Rejo and Ngagel sub-district, with a total of 14.247 women of fertile
age. The needed sample for this study is 163 married women of fertile age and aged 15-49 years
who live in the area of Puskesmas Ngagel Rejo Surabaya. The determination of the number of
samples is calculated using a sample size formula of two proportions. This study used cluster
sampling by grouping samples from every hamlet (RW) in the area of Puskesmas Ngagel Rejo
Surabaya. There are 12 hamlets in Ngagel Rejo and 5 hamlets in Ngagel. After the women’s
name was acquired, clustering is done in 17 hamlets to know the number of women in each
hamlet who can be used as samples.
The independent variables in this study are the parity and age of marriage, while the
dependent variable in this study is the act of taking the VIA test. This study collects primary data
by distributing questionnaires. Validity and reliability test were done before distributing. The
validity test was done by looking at the correlation between Statistical Package for the Social
Science (SPSS) application and Microsoft Office Excel. It is assumed that if the value of r > 0.3,
then the instrument is valid. The reliability test was done in Statistical Package for the Social
Science (SPSS) application by looking at Cronbach’s Alpha. It is assumed that if the value of
Cronbach’s Alpha > 0.6, then the instrument is reliable. The validity test result shows that the
whole questionnaire component is valid and reliable, with the value of r > 0.3 and Cronbach’s
Alpha > 0.6. This study’s questionnaire consists of questions to gain information from the
respondents, including measured cervical cancer risk factors (parity and age of marriage) and the
act of taking a VIA test. The parity variables are categorized as primiparous (given birth to only
one child) and multiparous (given birth to more than one child). The age of marriage variables is
categorized as women who marry for the first time aged > 20 years and women who marry for
the first time aged < 20 years. The act of taking VIA test variables are categorized as yes (have
taken a VIA test before) and no (have not taken a VIA test before).
The acquired data are then processed and analyzed with SPSS 23, a statistical software.
The data analysis used the chi-square test to determine the correlation between the independent
and dependent variables and used statistical measures using the Prevalence Ratio (PR) and 95%
CI.
Study Result
 According to the primary data analysis carried out in Ngagel and Ngagel Rejo sub-district
in 2020, the following is a table of the frequency distribution of the variables of parity, age of
marriage, and the act of taking VIA test in the area of Puskesmas Ngagel Rejo in 2020:
Table 1. The frequency distribution of the variables of parity, age of marriage, and the act of taking VIA test in
the area of Puskesmas Ngagel Rejo in 2020
Variable Parity Frequency Percentage (%)
Parity Primiparous 50 30,7
Multiparous 113 69,3

Total 163 100

Age of Marriage > 20 years of age 107 65,6

≤ 20 years of age 56 34,4

Total 163 100

Have taken VIA test No 95 58,3
before
Yes 68 41,7

Total 163 100

Source: Primary data

The Frequency Distribution of The Variables of Parity, Age of Marriage, and The Act of
Taking VIA Test in The Area of Puskesmas Ngagel Rejo in 2020
The parity variable shows that 113 out of 163 (69.3%) respondents are multiparous. The
age of marriage variable shows that 107 out of 163 (65.6%) respondents are married at > 20
years. The number of respondents who haven’t taken the VIA test was more than those who took
VIA test, specifically 95 out of 163 respondents (58.3%).
The Correlation Between Parity and The Act of Taking VIA Test in The Area of
Puskesmas Ngagel Rejo
The study showed that the group of respondents who underwent the VIA test was mostly
from the multiparous category, specifically 54 people with a percentage of 79.4%. Meanwhile,
most of the respondents who did not undergo the VIA test were also from the multiparous
category, specifically 59 respondents with a percentage of 62.1%. The parity distribution of
respondents based on the act of taking the VIA test can be seen in the following cross-tabulation
table:
Table 2. Cross-tabulation of the correlation between parity in fertile age women and IVA examination
behavior in the Ngagel Rejo Community Health Center, Surabaya in 2020
Took VIA test before PR
Total
Yes No P-value 95% CI
Parity
n % n % n %

Primiparous 14 20,6 36 37,9 50 30,7 2,354 (1,146-

Multiparous 54 79,4 59 62,1 113 69,3 4,832)
0,018
Total 68 100 95 100 163 100
Source: Primary data
 Table 2 shows a p-value of 0.018 with the PR of 2.354 (95% CI = 1.146 – 4.832) with α =
0,05. P-value is < α, which means there is a correlation between parity and the act of taking the
VIA test. From the Confidence Interval, it is known that CI is not more than 1, which means that
parity has a statistically significant correlation. A respondent that has given birth to more than
one child (multiparous) has a 2.354 bigger chance to undergo a VIA test than a respondent who
gave birth to one child (primiparous).
The Correlation Between Age of Marriage and The Act of Taking The VIA Test in The
Area of Puskesmas Ngagel Rejo
The study showed that most of the respondents who underwent the VIA test first got
married at > 20 years, specifically 54 respondents with a percentage of 79.4%. While the rest
who first got married at < 20 years are 14 respondents with a percentage of 20.6%. The age of
marriage distribution of respondents based on the act of taking the VIA test can be seen in the
following cross-tabulation table:
Table 3. Cross-tabulation of the correlation between age of marriage in fertile age women and IVA
examination behavior in the Ngagel Rejo Community Health Center, Surabaya in 2020
Took VIA test before PR
Total
Yes No P-value 95% CI
Age of Marriage
n % n % N %

> 20 year 54 79,4 53 55,8 107 65,6

≤ 20 year 14 20,6 42 44,2 56 34,4 3,05 (0,160-
0,002
0,668)
Total 68 100 95 100 163 100
Source: Primary data

Table 3 shows a p-value of 0.002 with the PR of 3.05 (95% CI = 0.160 – 0.668) with α =
0,05. P-value is < α, which means there is a correlation between the age of marriage and the act
of taking VIA test. From the Confidence Interval, it is known that CI is not more than 1, which
means that the age of marriage has a statistically significant correlation. Respondents who were
married at > 20 years had a 3.05 times bigger chance of undergoing VIA test than respondents
who were married at ≤ 20 years of age.
Discussion
The Correlation Between Parity and The Act of Taking VIA test in The Area of Puskesmas
Ngagel Rejo
Parity is a condition when a woman has given birth to a live baby. A woman who gives
birth frequently is at greater risk of developing cervical cancer (25). Multiparity is one of the
parity categories which is a risk factor for cervical cancer (26). Multiparity means a woman has
given birth twice or more. According to Novi Eniastina Jasa, a multiparous woman had 14.700
times the risk of developing cervical cancer (27). Having a lot of children will increase the risk
of a woman having cervical cancer. A fetus that passes through the cervix will cause a trauma on
the cervix. This trauma will lead to an infection susceptible to viruses, including Human
Papilloma Virus/HPV that could cause cervical cancer (28). Therefore, a multiparous woman
should have more consciousness about having early detection of cervical cancer. Undergoing a
VIA test is one of the ways.
 It is known that there is a correlation between parity and the act of taking the VIA test.
The results are in line with the theory and expectations that a woman with multiparity as one of
the risk factors of cervical cancer should do early prevention by undergoing a VIA test to detect
the presence of cancer cells in her body. This study is in line with Hakimah (2016) that stated a
correlation between parity and the act of taking the VIA test (29).
The results showed that the number of multiparous respondents who did not undergo a
VIA test was almost the same number of multiparous respondents who did a VIA test. From the
questionnaire, it is known that the reason the respondents didn’t undergo a VIA test was that the
respondents felt healthy and does not feel the symptoms of cervical cancer. This shows that most
multiparous women lack knowledge about cervical cancer. The risk of cervical cancer needs to
be presented to the general audience to generate interest and awareness of the VIA test’s
importance.
The Correlation Between Age of Marriage and The Act of Taking VIA test in The Area of
Puskesmas Ngagel Rejo
The age of marriage is the age where a woman got married for the first time. During a
marriage, sexual activity is sure to happen. However, female reproductive organs need the right
time for sexual activity until pregnancy. At a young age, the reproductive organ is not ready for
pregnancy because the cervical epithelium is not entirely covered by squamous and is not
prepared to accept foreign objects. This is what causes these cells and tissues to be easily injured
and susceptible to viruses, including Human Papilloma Virus/HPV (27).
A study by Gede Raka stated a correlation between age of marriage and the occurrence or
pre-cervical cancer lesion in women who got married at age < 21 years of age (30). The
biologically and psychologically ideal age for marriage is 21-25 years of age. This age is
considered mature, both in mindset and biologically. Women who are at risk because of early
marriage (≤ 20 years of age) should have more consciousness about having early detection of
cervical cancer. One way of early detection is the VIA test.
There is a correlation between the age of marriage and the act of taking the VIA test in
the area of Puskesmas Ngagel Rejo in this study. This is in line with a study by Hakimah that
stated a correlation between the age of marriage and the act of taking the VIA test (29). The
results showed that female respondents who were married at > 20 years old performed more VIA
tests than respondents who were married at ≤ 20 years of age. A study by Idaria Sidabukke also
stated that most women who have sexual intercourse at a young age are less interested in early
detection of cervical cancer. While on the other hand, women who didn’t have sexual intercourse
at a young age are more interested in undergoing the VIA test even though they are not in the
risk group (31).
This is because a woman’s education level is related to the age at which she first got
married. Women who were married at ≤ 20 years of age have a low level of education. It is
predicted that 6.7 percent of women who have elementary education will have an early age
marriage (32). Women who have a low level of education feel that they didn’t need to do early
detection of cervical cancer. Data from the questionnaire also stated that the reason for
respondents who were married at ≤ 20 years of age didn’t undergo VIA tests because they didn’t
know about early detection using the VIA test. Respondent only knew pap smear, which is quite
expensive, as a means of early detection. Some other respondents stated that they were
embarrassed by the VIA test procedure that required opening the genitals.
Conclusions and Suggestions
Conclusions:
Parity does correlate with the act of taking the VIA test. A woman who has given birth to
more than one child (multiparous) has a 2.354 bigger chance of undergoing a VIA test than a
woman who gave birth to one child (primiparous). The age of marriage does correlate with the
act of taking the VIA test. A fertile woman who was married at > 20 years had a 3.05 times
bigger chance of undergoing a VIA test than a woman who was married at ≤ 20 years of age.
Suggestions:
The risk factors of cervical cancer, VIA test, and the simple nature of the VIA test need
to be presented to the general audience, especially women who were married at ≤ 20 years of
age, to generate interest and awareness of the importance of the VIA test. The presentation could
be done in the form of holding seminars or by providing information media in the form of
leaflets or stickers that can be attached so that it can be read by the public, especially the target
group. The formation of VIA ambassadors can be done to facilitate socialization to the
community through meetings or via online so that more people undergo VIA tests.
Thank you note
1. Thank you to the kind respondents. Without you, this study wouldn’t have been possible.
2. Thank you to Puskesmas Ngagel Rejo, who helped the data collection process.
3. Thank you to Ngagel and Ngagel Rejo Sub-district, who helped the data collection process.