Path Analysis on the Biopsychosocial Determinants and Genital Hygiene on Cervical Cancer at Dr. Moewardi Hospital, Surakarta, Central Java

Afriza Umami, Setyo Sri Rahardjo, Bhisma Murti


Background: Cervical cancer is the fourth most common cancer in women worldwide and the second most common cancer in women in developing countries after breast cancer. The prevalence of cervical cancer in Indonesia was 0.8‰ with an estimated 98.692 cases. This study aimed to determine the biopsychosocial and genital hygiene factors for cervical cancer.

Subjects and Method: This was an analytic observational study with a case-control design, conducted at Dr. Moewardi Hospital, Surakarta, from December 2017 to February 2018. A total of 178 study subjects including 95 women with cervical cancer (case) and 83 women without cervical cancer (control) were selected by fixed disease sampling. The dependent variable was cervical cancer. The independent variables were the age at first sexual intercourse, a number of sexual partners, body mass index (BMI), stress, education, income, and genital hygiene. Cervical cancer data was collected by medical record. The other data were collected by questionnaire. The data were analyzed by path analysis model.

Results: The risk of cervical cancer increased with the number of sexual partner >1 (b=1.91; 95% CI= 0.31 to 3.49; p=0.019), BMI ≥25 (b= 0.98; 95% CI= -0.06 to 2.04; p=0.067), and stress (b= 1.59; 95% CI= 0.39 to 2.80; p=0.009). The risk of cervical cancer decreased with higher education (b= -3.58; 95% CI= -4.77 to -2.39; p<0.00­1), higher income (b= -1.49; 95% CI= -2.73 to -0.25; p=0.019), age at first sexual intercourse ≥18 years (b= -1.36; 95% CI= -2.52 to -0.21; p= 0.020), and genital hygiene (b= -1.24; 95% CI= -2.35 to -0.13; p=0.028).­ Income increased with higher education (b= 2.48; 95% CI= 1.71 to 3.25; p<0­.001). Genital hygiene increased with education (b= 1.16; 95% CI= 0.47 to 1.86; p=0.001). Age at first sexual intercourse ≥18 years increased with higher education (b= 1.30; 95% CI= 0.58 to 2.01; p<0.001). Stress increased with number of sexual partner >1 (b= 1.36; 95% CI= 0.12 to 2.61; p=0.032).

Conclusion: The risk of cervical cancer increases with the number of sexual partners, BMI, and stress, but decreases with higher education, higher income, age at first sexual intercourse, and genital hygiene.

Keywords: cervical cancer, biopsychosocial determinants, genital hygiene, path analysis

Correspondence: Afriza Umami. Masters Program in Public Health, Sebelas Maret University, Jl. Ir. Sutami 36 A, Surakarta, Indonesia. Email: Mobile : +6282254348041

Journal of Epidemiology and Public Health (2018), 3(2): 277-291 


Full Text:



Ali CI, Makata NE, Ezenduko P (2016). Cervical Cancer: A Health Limiting Condition. Gynecology & Obsetrics, 6(5): 378.

Aziz MF (2006). Skrining dan Deteksi Dini Kanker Serviks. (Eds): Ramli M, Umbas R, & Panigoro SS. Fakultas Kedokteran Universitas Indonesia Jakarta: 97-100

Bassal R, Schejter E, Bachar R, Perri T, Jakobsonsetton A, Bendavid LH, Cohen D. (2016). Risk Factors for Cervical Cancer and CIN3 in Jewish Women in Israel Two Case Control Studies. Asian Pac J Cancer Prev, 17(4): 2067–2073.

Basu P, Mittal S, Bhadra Vale D, Chami Kharaji Y (2017). Secondary prevention of cervical cancer. Best Practice & Research Clinical Obstetrics & Gynaecology, 3: 1–13.

Benedetto C, Salvagno F, Canuto EM, Gennarelli G (2015). Obesity and female malignancies. Best Practice & Research Clinical Obstetrics & Gynaecology, 29(4): 528–540.

Bezabih M, Tessema F, Sengi H, Deribew A (2015). Risk Factors Associated with Invasive Cervical Carcinoma among Women Attending Jima University Specialized Hospital, Southest Ethiopia: A Case Control Study. Ethiopian Journal of Health Sciences, 25(4): 345–352.

Bhaskaran K, Douglas I, Forbes H, et al. (2014) Bodymass index and risk of 22 specific cancers: a populationbased cohort study of 5.24 million UK adults. Lancet,384:755-765.

Braveman P & Gottlieb L. (2014). The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Reports, 129(2), 19–31.

Bruni L, Barrionuevo Rosas L, Albero G, Serrano B, Mena M, Gómez D, Muñoz J, Bosch FX, de S. S. (2017). Human Papillomavirus and Related Diseases Report, (May).

Chelimo C, Wouldes TA, Cameron LD, Elwood JM. (2013). Risk factors for and prevention of human papillomaviruses (HPV), genital warts and cervical cancer. Journal of Infection, 66(3): 207–217.

Dahiya N, Bachani D, Acharya A., Sharma DN, Gupta S, Haresh KP (2017). SocioDemographic, Reproductive and Clinical Profile of Women Diagnosed with Advanced Cervical Cancer in a Tertiary Care Institute of Delhi. Journal of Obstetrics and Gynecology of India, 67(1): 53–60.

Damayanti IP (2013). Factors Associated with Cervical Cancer Incidence Arifin Achmad Hospital in Pekanbaru Year 20082010, jurnal Kesehatan Komunitas, 2(5): 88–93.

Fang CY, Miller SM, Bovbjerg DH, BergmanC, Edelson MI, Rosenblum NG , Bove BA, et al. (2008). Perceived stress is associated with impaired tcell respopse to HPV16 in women with cervical dysplasia. Annals of Behavioral Medicine, 35(1): 87–96.

Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C et al. (2013). GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11. Lyon, France: International Agency for Research on Cancer.

Green McDonald P, O’Connell M, Lutgendorf SK. (2013). Psychoneuroimmunology and cancer: A decade of discovery, paradigm shifts, and methodological innovations. Brain, Behavior, and Immunity, 30(SUPPL.): S1–S9.

Hammouda D, Muñoz N, Herrero R, Arslan A, Bouhadef A, Oublil M, Djedeat B, et al. (2005). Cervical carcinoma in Algiers, Algeria: Human papillomavirus and lifestyle risk factors. International Journal of Cancer, 113(3): 483–489.

Hinkula M, Pukkala E, Kyyrönen P, Laukkanen P, Koskela P, Paavonen J, Lehtinen. (2004). A populationbased study on the risk of cervical cancer and cervical intraepithelial neoplasia among grand multiparous women in Finland. British Journal of Cancer, 90(5): 1025–1029.

Hope KA, Moss E, Redman CWE, Sherman SM. (2017). Psychosocial influences upon older women’s decision to attend cervical screening: A review of current evidence. Preventive Medicine, 101: 60–66.

Jensen SE, Lehman B, Antoni MH, Pereira DB (2007). Virally mediated cervical cancer in the iatrogenically immunocompromised: Applications for psychoneuroimmunology. Brain, Behavior, and Immunity, 21(6): 758–766.

Kementrian Kesehatan RI Pusat Data dan Informasi Kesehatan (2015). Stop Kanker. InfodatinKanker, hal 3.

Kessler TA (2017). Cervical Cancer: Prevention and Early Detection. Seminars in Oncology Nursing, 33(2): 172–183.

Lowy DR, Solomon D, Hildeshein A, et al. (2008). Human Papiloma Virus Infection and the primary and secondary prevention of cervical cancer. Journal Cancer, 113: 93-98.

Lu Donghao (2017). The Role Of Psyhological Stress In Cervical And Prostate Carcinogenesis. Department of Medical Epidemiology and Biostatistics Karolinska Institutet, Stockholm, Sweden

Makuza JD, Nsanzimana S, Muhimpundu MA, Pace LE, Ntaganira J, Riedel DJ. (2015). Prevalence and risk factors for cervical cancer and precancerous lesions in Rwanda. The Pan African Medical Journal, 22, 26.

Murti B. (2016). Prinsip dan Metode Riset Epidemiologi. Program Studi Ilmu Kesehatan Masyarakat. Program Pascasarjana, Universitas Sebelas Maret: Yuma Pustaka.

Natphopsuk S, SettheethamIshida W, Sinawat S, Pientong C, Yuenyao P, Ishida T (2013). Risk Factors for Cervical Cancer. Asian Pacific J Cancer Prev, 13(11): 5489–5495.

Plummer M, de Martel C, Vignat J, Ferlay J, Bray F, Franceschi S. (2016). Global burden of cancers attributable to infections in 2012: a synthetic analysis. The Lancet Global Health, 4(9): e609e616.

Poorolajal J & Jenabi E. (2016). The association between BMI and cervical cancer risk: A metaanalysis. European Journal of Cancer Prevention, 25(3): 232–234.

Rai B, Khosla D, Patel F, et al. (2012). Palliative radiotherapy in advanced cancer of the cervix. Int J Pain, Symptom Control Palliat Care, 9(1).

Rajarao P, Hemanth Kumar B. (2012). Study of socio demographic profile of cancer cervix patients in tertiary care hospital, Karimnagar (Andhra Pradesh). Int J Biol Med Res, 3(4): 2306–2310.

Rajkumar T, Cuzick J, Appleby P, Barnabas R, Beral V, Berrington De González A, et al. (2006). Cervical carcinoma and reproductive factors: Collaborative reanalysis of individual data on 16,563 women with cervical carcinoma and 33,542 women without cervical carcinoma from 25 epidemiological studies. International Journal of Cancer, 11-9(5): 1108–1124.

Reis N (2011). Risk Factors for Cervical Cancer: Results from a HospitalBased CaseControl Study. International Journal of Hematology and Oncology, 21-(3): 153–159.

Roy B, Tang TS. (2008). Cervical cancer screening in Kolkata, India: Beliefs and predictors of cervical cancer screening among women attending a women’s health screening in Kolkata. India. J Cancer Edu, 23: 9-253.

Sari HE, Mudigdo A, Dermatoto A. 2016. Multilevel Analysis on the Social Determinants of Cervical Cancer in Yogyakarta. Journal of Epidemiology and Public Health, 1, (2):102-109. eISSN: 2549-0273

Sharma P, & Pattanshetty SM. (2017). A study on risk factors of cervical cancer among patients attending a tertiary care hospital: A casecontrol study. Clinical Epidemiology and Global Health.

Shaw E, Ramanakumar AV, ElZein M, Silva FR, Galan L, Baggio ML, Villa LL, et al. (2016). Reproductive and genital health and risk of cervical human papillomavirus infection: Results from the LudwigMcGill cohort study. BMC Infectious Diseases, 16(1): 1–10.

Song H. Saito E, Sawada N, Abe SK, Hidaka A, Shimazu T, Yamaji T, et al. (2017). Perceived stress level and risk of cancer incidence in a Japanese population: The Japan Public Health Center (JPHC)based Prospective Study. Scientific Reports, 7(1): 1–10.

Torre L, Rebecca Siegel AJ. (2015). Global Cancer Facts & Figures 3rd Edition. American Cancer Society, (800): 1–64.

Videbeck, S. L. (2008). Keperawatan Jiwa. Jakarta: EGC.

Vigod SN, Kurdyak PA, Stewart DE, Gnam WH, Goering PN. (2001). Depressive symptoms as a determinant of breast and cervical cancer screening in women: a populationbased study in Ontario, Canada. Arch Womens Ment Health, 14 :159-168.

Wang Z, Wang J, Fan J, Zhao W, Yang X, Wu L, Li D, et al. (2017). Risk factors for cervical intraepithelial neoplasia and cervical cancer in Chinese women: Large study in Jiexiu, Shanxi Province, China. Journal of Cancer, 8(5): 924–932.

Wilkerson JE, Bailey JM, Bieniasz ME, Murray SI, Ruffin MT. (2009). Psychosocial Factors in Risk of Cervical Intraepithelial Lesions. Journal of Women’s Health, 18(4): 513–518.

World Health Organization. (2014). 2014b. Cancer Country Profiles, Indonesia. available on the WHO website ( Accessed (10/9/2017)

_____ (2016). Human Pappiloma virus (HPV) and Cervical Cancer. on

_____ (2017). Cancer. available on


  • There are currently no refbacks.