presented in International Conference on Indonesia Family Planning and Reproductive Health, Yogyakarta, 2019

1. Husband’s knowledge:
its key role in making wife’s health seeking behaviours
in cervical cancer preven;on peaceful
Abigael W. A+
Young-Mi Kim

2. • Temanggung
A significant posi+ve correla+on between husband’s
support and wife’s taking VIA test (Parapat, Setyawan, &
Saraswa+, 2016)
• Medan
Mul+parous women that had PAP smear perceived low
support from husbands (Feriyawa+, Anggraini, Fitrie, &
Anggreini, 2018)
• West Java
Lack of support from Muslim husbands related to wife’s
cancer screening (Widiasih & Nelson, 2018)
Husband’s role
in wife’s cervical cancer screening

3. CECAP program
• A low-cost and effec+ve method of cervical
cancer early detec+on and preven+on
program
• Visual Inspec+on with Ace+c Acid (VIA) screening
à pre-cancerous lesion in the cervix
• Cryotherapy for VIA+ women in Puskesmas or
further examina+on in hospital for cancer suspect
• Pilo+ng area: Karawang regency
• Targe+ng 80% from the popula+on of
married women at reproduc+ve age

4. CECAP program components
• Providing quality CECAP service
trainings for providers, dissemina+ng SBMR
monitoring forms and visi+ng Puskesmas regularly
for monitoring purpose
• Crea+ng awareness about cervical cancer
and the availability of CECAP service through
advocacy
• 2009 with health volunteers
• 2010 established advocacy teams at district and
sub-district à community and religious leaders,
ac+vists of community-based organiza+ons such
as PKK, and providers from Puskesmas.

6. • Socializa+on by the GP
• Using flipchart developed by Jhpiego
• Replacing one-on-one counselling --reducing the
queuing +me,
• Nega+ve effect:
• Not all audience comprehended the informa+on and
• Not all informa+on was excerpted well by the audience
• Not all audience feel comfortable and secure to ask
ques+ons in public
She [the provider] said, ‘you have many diseases, so you have
to come to Puskesmas. There’s a white spot inside, so you
need to get therapy.’ No, I never heard about cervical cancer.
(Wife with VIA+)
VIA screening – Mobile outreach

7. • VIA test in semi-private rooms
• Providers kept talking with the pa+ent to make
them feel secure and comfortable
• Uncomfortable to ask ques+on s+ll because
“the doctor’s Ame is limited, a lot of people queuing” (Wife
with VIA+)
• VIA screening result given afer the test
• VIA- can go home happily
• VIA+
• plan to visit Puskesmas for cryotherapy.
• talk to husband regarding the requirement of
cryotherapy: 40-day sexual abs+nence,
signing consent form, coming together to
Puskesmas

8. STUDY OBJECTIVE
• To explore husbands’ responses towards
psychosocial and cultural burdens of having
VIA+ wife
• To iden+fy husbands’ responses that affect
wife’s taking cryotherapy treatment

9. METHODOLOGY
• Part of evalua+on series of CECAP program
(Dec 2010 - Dec 2011)
• 6 Puskesmas
• Qualita+ve à in-depth interview and FGDs
• Purposive, snowballing

10. Pre-evalua;on
• 4 high performing Puskesmas (Klari, Pedes,
Tempuran, Kotabaru)
• In-depth interviews
• 4 doctors (one per Puskesmas)
• 8 midwives (two per Puskesmas)
• FGDs
• 20 VIA+ women who had cryotherapy
• 20 husbands of VIA+ women who had cryotherapy

11. Evalua;on
• 3 Puskesmas (Klari, Pangkalan, Karawang)
• In-depth interviews
• 1 obstetrician-gynecologist at the district hospital
• 5 general prac++oners at 5 puskesmas
• 10 midwives at 5 puskesmas
• 2 members of the district advocacy team
• 3 officials from the DHO
• 4 women with cervical cancer
• 1 woman who was VIA+ at the first screening, but
proved to be VIA-nega+ve at a second screening (a
false-posi+ve)
• 2 women who received cryotherapy immediately afer
VIA screening (SVA pa+ents).
• FGD
• 13 advocacy team members

12. Dates
Number
of puskes-
mas
Number of
women
screened
Among women screened,
number (%) who were:
Among VIA-positive women,
number (%) who:
VIA-positive
Suspected of
having
cancer
Did not seek
cryotherapy
Sought
cryotherapy
1
July – Dec. 2007 4 777 27 (3.5) 0 (0) 10 (37.0) 17 (63.0)
Jan. – Dec. 2008 12 4,874 157 (3.2) 21 (0.4) 64 (40.8) 93 (59.2)
Jan. – Dec. 2009 17 10,298 164 (1.6) 43 (0.4) 44 (26.8) 120 (73.2)
Jan. – Dec. 2010 17 16,366 269 (1.6) 43 (0.3) 33 (12.3) 236 (87.7)
Jan. – Aug. 2011 17 9,771 157 (1.6) 29 (0.3) 46 (29.3) 111 (79.7)
Total 17 42,086 774 (1.8) 136 (0.3) 197 (25.5) 577 (74.5)
Five-year achievements of
CECAP Program

13. The role of significant others
• (1) husband, (2) children, (3) extended family; (4) friends and
neighbours; (5) providers
• Encouraging or discouraging VIA+ women to get cryotherapy
• When discouraged by one significant other tends to turn to the
other significant others
The first Ame I was told the result [VIA+] I cried. My husband said something
like this, ‘you just make it, you just don’t want to serve me!!’ He really said
that! I am stressed out, I got that bad result from the VIA screening and now
he said that. In a week, I lost 4 kgs of my weight. But, aLer the screening in
Terangsari, maybe my friends saw I was called by the midwife, so they
thought there must be something wrong.. so they all visited me at home,
they all supported me.. oh I felt so loved, made me want to cry, you know...

14. From gendered norms to gendered regula5on
• Husband as the “imam” of the family
• Perceived as husband’s superiority and authority over wife
• People always refer sexual intercourse as an obliga+on of
the wife and a service for the husband
• Wife-husband-provider agree that husband’s consent
signing is required before wife’s taking cryotherapy
• Formalized by the program and MoH
It’s the standard operaAon procedure. Actually, there was one Ame that I
conducted cryotherapy without the husband’s consent. We have asked the paAent
to get her husband’s sign or ask the husband to come for counselling but it was
really difficult because the husband worked [out of town] so she said, ‘let me sign
this, I will be held responsible if my husband ask or complain,’ Now, that’s what we
actually need, a statement that someone is responsible on that. But of course I am
sAll afraid to apply that, because the standard procedure is husband has to be the
one who sign, that’s what we got from the training… because it involved the
couple, not only the wife.

15. The contradic5on of husbands’ claims and ac5ons
Claims
• Leqng wife do anything to
stay healthy
• Protec+ng wife
• Demanding detail informa+on
from wife and provider
• Seeking informa+on about
wife’s health problems from
other sources
Ac*ons
• Demanding wife to ask for
permission for geqng cryotherapy
• Signing the consent form without
reading/understanding the issue
• Refusing to come to Puskesmas
• Restric+ng wife from geqng
cryotherapy
• Having sexual intercourse (without
condom) within 40-day abs+nence
period
• Not having enough informa+on
about wife’s health problem

16. CECAP provider
• The wife said her husband understood, and I saw
there was his signature too [on the informed
consent form], but in fact, the informaAon given to
her husband was inaccurate, so he thought she was
going to have sterilizaAon. He burst out. He thought
she was sterilized because of the 30 days
absAnence. But aLer we [provider] explained to
him [about cryotherapy and all related issues], he
understood.

17. Husband of VIA+ woman
• If a person does bad things, it’s easier for us to sue. So we
[husbands] must know. I expected wriVen consent from any
treatment of reproducAve organs. Yea, I didn’t read it, but
that doesn’t mean I didn’t sign it. I read it, but not
thoroughly, she gave it to me when I was busy.
TheoreAcally, I have known about it. My wife has told me,
‘the treatment is like this and this.’ Besides, there’s no
problem because of that. If there’s a problem, I will surely
take a follow-up. Because there’s no problem and the result
was good, I didn’t memorize it. [Q: have you ever heard
about cervical cancer, Sir?] Hmm… cancer, I heard about it a
lot: breast cancer, brain cancer. But ‘kanker leher
rahim’ [cervical cancer], no I have never heard about it.

18. Wife with VIA+
• The first Ame I told him about this... he said, ‘you are just
making it up, so you don’t have to serve me [sexual
intercourse].’ So that’s how he responded to me ... that’s
why I cried. I was depressed; I lost four kilograms within a
week
• We had a fight. I was so mad. I have never had sex with
any other man, how could I get VIA+. So, the impact [of
the husband’s extra marital sexual adventure] is on me. I
never did anything wrong, never had extra marital sex.

19. Wife with VIA+
• He said, ‘NO. No, you are not allowed [to get
cryotherapy]. You are perfectly healthy’. I said,
‘who said I am healthy? I am the one who feels it,
dear. I feel I am unhealthy. Do you want me to have
cervical cancer? The midwife said if I don’t get
treatment in five years I will have cervical cancer’. I
am so scared, ma’am, scared of ge_ng cervical
cancer. What will I do? So I said, ‘if I die, you might
be happy because you can get married again,’
remembering the requirement for not having sex
for 40 days. ALer begging him the whole night, he
finally let me get cryotherapy.

20. • Signing informed consent does not mean husband
has sufficient informa+on about his wife’s health
problem and the treatment
• Conflicts and arguments, mostly due to the 40-day
sexual abs+nence afer cryotherapy s+ll happened
although husband had signed the consent form
• Husbands claimed to look for informa+on from
sources other than wife, provider, and the consent
form (health providers and wives are not their
preferred source of informa+on?)
• Knowledge or informa+on seeking is perceived to
enhance image as a caring husband

21. Implica;ons
• Giving informa+on about VIA and cervical cancer to
husbands is essen+al, more than geqng husband’s
signature in the consent form
• Finding a more comprehensible way to provide
informa+on to wife is necessary
• Assis+ng the informa+on flows to husbands
through various channels, through religious and
community leaders, peer-to-peer discussions as
husband’s trusted communica+on channels, and
convincing promo+on materials such as TV,
brochures and posters

22. Terima kasih!