Self-concept of cervical cancer patients after chemotheraphy in Yogyakarta

C ervical cancer is one of the deadliest types of cancer that attacks women in the world. One of the treatment efforts for cancer is chemotherapy. Patients with cervical cancer who receive chemotherapy more than twice will experience impaired self-concept. This study aims to determine self-concept in cervical cancer patients who have undergone chemotherapy in Yogyakarta. This research uses qualitative method with phenomenology approach. Data collection is done with interview and observation. Participants totaling five people were determined by purposive sampling. The validity of the data used source triangulation and checked the data back to the participants. Analysis of data were by comparing among categories, marking and describing descriptively. The results of the study are 6 themes, namely physical changes, emotional changes, changes in sexual relations, changes in relationships with family, changes in the role of parenting and social changes in society. The impact of chemotherapy causes various changes in cervical cancer patients which make the self-concept of cervical cancer patients undergo changes the CC–BY-SA

preliminary study that was carried out in the Special Region of Yogyakarta, there were 198 women suffering from cervical cancer who were hospitalized in hospitals throughout Yogyakarta.

Method
This study uses a qualitative research method with a phenomenological approach to translate a person's life experience related to certain concepts or phenomena (Creswell, 1998). The number of participants in this research is 5 people with criteria: the client can communicate verbally well, the client is willing to be the respondent, the client does not have comorbidities. This research was conducted in the Special Region of Yogyakarta in December 2019 -April 2020. The variable in this study was the body image in cervical cancer patients after undergoing chemotherapy (Denny et al., 2015). The tools used in this study were interview guides, recorders, and field notes. The data analysis step in this study was by transcribing all the data from the interviews with participants, analyzing the data more deeply, then coding the data, grouping the data into small sub-themes then making them into large theme groups to form a narrative before finally being validated. This research has passed the ethical test by Bethesda Hospital Yogyakarta ethics committee with ethics number 035/KEPK-RSB/II/2020.

Characteristics of Participants
The first participant is a 51 years old woman, Muslim, works as a PAUD teacher, her status is currently married and has 2 children, the participant lives with the child and her husband. Participants were diagnosed with stage 2 cervical cancer since February 2018 and have undergone treatment from surgery, external rays, internal rays, and chemotherapy. Currently, the participants are still in control of medication and Pap smears every 3 months. Apart from working as PAUD teachers, participants also take an active role in being members of social activities in their village.
The second participant is a 43 years old woman who works as a laborer to make woven plastic bags, her status is currently married and has 3 children, the participant lives with 2 children because her husband has left the house since several years ago and her first child lives with her adoptive parents. Participants were diagnosed with stage 2 cervical cancer since May 2018 and have undergone chemotherapy treatment and other surgical treatments, external rays, and internal rays. Currently, the participants are still in control for 6 months of treatment and pap smears The third participant is a woman aged 36 years, a housewife, married and has 2 children, the participant lives with her husband and 2 children. Participants have undergone chemotherapy and other complementary treatments such as surgery, external rays and internal rays. Currently, the participants are still under control of the 6 months san pap smear treatment.
The fourth participant is a 63 years old woman, a retiree, currently married but her husband has died and has 2 children, the participant lives with her last child. Participants have undergone chemotherapy and other complementary treatments such as surgery, external rays and internal rays. Currently, the participants are still under treatment control for 2 weeks and still need to continue chemotherapy.
The fifth participant is a 39 years old woman, a housewife, currently married and has 3 children. Participants live with their husbands and 3 children. participants have undergone treatment from surgery, external rays, internal rays, and chemotherapy, currently participants are still in the control treatment process every 3 months and must have a pap smear.
In this study, researchers found 6 main themes which are related to self-concept in participants after chemotherapy and changes that occur after chemotherapy. These themes include:

a. Physical Changes After Undergoing Chemotherapy
Side effects experienced by all participants were alopecia (hair loss), nausea, vomiting, dry and blackened skin, weight loss, weakness and difficulty sleeping. This is consistent with the results of interviews with the following participants:

b. Emotional Changes After Undergoing Chemotherapy
Participant feelings of sadness, shame, and even stress with their physical changes after chemotherapy. This is consistent with the results of interviews with the following participants: The four participants experienced changes in sexuality after undergoing chemotherapy, 1 participant did not experience any effects related to sexuality because her husband had died. This is consistent with the results of interviews with the following participants: The answers from the participants' husbands related to changes in their sexuality with the participants after chemotherapy were in accordance with the statements of the participants if since being sick they had not sexual intercourse, even until now there was no desire to have sex.

d. Changes in Relationships with Family After Undergoing Chemotherapy
After undergoing chemotherapy, cancer patients experience limitations in taking care of their families due to their weak physical condition. This is consistent with the results of interviews with the following participants: The five participants were very worried about their families, the participants felt they could not take care of their families like they used to. e. Changes in the role of parenting after chemotherapy Some of the side effects caused disrupt the daily activities of the patient, one of the activities that disturbs him is in childcare. The difference in parenting patterns occurs because of the physical and psychological symptoms experienced by the patient, causing the inability to maintain parenting styles such as before undergoing chemotherapy. Following are the participants' expressions related to changes in caring for children:

f. Social Change in Society After Undergoing Chemotherapy
Participants' social activities after undergoing chemotherapy changed because participants restricted their activities outside the home. In addition to a weak physical condition and it is not possible to do activities like healthy people in general, another factor that causes social change in participants is a feeling of shame or insecurity to meet and gather with the surrounding community. This is consistent with the results of interviews with the following participants:

Discussion
The side effects caused by chemotherapy which kill cells in the body, both cancer cells and normal cells, will cause changes in the mouth, skin, reproductive organs, and other body parts (Patel, 2018). Changes that occur in the body after undergoing chemotherapy include nausea, vomiting, diarrhea, constipation, alopecia (hair loss), anorexia (loss of appetite), weight loss, nerve damage, skin irritation, pain and bleeding (Remesh, 2016). This is in accordance with research conducted by (Darmawan et al., 2019) which states that the side effects caused by chemotherapy can cause changes in the physical part, but the physical changes that occur are not the same depending on the response of the body of each individual. The psychological impact after undergoing chemotherapy that is most often encountered apart from anxiety and depression is irritability, irritability, sensitivity, and some even experience frustration (C & RA., 2011). According to research conducted by (Abhishek et al., 2017) states that if sexual dysfunction is still a problem for cancer patients receiving chemotherapy treatment, sexual dysfunction after cancer treatment is usually caused by drastically dropping levels of estrogen, progesterone, and testosterone, which will interfere with their sexuality (Hwang et al., 2016). Another study conducted by (Barthakur et al., 2017) stated that changes that occur after chemotherapy make cancer patients feel anxious about having sex.
Changes in the body image of cancer patients after chemotherapy can cause mental disorders and affect their decreased sexual function. (Sampoornam, 2015) which state that Concern arises because cancer patients are not sure whether they will recover after undergoing chemotherapy or will even stop there, even though many cancer sufferers still have responsibility for their children and husbands.
According to (Thastum et al., 2016)(C & RA., 2011 children whose parents suffer from cancer and undergo chemotherapy treatment have a risk of anxiety, depressive symptoms, and depression or psychosocial difficulties. This is due to the emotional pressure on the child when he accepts that there are physiological and psychological changes in the mother. The changes in parenting styles that occur are also a factor in the occurrence of emotional distress in children. (Thastum et al., 2016) said that the effects of psychological chemotherapy treatments such as patient mood, memory, and physiological effects such as energy levels, changes in appearance, have an impact on changes in parenting styles (Huang et al., 2017). In a study according to (Levkovich et al., 2019) revealed that fatigue due to chemotherapy side effects greatly affects changes in family roles, one of which is changes in parenting styles.
According to (Moore et al., 2016) the results of research conducted by patients who have undergone chemotherapy cannot meet the needs of children such as before undergoing chemotherapy, this is due to a decrease in the physical and psychological conditions experienced by patients, this change is an activity in managing the household (Banoycinova & Baskova, 2014). The impact of these changes creates psychological distress for the patient. These changes need support for those who come from the family to minimize these changes. (Aamotsmo & Bugge, 2016) said that the lack of interaction and time with children due to the effects of chemotherapy causes a lack of assistance in decision making to children. On the other hand, children still need the role of mothers as caregivers and mentors, this requires collaboration to stabilize the place of change in caring for children. According to (Meng-Yao et al., 2016) activities in managing the household and affecting the quality of life after chemotherapy, namely cooking, cleaning the house, and taking care of children because patients have to rest completely after undergoing chemotherapy.
According to (Meng-Yao et al., 2016), patients experience instability in caring for children, so one family must help stabilize the problem by replacing the patient's role as caregiver. This will reduce emotional stress on the child and patient. Apart from the coping efforts that must be done is to control the emotional pressure of children by providing understanding.
Social relations have a very strong role in the optimism of cancer patients in undergoing treatment, after undergoing chemotherapy, social life will experience changes, whether it is caused by decreased body function or emotional changes in cancer patients (Banoycinova & Baskova, 2014)This is in accordance with research conducted by (Lienert et al., 2018) which states that the social changes that arise in cancer patients after chemotherapy are due to disruption of body functions which causes the participants' social activities to be limited and the participants themselves limit their social activities because they feel inadequate (Pakenham, 2012). Social support from the community is needed to foster enthusiasm and feelings of respect in the community (Wang et al., 2017). Support can come from friends, neighbors, medical personnel who handle it, which can improve the quality of life of cancer patients undergoing chemotherapy (Barthakur et al., 2017) Social support from the community shows a good quality of life for cancer sufferers (Lienert et al., 2018).

Conclusion
The impact of chemotherapy causes various changes in cervical cancer patients which make the self-concept of cervical cancer patients undergo changes.