Easy access to vaccination was important for adherence during the 2016–2019 HPV catch-up vaccination in Norway

Figures & data

Table 1. Demographic characteristics of study participants: women born between 1991 and 1996 who adhered and did not adhere to the free catch-up HPV vaccination between 1 November 2016 and 30 June 2019 in Norway (N = 3,762)

	Non-adhering			Adhering
	Sample		Weighted % (95% CI)^a	Sample		Weighted % (95% CI)^a
	n	%		n	%
Overall	298	7.9	9.3 (8.1–10.6)	3,464	92.1	90.7 (89.3–91.9)
Country of origin (study participant) (n = 3,760)
Norway	255	7.4	7.6 (6.7–8.6)	3,193	92.6	92.4 (91.4–93.3)
EU, USA, Canada, Australia, New Zealand	17	13.2	13.3 (8.4–20.3)	112	86.8	86.7 (79.7–91.6)
Asia, Africa, Latin America, Oceania, Europe (outside EU)	26	14.2	14.4 (10.0–20.4)	157	85.8	85.6 (79.6–90.0)
Duration of residence in Norway for non-Norwegians (study participant) (n = 314)
0–4 years	16	17.0	16.5 (10.3–25.4)	78	83.0	83.5 (74.6–89.7)
5–9 years	4	10.3	20.3 (3.9–24.7)	35	89.7	89.7 (75.4–96.2)
10 years or more	23	12.7	13.3 (9.0–19.3)	158	87.3	86.7 (80.7–91.0)
Country of origin (caregivers) (n = 3,395)
Both caregivers from Norway	207	7.11	7.1 (6.2–8.1)	2,703	92.89	92.9 (91.9–93.8)
At least one caregiver from EU, USA, Canada, Australia, New Zealand	20	10.0	13.5 (8.1–21.9)	181	90.0	86.5 (78.2–91.9)
At least one caregiver from Asia, Africa, Latin America Oceania, Europe (outside EU)	27	9.5	12.2 (8.0–18.2)	257	90.5	87.8 (81.8–92.0)
Region of residence (n = 3,762)
Akershus og Oslo	114	10.0	11.0 (8.8–13.7)	1,030	90.0	89.0 (86.3–91.2)
Hedmark og Oppland	11	5.3	8.9 (4.5–17.0)	196	94.7	91.1 (83.0–95.6)
Østlandet ellers	34	6.6	8.3 (5.4–12.5)	482	93.4	91.7 (87.5–94.6)
Agder og Rogaland	43	8.5	9.3 (6.5–13.1)	465	91.5	90.8 (86.9–93.5)
Vestlandet	45	6.9	9.8 (6.9–13.6)	604	93.1	90.3 (86.5–93.1)
Trøndelag	26	6.1	5.7 (3.9–8.3)	399	93.9	94.3 (91.7–96.2)
Nord-Norge	25	8.0	8.5 (5.3–13.5)	288	92.0	91.5 (86.6–94.7)
Marital status (n = 3,762)
Single	76	6.0	7.6 (5.8–9.9)	1,187	94.0	92.4 (90.1–94.2)
In a relationship	62	8.0	9.3 (6.8–12.5)	717	92.0	90.8 (87.6–93.2)
Cohabitating	126	8.8	9.5 (7.8–11.6)	1,305	91.2	90.5 (88.4–92.2)
Married	33	11.7	14.4 (9.6–21.0)	249	88.3	85.6 (79.0–90.4)
Separated	1	14.3	20.4 (2.8–69.2)	6	85.7	79.6 (30.8–97.2)
Children (n = 3,762)
Yes	73	12.4	13.6 (10.4–17.6)	518	87.6	86.4 (82.4–89.6)
No	225	7.1	8.5 (7.2–9.9)	2,946	92.9	91.5 (90.1–92.8)
Highest completed education (n = 3,762)
Primary	41	12.1	14.6 (10.5–19.9)	298	87.9	85.4 (80.1–89.5)
Secondary	83	9.0	10.1 (7.9–12.8)	841	91.0	89.9 (87.2–92.1)
University or college	174	7.0	7.8 (6.4–9.3)	2,325	93.0	92.3 (90.7–93.6)
Household income after tax (in NOK) (n = 3,711)
P10 214000	100	7.8	9.2 (7.3–11.6)	1,191	92.3	90.8 (88.4–92.7)
P20 266000	30	8.4	10.7 (6.9–16.2)	327	91.6	89.3 (83.8–93.1)
P30 305000	23	8.4	8.9 (5.5–14.0)	251	91.6	91.1 (86.1–94.5)
P40 339000	21	8.0	10.2 (6.1–16.5)	240	92.0	89.8 (83.5–93.9)
P50 372000	18	7.0	8.8 (5.0–15.0)	241	93.0	91.2 (85.0–95.0)
P60 408000	18	6.6	8.6 (5.0–14.5)	256	93.4	91.4 (85.5–95.0)
P70 450000	17	6.0	6.2 (3.6–10.4)	266	94.0	93.8 (89.6–96.4)
P80 507000	24	8.9	9.9 (6.1–15.7)	247	91.1	90.1 (84.4–93.9)
P90 606000	22	8.1	8.1 (5.0–13.0)	250	91.9	91.9 (87.0–95.0)
P100 > 606001	20	11.8	12.3 (7/4-20.0)	149	88.2	87.7 (90.0–92.7)
	Median (range)			Median (range)
Age (n = 3,762)	26 (23–28)			26 (23–28)

^aWeighted on education level, country of origin and age of the study participants.

Table 2. Opinions and preferences regarding the organization of HPV vaccination and communication strategies of women born between 1991 and 1996 who were invited for free catch-up HPV vaccination between 1 November 2016 and 30 June 2019 in Norway

	All women		Non-adhering (N = 298; 7.9%)		Adhering (N = 3,464; 92.1%)		χ^2 (d^b, p^c)
	Sample	Weighted % (95% CI)^a	Sample	Weighted % (95% CI)^a	Sample	Weighted % (95% CI)^a
	%		n		n
What do you think about receiving information from NIPH via SMS? (n = 2,866)							1.44 (1, .230)
Good	98.9	98.6 (97.8–99.1)	199	7.9 (6.7–9.3)	2,635	92.1 (90.7–93.3)
Not good	1.1	1.4 (0.9–2.2)	4	15.6 (4.9–40.1)	28	84.4 (59.9–95.1)
Over a 2-year period, NIPH sent 5 SMSs to remind people of the free HPV vaccination, what do you think about it? (n = 2,834)							1.35 (1, .510)
Good to be reminded	93.0	93.2 (92.0–94.2)	187	7.9 (6.7–9.4)	2,450	92.1 (90.6–93.3)
Good to be reminded, but 5 SMS is too many	5.5	5.2 (4.4–6.3)	8	4.7 (2.3–9.4)	148	95.3 (90.6–97.7)
Do not think SMS should be sent	1.4	1.6 (1.1–2.3)	4	18.2 (6.4–4.2)	37	81.9 (58.1–93.6)
Where did you get the HPV vaccine? (multiple locations possible)
Community health service (n = 2,616)**
Yes	69.6	69.0 (67.1–70.8)	224	10.0 (8.5–11.7)	2,392	90.0 (88.4–91.5)	4.72 (1, .030)*
Student health service (n = 339)**
Yes	9.0	8.7 (7.7–9.9)	20	7.4 (4.3–12.6)	319	92.6 (87.4–95.7)	2.10 (1, .147)
Military (n = 15)**
Yes	0.4	0.4 (0.2–0.7)	2	12.6 (3.0–39.9)	13	87.4 (60.1–97.0)	0.60 (1, .438)
General practitioner (n = 584)**
Yes	15.5	15.0 (13.7–16.4)	33	7.2 (4.8–10.6)	551	92.8 (89.4–95.2)	4.92 (1, .027)*
Infection control office (n = 498)**
Yes	13.3	12.1 (11.0–13.4)	33	6.1 (4.1–9.1)	465	93.9 (90.9–95.9)	1.34 (1, .248)
Other (n = 328)**
Yes	8.7	9.7 (8.5–11.0)	19	7.5 (4.3–12.8)	309	92.5 (87.2–95.7)	2.23 (1, .134)
Did you receive the vaccine at your preferred location? (n = 3,762)							9.87 (1, .002)*
Yes	78.3	77.3 (75.5–78.9)	212	8.4 (7.1–9.8)	2,735	91.6 (90.2–92.9)
No	21.7	22.7 (21.1–24.5)	86	12.6 (9.7–16.1)	729	87.5 (83.9–90.3)
How easy or difficult was it for you to find out where you could get the free HPV vaccine? (n = 3,762)							175.15 (5, <.001)*
Very easy	62.0	60.4 (58.5–62.4)	107	5.4 (4.3–6.8)	2,226	94.6 (93.2–95.7)
Easy	26.9	27.6 (25.8–29.4)	101	11.6 (9.2–14.6)	911	88.4 (85.5–90.8)
Neither easy nor difficult	7.8	8.5 (7.4–9.8)	52	18.2 (13.3–24.5)	241	81.8 (75.5–86.7)
Difficult	2.7	3.0 (2.3–3.8)	34	38.4 (27.0–51.1)	69	61.7 (48.9–73.0)
Very difficult	0.5	0.5 (0.3–0.9)	4	32.7 (11.3–65.1)	13	67.3 (34.9–88.8)
If you wanted to get more information, where would you get it? (multiple locations possible)
Internet (n = 3,762)							0.87 (1, .352)
Yes	83.5	81.3 (79.7–82.9)	243	9.3 (8.0–10.8)	2,897	90.7 (89.2–92.0)
No	16.5	18.7 (17.1–20.4)	55	9.4 (6.9–12.8)	567	90.6 (87.2–93.1)
Friends or colleagues (n = 3,762)							0.09 (1, .760)
Yes	24.2	23.9 (22.3–25.6)	70	9.9 (7.5–13.1)	841	90.1 (86.9–92.5)
No	75.8	76.1 (74.4–77.7)	228	9.1 (7.8–10.6)	2,623	90.9 (89.4–92.2)
Family (n = 3,762)							1.71 (1, .192)
Yes	19.0	19.0 (17.5–20.6)	48	8.7 (6.2–12.1)	665	91.3 (87.9–93.8)
No	81.0	81.0 (79.4–82.5)	250	9.5 (8.2–11.0)	2,799	90.5 (89.1–91.9)
Community health service (n = 3,762)							0.19 (1, .663)
Yes	40.1	41.1 (39.2–43.1)	116	9.4 (7.5–11.6)	1,393	90.6 (88.4–92.5)
No	59.9	58.9 (56.9–60.8)	182	9.3 (7.8–11.0)	2,071	90.7 (89.0–92.2)
GP (n = 3,762)							0.15 (1, .694)
Yes	55.4	57.1 (55.1–59.0)	162	9.8 (9.1–11.7)	1,924	90.2 (88.3–91.9)
No	44.6	42.9 (41.0–44.9)	136	8.7 (7.1–10.6)	1,540	91.3 (89.5–92.9)
Health authorities (n = 3,762)							11.23 (1, .001)*
Yes	43.8	42.9 (41.0–44.9)	103	6.9 (5.5–8.7)	1,545	93.1 (91.3–94.5)
No	56.2	58.6 (56.7–60.5)	195	11.0 (9.3–13.0)	1,919	89.0 (97.0–90.7)
What were the reasons why you completed the HPV vaccination?
… information from the media (n = 3,001)							4.17 (1, .041)*
Agree	88.5	87.4 (85.8–88.8)	201	8.6 (7.3–10.2)	2,455	91.4 (89.9–92.7)
Disagree	11.5	12.6 (11.2–14.3)	37	13.7 (9.3–19.6)	308	86.3 (80.4–90.7)
… information from NIPH via SMS and social media (n = 3,151)							1.801 (1, .180)
Agree	89.9	88.7 (87.1–90.1)	215	8.5 (7.2–9.9)	2,617	91.5 (90.1–92.8)
Disagree	10.1	11.3 (9.9–12.9)	31	14.9 (10.0–21.8)	288	85.1 (78.2–90.1)
… HPV vaccination was free of charge (n = 3,614)							0.414 (1, .520)
Agree	95.9	96.0 (95.2–96.7)	275	9.1 (7.9–10.5)	3,190	90.9 (89.5–92.1)
Disagree	4.1	4.0 (3.3–4.8)	14	13.7 (7.2–24.3)	135	8.6 (75.8–92.8)
… HPV vaccination was readily available (n = 3,580)							98.33 (1, <.001)*
Agree	96.4	96.1 (95.2–96.9)	234	8.0 (6.8–9.3)	3,218	92.0 (90.7–93.2)
Disagree	3.6	3.9 (3.1–4.8)	39	34.0 (24.2–45.5)	89	66.0 (54.5–75.8)
… my parents and/or friends thought I should take the vaccination (n = 3,037)							0.32 (1, .570)
Agree	91.6	90.5 (89.0–91.8)	203	8.3 (7.0–9.8)	2,580	91.7 (90.2–93.0)
Disagree	8.4	9.5 (8.2–11.0)	21	10.4 (6.2–17.0)	233	89.6 (83.0–93.8)
… healthcare professionals and central health authorities recommended vaccination (n = 3,355)							1.94 (1, .164)
Agree	97.1	97.0 (96.2–97.7)	248	8.7 (7.6–10.2)	3,011	91.3 (89.9–92.5)
Disagree	2.9	3.0 (2.3–3.8)	11	13.6 (6.7–25.6)	85	86.4 (74.5–93.3)
… the vaccine can prevent cervical cancer (n = 3,644)							0.67 (1, .415)
Agree	99.8	99.8 (99.6–99.9)	279	8.9 (7.7–10.2)	3,357	91.1 (89.8–92.3)
Disagree	0.2	0.2 (0.0–0.4)	0	0	8	1
… I, or someone I know, has had cell changes/cervical cancer (n = 3,174)							0.369 (1, .544)
Agree	66.3	64.6 (62.5–66.7)	168	9.4 (7.8–11.2)	1,937	90.6 (89.0–91.8)
Disagree	33.7	35.4 (33.3–37.5)	92	9.9 (7.7–12.5)	977	90.1 (87.5–92.3)

^aWeighted on education level, country of origin and age of the study participants.

^bd = degrees of freedom.

^cp = p value.

* = p value significant at p < .05.

**The reference used for these categories is those not vaccinated at the indicated location.

Table 3. Univariable and multivariable analyses of determinants of full HPV vaccination adherence with those non-adhering to the full vaccination regime as reference group

	Univariable analysis			Multivariable analysis (n = 3,458)
	OR	95% CI	p	aOR	95% CI	p
Age (n = 3,762)	0.96	0.89–1.02	.193	0.99	0.91–1.08	.850
Country of origin (study participant) (n = 3,760)			.001*			.031*
Norway	1			1
Not Norway	0.39	0.21–0.65		0.43	0.47–0.97
Country of origin (caregivers) (n = 3,475)			.001*			.468
Both caregivers from Norway	1			1
At least one caregiver from outside of Norway	0.72	0.44–1.16		0.75	0.45–1.25
Both caregivers from outside of Norway	0.53	0.38–0.75		0.81	0.45–1.45
Region of residence (n = 3,762)			.051			.153
Akershus og Oslo	1			1
Hedmark og Oppland	1.97	1.04–3.72		1.87	0.93–3.77
Østlandet ellers	1.57	1.05–2.34		1.69	1.08–2.64
Agder og Rogaland	1.20	0.83–1.73		1.22	0.80–1.84
Vestlandet	1.49	1.04–2.13		1.39	0.93–2.07
Trøndelag	1.70	1.09–2.64		1.66	1.02–2.70
Nord-Norge	1.28	0.81–2.00		1.21	0.73–2.00
Marital status (n = 3,762)			.009*			.417
Single	1			1
In a relationship	0.74	0.31–0.74		0.80	0.54–1.17
Cohabitating	0.66	0.05–3.23		0.71	0.51–1.01
Married	0.48	0.52–1.05		0.76	0.46–1.28
Separated	0.38	0.49–0.89		1.31	0.12–13.99
Children (n = 3,762)			<.001*			<.001*
Yes	0.54	0.41–0.72		0.51	0.35–0.73
Highest completed education (n = 3,762)			.002*			.094
Primary or none	1			1
Secondary	1.39	0.94–2.07		1.11	0.70–1.77
University or college	1.84	1.28–2.64		1.46	0.94–2.27
Household income after tax (in NOK) (n = 3,711)			.689
P10 214000	1
P20 266000	0.92	0.60–1.40
P30 305000	0.92	0.57–1.47
P40 339000	0.96	0.59–1.57
P50 372000	1.12	0.67–1.89
P60 408000	1.19	0.71–2.01
P70 450000	1.31	0.77–2.23
P80 507000	0.86	0.54–1.38
P90 606000	0.95	0.59–1.54
P100 > 606001	0.63	0.38–1.04
Ease to find out where you could get the free HPV vaccine (n = 3,762)	2.05	1.82–2.30	<.001*	1.94	1.69–2.23	<.001*
Receipt of vaccination at your preferred location (n = 3,762)			.002*			.664
Yes	1.52	1.17–1.98		1.07	0.79–1.45
If you wanted to get more information about the vaccines, where would you get this? (multiple locations possible) (n = 3,762)
Internet	1.16	0.85–1.57	.352
Friends or colleagues	1.04	0.79–1.38	.761
Family	1.24	0.90–1.71	.192	1.08	0.76–1.54	.667
Community health service	1.06	0.83–1.35	.664
GP	1.05	0.83–1.33	.694
Health authorities	1.52	1.19–1.95	.001*	1.37	1.04–1.81	.025*
What were the reasons why you completed the HPV vaccination? (multiple answers possible)
… information from the media (n = 3,754)	1.18	0.92–1.52	.192	1.03	0.76–1.41	.842
… information from NIPH via SMS and social media (n = 3,755)
Country of origin: Norway	1.09	0.81–1.46	.584	0.68	0.46–1.01	.034*
Country of origin: Not Norway	1.76 ▪	0.91–3.41	.092	1.48 ▪▪	0.69–3.14	.312
… HPV vaccination was free of charge (n = 3,758)	0.99	0.63–1.54	.958
… HPV vaccination was readily available (n = 3,760)	3.61	2.65–4.90	<.001*	2.28	1.50–3.37	<.001*
… my parents and/or friends thought I should take the vaccination (n = 3,762)	1.37	1.06–1.76	.017*	1.20	0.89–1.62	.226
… healthcare professionals and central health authorities recommended vaccination (n = 3,761)	1.34	0.98–1.85	.070	0.68	0.46–1.01	.057
… the vaccine can prevent cervical cancer (n = 3,761)	2.16	1.30–3.57	.003*	1.31	0.70–2.43	.395
… I, or someone I know, has had cell changes/cervical cancer (n = 3,756)	0.99	0.78–1.25	.904

▪The estimate of OR of receiving information from FHI via SMS and social media for study participants whose country of origin is not Norway is based on the multiplication of the estimate of the OR of study participants whose country of origin was Norway (presented in the Table 3) * the interaction term (1.62 (95%CI: 0.79–3.35), p-value: 0.19).

▪▪The estimate of aOR of receiving information from FHI via SMS and social media for study participants whose country of origin is not Norway is based on the multiplication of the estimate of the aOR of study participants whose country of origin was Norway (presented in the Table 3) * the interaction term (2.18 (95%CI: 0.98–4.88), p-value: 0.06).

* = p value significant at p < .05.

(a)OR = (adjusted)odds ratio.

Table 4. Self-reported reasons for incomplete HPV vaccination according to women who did not adhere to the free HPV vaccination (n = 298) between 1 November 2016 and 30 June 2019 in Norway (weighted percentage and 95% confidence interval)

	Totally agree	Fairly agree	Neither agree/ disagree	Fairly disagree	Completely disagree
	% (95% CI)	% (95% CI)	% (95% CI)	% (95% CI)	% (95% CI)
I forgot to finish the 3 doses	40.4 (33.5–47.8)	15.8 (11.7–21.1)	13.9 (9.5–19.9)	7.9 (4.9–12.5)	21.9 (16.7–28.3)
I did not have time to finish the 3 doses	32.9 (26.2–40.4)	16.0 (11.7–21.5)	18.6 (13.9–24.6)	8.4 (5.0–13.6)	24.1 (18.6–30.6)
It took too long between doses and I did not want to start again	18.1 (12.9–24.8)	18.6 (13.5–25.0)	21.8 (16.4–28.3)	5.9 (3.7–9.3)	35.7 (29.2–42.8)
I became pregnant and could not complete the vaccination	16.2 (11.9–21.8)	0.9 (0.3–2.5)	2.3 (0.7–7.3)	0.5 (0.1–2.1)	80.0 (73.9–85.0)
I moved and did not know where to get the vaccination	9.3 (5.8–14.4)	11.6 (7.5–17.6)	6.8 (3.9–11.8)	3.8 (1.9–7.4)	67.6 (60.4–74.1)
I moved abroad	5.8 (3.2–10.4)	5.3 (2.6–10.6)	3.4 (1.3–8.3)	3.1 (1.1–8.4)	82.5 (75.4–87.8)
I read that someone was skeptical of the vaccination, and became skeptical myself	2.2 (0.7–6.7)	8.0 (4.5–13.8)	5.3 (2.7–9.9)	2.3 (0.9–5.5)	82.3 (75.5–87.5)
I became uncertain of the side effects of the vaccination and did not want to take more doses	3.1 (1.5–6.3)	5.4 (2.6–11.2)	7.5 (4.0–13.6)	4.7 (2.3–9.4)	79.3 (72.0–85.1)