Introduction

High levels of mortality and morbidity were created by the COVID-19 pandemic, that started in Romania in 2020. Due to new mutations and vaccine hesitancy, every few months new waves of disease appeared (de Vries et al., 2022). Vaccine hesitancy may be influenced by the information obtained from different social media sources (Puri et al., 2020). In fact, there are many different factors that could influence the vaccination process, like: predisposing, awareness, motivational and informational factors (de Vries et al., 2022).

In Romania, there were several waves of cases over time, from the beginning of the pandemic. The present study was carried out during the fourth wave, which was considered to be the most severe wave of COVID-19 in Romania, until then. Among the European Union states, Romania occupied the penultimate place in terms of the vaccination percentage of the population, with Bulgaria in last place. Also, it could be observed that worldwide, on October 13, 2021, Romania was ranked number 3 with regard to number of new deaths and number 4 with regard to number of new infections with the COVID-19 virus; on October 19, 2021, Romania occupied the 2nd place, worldwide, regarding per capita COVID-19 death rates (COVID-19 Pandemic in Romania- Wikipedia, 2022).

According to a descriptive study using data from the National Electronic Registry of Vaccinations from Romania, a total of 41% of the population received at least one dose of the COVID-19 vaccine; the study took into account the vaccinations carried out during the period between 27 December 2020 and 31 December 2021 (Enciu et al., 2023). At the beginning of the vaccination campaign in Romania, on December 28th, 2020, 1101 doses were administered; a similar number was administered in Italy (1505) and a much larger number in Germany (18073). The highest number of vaccine doses administered daily in Romania was on October 28, 2021 -131697 doses (Mathieu et al., n.d.).

On the other hand, 69.9% of the world population has received at least one dose of a COVID-19 vaccine (Mathieu et al., n.d.). According to data available on the John Hopkins University website, 42.55% of the Romanian population received at least one dose of the COVID-19 vaccine, being below world average; the percentage for other European countries were the following: 84.16% for Italy, 66.46% for Hungary, 30.31% for Bulgaria, 27.47% for Moldova, 88.42% for Spain; 81.81% of the population of the United States of America received at least one dose of the COVID-19 vaccine (Understanding Vaccination Progress by Country- Johns Hopkins Coronavirus Resource Center, 2023).

It was observed that the acceptance rate of the vaccine against COVID-19 was very different, depending on the country where the studies were performed, without necessarily being able to notice a certain pattern (Sallam, 2021), but still, in developing countries, the percentage of the population that rejects the idea of vaccination was significantly higher than in developed countries (Hawlader et al., 2022).

The reasons why people choose or not to vaccinate against COVID-19 are many, diverse, and have drawn the attention of research studies from several countries. For example, a French study performed among university students shows that the main motivation to accept the vaccination was that of not transmitting the disease to other people, and the main reason for not wanting the vaccination was that there is not enough experience yet with this type of vaccine (Tavolacci et al., 2021). A true trust of the general population in vaccines can only be achieved if the public health services focus their work on the social, moral, political, and not only the biological side of the vaccination processes (Harrison& Wu, 2020).

A study on the Israeli population, aged 18 and older, participants being from both general population and healthcare employees, showed that medical personnel involved in the care of COVID-19-positive patients and people considered at risk were more willing to accept the vaccine than people who were not involved in the treatment of these patients (Dror et al., 2020).

In a study carried out in the USA it was observed that the participants who were not convinced of the safety of the vaccine against COVID-19 were more inclined to believe the unfounded information circulating about the COVID-19 virus; those participants had a lower educational level, a lower salary, weaker economic situation and many of them lived in the countryside (Kricorian et al., 2022).

According to a Romanian study, carried out during the 5th wave of illnesses in our country (the questionnaires were distributed in the time interval January 2022-March 2022), on 2297 Romanian inhabitants, which were 18 years old or older and were vaccinated, the main reasons people chose to vaccinate were: for “protecting their own health or for protecting against the virus” (18.3%), because of the “fear of the disease” (17%), to help stop the pandemic and return to their previous lifestyle (8.8%) and for obtaining the vaccination certificate in order not to be affected by the restrictions imposed by law (8.5%) (Mărcău et al., 2022). Another Romanian study carried out during the fourth wave of COVID-19 pandemic in Romania, which was addressed to the general population (both medical and non-medical participants) and focused on parental avoidance of children vaccination against COVID-19 showed that the main aspects that cause the avoidance of vaccination among children were: the fact that the vaccine against COVID-19 is a new type of vaccine (47.32%), the participants were afraid of potential adverse effects (24.42%) and the idea of anti-vaccinism regarding other vaccines too (22.13%) (Manolescu et al., 2022).

A tool that contributed to an increase in vaccination hesitancy in several geographic areas was the “infodemic”; this term refers to the multitude of information circulating among the population, with not quite adequate scientific content, coming from unreliable sources, spreading quickly and preventing people from acting appropriately during serious events such as pandemics (Cardenas, 2022).

Modern social media allows practically anyone to create content and distribute it widely, without being verified in any way. This can represent a disadvantage during a complex process such as anti-COVID-19 vaccination, generating many opinions pro and against this subject (Puri et al., 2020). According to a study carried out in the UK, it is important to evaluate the consequences that the pandemic has brought on patients infected with the new virus, vulnerable groups and the general population. Regarding this aspect, media messages about health and COVID-19 can have a great influence (Holmes et al., 2020).

This study was performed during the fourth wave of COVID-19 pandemic in Romania, when limited information about vaccination acceptance, hesitancy and factors influencing them were available in Romania and worldwide, and had three objectives. First, it has assessed the opinions regarding COVID-19 vaccination during a severe wave of the pandemic among Romanian adults. Second, it aimed to get insights into their behavior regarding vaccination and factors influencing it. Last, but not least, intention regarding future vaccination and associated factors was assessed.

Materials and methods

Procedure for data collection

A cross-sectional study was conducted in 3 general practitioners’ (GP) medical offices, in the city of Câmpia Turzii from Cluj county, Romania, from October 2021 to December 2021; the study was implemented only in this city due to limited possibilities to perform research activities in health institutions and at community levels because of the high pressure of the COVID-19 pandemics and isolation measurements in place at that time. The persons responsible for conducting the survey in all 3 medical offices were the researchers, the medical team did not interfere with the study, but they all gave their permission to the researchers to carry out the study and distribute the questionnaire in their waiting rooms.

Characteristics of the medical offices

Those 3 medical offices were chosen to participate in the study due to the large number of patients who attend them and due to the fact that they carry out their activity in the same building (within a medical polyclinic) as well as because of the availability of the GPs to allow the implementation of the study during a difficult period with a lot of restrictions in place.

In each of the 3 medical offices, the medical staff consists of one family doctor and one medical nurse. In these offices, only family medicine is practiced, not any other medical specialities. Each medical office operates on the basis of a list of patients, each of the 3 having a number of over 2000 registered patients. The offices offer free medical services, settled through the National Health Insurance House, to those patients who have medical insurance. For the patients who are not insured, they only offer a package of basic medical services, while the medical services not included in this package are paid by the patient. In order to benefit from these services, patients present themselves at the office based on a prior telephone appointment, or without an appointment in the case of those conditions that represent medical emergencies.

Sample selection

The study involved a convenience sample of Romanian adults, aged 18 and older, who came at their GP’s office for different health problems: acute/subacute/chronic disease or even routine medical check-ups. Patients were informed both orally as well as through a short written introduction at the beginning of the questionnaire that they were invited to participate in a research study, that the participation is voluntary and involves filling in an anonymous questionnaire, with no identification data being asked; by accepting to fill in the questionnaire the participant gave their consent for participation.

Taking into account the fact that the 3 medical practices targeted in the study together have approximately 7000 patients, we tried to approach approximately 10% of them, meaning 700 people. There were 502 respondents, who fully completed the questionnaire out of 700 patients who were asked to fill in the questionnaire (acceptance rate 71.7%). Due to the restriction conditions during the pandemic, the people who did not fill the questionnaire were not contacted later on and there were no possibilities to collect data regarding their characteristics or reasons behind the refusal. Also, most of the patients who refused to participate had non-cooperant behavior, making their follow-up impossible.

Ethical approval

This study is part of a research project which received the approval of Ethic Commission of Iuliu Hatieganu University of Medicine and Pharmacy (Approval no. 279/30.06.2021). The project aimed to investigate several opinions and practices regarding COVID-19 infection prevention and control, as well as lifestyle among Romanian adults.

Instrument for data collection

A questionnaire was designed for this study in order to assess socio-demographic characteristics, history of COVID-19 infection, opinions about COVID-19 vaccination, behavior and intention regarding COVID-19 vaccination. At the moment when the study was performed few studies were performed with regard to this topic, there were no validated instruments in place and we developed an instrument for an exploratory study in order to get specific information from Romania- a country confronted with lower vaccination rate than several other countries of European Union, despite a good accessibility to vaccination. Time and logistical constraints because of the limitations set up by the pandemic in terms of getting access to the patients, as well as the need to collect the data during a very intense phase of COVID-19 pandemic in Romania deterred us from validation of the questionnaire.

Participants were asked to indicate some socio-demographic data about themselves like: their age, their gender (1 = male, 2 = female), the environment of origin (1 = urban, 2 = rural), their marital status (1 = married, 2 = unmarried, 3 = divorced, 4 = widow), their highest completed education (1 = gymnasium, 2 = vocational school, 3 = high school, 4 = university, 5 = postgraduate studies).

In the next part of the questionnaire, the patients were asked if they had the disease COVID-19 (1=yes, 0=no) and how long has it been since they had the disease (1 = more than 1 year, 2 = between 6 and 12 months, 3 = between 3 and 6 months, 4 = less than 3 months).

In order to assess opinions, there were 12 statements related to the vaccine against COVID-19, about which the patients had to express their answer (1 = I totally disagree, 2 = I partially disagree, 3 = I do not know, 4 = I partially agree, 5 = I totally agree).

The patients were asked if they were vaccinated against COVID-19 (1=yes, 0=no), what their vaccination situation was (1 = I was vaccinated with a vaccine that is administered in a single dose, 2 = I was vaccinated with a vaccine that is given in several doses and I only received the first dose, 3 = I was vaccinated with a vaccine that is given in several doses and I also received the second dose, 4 = I was vaccinated with a vaccine that is given in several doses and I also received the third dose), how long has it been since the last dose of vaccine (1=more than 6 months, 2 = 3–6 months, 3 = 1–2 months, 4=less than 1 month). The patients who were vaccinated were asked to answer questions about the vaccine process (1=yes, 0=no).

Both vaccinated and unvaccinated patients were asked to indicate the reasons why they chose or not to get vaccinated (1=checked statement, 0=unchecked statement). The unvaccinated participants were asked to choose the factors that would make them change their minds and accept the vaccination (1=checked statement, 0=unchecked statement). They were also asked about their intention of getting the vaccine in the future, having to choose between 5 answer options (1=yes, in a few days, maximum 1 month, 2=yes, in the next 1–2 months, 3=yes, in more than 2 months, 4=no, 5 = I do not know).

Data Analysis

There were calculated frequencies for the investigated issues: socio-demographic characteristics, opinions about vaccines, behavior regarding vaccination, facilitators and barriers for vaccination and intention to get vaccinated in the future and factors influencing it.

Linear regressions were performed to identify socio-demographic factors (age, gender, educational level) which interfere with the opinions about vaccines; backward method was used. Bivariate correlation was used to assess correlations between different opinions about the vaccine and hence to identify also possible collinearities. According to Cohen, strong correlation was considered at r > 0.50, while medium and small correlation was considered at r > 0.30 and r > 0.10, respectively.

In order to identify factors which influence the behaviors regarding vaccination logistic regression was performed with dependent variable being vaccination status (0-no, 1-yes) and the independent variables being age, gender, education, if they were infected before with COVID-19, as well as opinions about COVID-19 vaccination; the backward conditional method was used. Because a collinearity was identified between the following opinions about vaccine: “The vaccine against COVID-19 can cause infertility/sterility in women” and “The vaccine against COVID-19 can cause infertility/sterility in both women and men”, as well as between “The COVID-19 vaccine is a first step to getting back to normal and everyone should get it as soon as possible” and “The administration of the 3rd dose (booster) is also important”, we included in the analyses only one of the colinear variables (“The vaccine against COVID-19 can cause infertility/sterility in women”, respectively “The COVID-19 vaccine is a first step to getting back to normal and everyone should get it as soon as possible”) and excluded from the analyses the other one (“The vaccine against COVID-19 can cause infertility/sterility in both women and men” and “The administration of the 3rd dose (booster) is also important”).

In order to assess factors which influenced intention to get vaccinated in the near future among those who did not do so, logistic regression was also performed with the dependent variable being intention to get vaccinated among those who did not do so (0-no/I do not know, 1-yes) and the independent variables as follows: age, gender, education, if they were infected before with COVID-19, as well as opinions about COVID-19 vaccination; the backward conditional method was used and because of the collinearity a similar approach was used as for the logistic regression described above.

Data was analyzed using SPSS version 26. Statistical significance was considered at p < 0.05.

Results

Socio-demographic characteristics

The study participants were between 18 and 89 years old (mean age 50; SD 14.9). The first aspects revealed by the questionnaire were the socio-demographic characteristics of the participants: more than half of them were women (58.6%), the majority of the participants lived in an urban environment (81.5%), most of them were married—72.1%, 14.7% were unmarried, 5.8% were divorced, 7.4% were widows; regarding their education, the most of the participants answered that their highest completed education was high school—42.6%, for 7.2% of them the highest completed education was gymnasium, for 16.5% was vocational school, for 24.1% was university and for 9.6% was postgraduate studies.

The distribution of the participating patients according to the presence of COVID-19 infection in their medical history showed that only about a third (32.1%) of the participants had the COVID-19 disease; 23.6% of those patients have had it more than 1 year ago, about half-44.7% have had it between 6 to 12 months ago, 6.2% have had it between 3 to 6 months ago and 25.5% have had it less than 3 months ago.

Opinions about vaccine

Table 1 shows patients’ opinions about the vaccine against COVID-19. With regard to the safety/possible risks of the vaccines, two-thirds declared that they did not know if the vaccine can cause infertility/sterility in women or in both women and men, while more than half did not know if it can be dangerous for a pregnant woman and the fetuses or if the vaccine is dangerous because it can alter the structure of the DNA. Around one-third declared they cannot say if the vaccine is dangerous because it contains virus fragments or virus-like structures. On the other hand, we noticed the percentage of those who believe that the vaccine can have these kinds of effects varies between 7 and 14%, while those who were convinced that these risks were not real varied between 26% and 49%.

Table 1 Patients’ opinions about the vaccine against COVID-19.
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One-quarter of the participants did not know if the vaccine against COVID-19 is safe and effective, but almost two-thirds agreed or totally agreed with this.

Regarding the efficacy of the vaccine, more than half did not agree that after the vaccination a person can not get infected, while 75% agreed that after receiving the vaccine, it is possible for a person to become infected with the virus COVID-19, but it will be a much milder form of the disease. Two-thirds of the persons rejected the idea that the vaccine was not useful, while around 42% did not agree with the fact that the vaccine was not useful for delta variant of the virus.

Two-thirds were convinced that the third dose plays an important role, too. More than 70% believed that the vaccine was the first step to the normality and everybody should get it as soon as possible.

The results of linear regression showed that women were less convinced that the vaccine against COVID-19 can cause infertility/sterility in both women and men (standardized coefficient Beta = −0.104, CI = −0.396, −0.036). Also, the results of linear regression showed that older ages had the tendency to believe more that the COVID-19 vaccine is a first step to getting back to normal and everyone should get it as soon as possible (standardized coefficient Beta= 0.107, CI = 0.001, 0.017) and the administration of the 3rd dose (booster) was also important (standardized coefficient Beta= 0.132, CI = 0.004, 0.020).

People with higher educational level were less convinced that the vaccine against COVID-19 can cause infertility/sterility in women (standardized coefficient Beta = −0.158, CI = −0.248, −0.072), that the vaccine against COVID-19 can cause infertility/sterility in both women and men (standardized coefficient Beta = −0.151, CI = −0.237, −0.064) and that the vaccine against COVID-19 can be dangerous for a pregnant woman and the fetus, so it should not be given in that case (standardized coefficient Beta = −0.139, CI = −0.238, −0.054); also, the participants with higher educational level had the tendency to believe less that after receiving the vaccine, a person can no longer be infected with the virus COVID-19 (standardized coefficient Beta = −0.209, CI = −0.397, −0.158), that vaccination makes no sense, since even vaccinated people can get infected and get sick (standardized coefficient Beta = −0.171, CI = −0.341, −0.112), that the COVID-19 vaccine is dangerous because it contains virus fragments or virus-like structures (standardized coefficient Beta = −0.225, CI = −0.384, −0.172), that the vaccine against COVID-19 is not effective against the Delta variant of the coronavirus, making it unnecessary to administer it during that period (standardized coefficient Beta = −0.190, CI = −0.318, −0.119).

At the same time, having higher educational level made people to believe more that after receiving the vaccine, it is possible for a person to become infected with the virus COVID-19, but it will be a much milder form of the disease (standardized coefficient Beta = 0.205, CI = 0.129, 0.317) and that the administration of the 3rd dose (booster) was also important (standardized coefficient Beta = 0.106, CI = 0.018, 0.253).

As can be seen in Table 2, there are moderate and strong correlations between different statements related to the vaccine. However, the strongest observed correlations were between opinions that the vaccine against COVID-19 can cause infertility/sterility in women and that the vaccine against COVID-19 can be dangerous for a pregnant woman and the fetus, so it should not be given in that case as well as between the following 2 affirmations: The COVID-19 vaccine is a first step to getting back to normal and everyone should get it as soon as possible and The administration of the 3rd dose (booster) is also important. The participants who thought that the vaccine against COVID-19 is safe and effective also believed more that the COVID-19 vaccine is a first step to getting back to normal and everyone should get it as soon as possible, while the administration of third dose is also important. Strong correlation was also found between opinions that vaccination makes no sense since even vaccinated people can get infected and get sick and the fact that COVID-19 vaccine is dangerous because it contains virus fragments or virus-like structures. Another important correlation was between the fact that the COVID-19 vaccine is dangerous because it contains virus fragments or virus-like structures and the opinion saying that the vaccine against COVID-19 is not effective against the Delta variant of the coronavirus, making it unnecessary to administer it during that period. Another strong correlation was between the opinion that the COVID-19 vaccine can cause infertility/sterility in women and that it is dangerous for pregnant women and the fetus.

Table 2 Correlations between participants’ opinions about the vaccine against COVID-19 (Pearson Correlation).
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Behavior regarding vaccination

71.7% of the participants were vaccinated and most of those patients were vaccinated with a vaccine that is given in several doses and received the second dose-45% or even the third one-33.1%; for highest percentage of participants (31.1%), the time that has passed since the last dose was 3–6 months (see Table 3).

Table 3 Vaccination schedule of vaccinated patients and the amount of time that has passed since the last vaccine dose.
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97.2% of the vaccinated patients think the vaccination was beneficial for them and 90.8% of them would advise other people to get vaccinated; only small percents of the vaccinated patients were infected with COVID-19 during the period between vaccination and performance of this study (6.4%). Almost all vaccinated participants (95.6%) declared that they had no regrets that they have got vaccinated.

The results of the logistic regression analyses show that there were no age, gender or educational level differences regarding vaccination status. On the other hand, people who got the disease (OR = 0.533, CI = 0.315–0.903) or thought the vaccine provoked sterility for women (OR = 0.635, CI = 0.453–0.888) were less likely to get vaccinated. People who were more convinced about the efficacy and safety of the vaccine (OR = 1.718, CI = 1.338–2.206) and its importance for getting back to normality (OR = 2.151, CI = 1.705–2.713) were also more likely to get vaccinated.

Facilitators and barriers for vaccination

Tables 4 and 5 present the factors that determined the patients to get vaccinated or not. Most of the vaccinated patients said that what made them to get vaccinated was: believing that vaccination is an important step for society to return to normality (66.4%), getting vaccinated for the protection of family members (65.3%), and getting vaccinated for the protection of other people, not only family members (57.8%). More than 40% also mentioned their own protection (even if they did not suffer from chronic diseases) and the trust in the medical advice regarding vaccination, while one-third declared their chronic diseases convinced them to get vaccinated to be protected.

Table 4 Declared reasons for getting vaccinated.
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Table 5 Barriers against vaccination.
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The main declared reasons for unvaccinated patients were the fact that the vaccine was still insufficiently tested and studied (50.7%), they were afraid of the effects of the vaccine on their health (46.5%), did not trust the vaccination-related studies that have been done up to that point (26.8%). 15% of the participants believed that the pandemic would pass without the vaccine and 12% even declared that they thought that the virus did not exist.

Intention to get vaccinated in the future and factors influencing it

A percentage of 42.3% of those who were not vaccinated said they do not know if they would get vaccinated, 33.1% of them said they would not get vaccinated, while around one quarter declared their intention to get vaccinated in the near future: 9.2% of them would like to get the vaccine in more than 2 months, 7% in the next 1–2 months and 8.4% in a few days, maximum 1 month. 30.3% of the unvaccinated participants said that carrying out more detailed studies on these new vaccines could make them change their minds and get vaccinated; a quarter of them—25.4% said that the presentation by the authorities of clearer and more certain information on the effects of the vaccine could make them change their mind and accept the vaccine; for 12% of them severe illness/death of a family member/colleague/friend due to COVID-19 infection was a factor that could make them change their mind; for 28.9% of them mandatory vaccination imposed at the workplace could make them accept the vaccine; 16.2% of the unvaccinated patients said that mandatory vaccination to have access to shops/cultural events/restaurants, others would make them accept the vaccination; 21.8% of them said there is nothing that would make them accept the vaccine.

The results of the logistic regression analyses show that there were no differences regarding the intention to get vaccinated based on age, gender or educational level, but people who had stronger beliefs that the vaccine is not protecting against the disease, so is not useful were less convinced that they will get vaccinated (OR = 0.600, CI = 0.402–0.894). On the other hand, those who believe it will help our return to normality were more likely to declare their intention to get vaccinated (OR = 2.355, CI = 1.544–3.592).

Discussion

The main objective of this study was to determine the percentage of vaccination and, respectively, the intention to get vaccinated among Romanian adults from one city in the Cluj county, Romania. The study revealed that more than 70% of the participants were vaccinated at the time of distribution of the questionnaire; almost a half of the vaccinated patients were fully vaccinated (patients who were vaccinated with a vaccine that was administered in a single dose and patients who were vaccinated with a vaccine that was given in several doses and also received the third dose). It can be observed that there is a difference between the vaccination percentage in Romania—42.55% (Understanding Vaccination Progress by Country- Johns Hopkins Coronavirus Resource Center, 2023) and the one obtained by the present study—71.7%; it is possible that this difference may have appeared because of the 71% acceptance rate to participate in the study so that more already vaccinated patients were self-selected or it may have appeared because of the selection of the group of patients who came to their GP’s practice. On the other hand, the Cluj county, where the study was performed had even from the beginning of the vaccination campaign higher percentages of vaccination than several other counties of the country (Aplicatie STS, n.d.). At the same time, most of the participants were from the urban environment, therefore having easier access to vaccination and health services in general. There were no age, gender or educational level differences regarding vaccination status in our study.

Regarding the knowledge of the patients about the vaccine against COVID-19 it can be observed that more than 70% of them partially and totally agreed that the vaccine is a first step to getting back to normal and everyone should get it as soon as possible; almost three-quarters of the participants also partially and totally agreed that after receiving the vaccine, it is possible for a person to become infected with the virus COVID-19, but it will make a much milder form of the disease. Two-thirds of the participants recognized the importance of administration of the third dose of the vaccine. All these demonstrate that among the sample of our study, many participants recognized the importance and benefits of the vaccination. It was observed the tendency for several wrong ideas to be present simultaneously; for example, those who believed that the vaccine against COVID-19 can cause infertility/sterility in women also believed that the vaccine against COVID-19 can be dangerous for a pregnant woman and the fetus. Also, more pro-vaccine opinions had the tendency to be present concomitant; for example, those who believed that the vaccine against COVID-19 is safe and effictive also believed that the COVID-19 vaccine is a first step to getting back to normal and everyone should get it as soon as possible.

Studies about the knowledge of the population regarding these subjects were also done in other countries. In one of those studies, performed in Saudi Arabia, it was demonstrated that most of the participants had adequate knowledge about the COVID-19 illness; also, it was observed that male participants had less knowledge than female participants, they were less optimistic than women and they had fewer correct practices regarding the COVID-19 infection than women. Our study showed that women were less convinced that the vaccine against COVID-19 can cause infertility/sterility in both women and men, than the male participants. It was also observed that the participants who were older were more likely to know better information about COVID-19 and to have better attitudes, than the younger persons (Al-Hanawi et al., 2020). Our study showed that the older participants had the tendency to believe more that the COVID-19 vaccine is a first step to getting back to normal and everyone should get it as soon as possible and the administration of the 3rd dose (booster) was also important.

According to a cross-sectional survey, carried out in the United States of America, on a sample recruited from an online panel, people who had less knowledge considered that they were putting themselves in danger by accepting the vaccination because of its potential adverse reactions. If the population had more correct information about the vaccination process, maybe they would no longer perceive it as a health hazard and would accept the inoculation (Zheng et al., 2022). Our study revealed that patients with higher educational levels were less convinced that the vaccine against COVID-19 can cause infertility/sterility, that the vaccine against COVID-19 can be dangerous for a pregnant woman and the fetus, that vaccination makes no sense since even vaccinated people can get infected and that the COVID-19 vaccine is dangerous because it contains virus fragments or virus-like structures. According to a Dutch study, it can be seen that patients who were hesitant about the vaccine had less correct knowledge about it than non-hesitant patients; for instance, the non-hesitant participants agreed to a greater extent that the vaccine would protect them and the people around them from getting COVID-19, that it would help to stop the spreading of the disease, that would have a role in stopping the emergence of new viral variants. Also, the non-hesitant participants disagreed to a greater extent that the vaccine “will not be effective”, that they would put themselves at “risk of getting severe side-effects”, that they would “predominantly support the pharmaceutical industry with it”, than the hesitant participants (de Vreis et al., 2022). As reported by a web-based survey among Malaysians, the respondents who had higher knowledge scores were observed to have higher educational levels, a better financial situation and sharing the same home with a person who could suffer from a severe form of the COVID-19 disease, in case of infection; also, participants having a lower age, being female and having a better education were more likely to accept the vaccination (Mohamed et al., 2021). Our study pointed out that people with higher educational levels believed more that after receiving the vaccine, it is possible for a person to become infected with the virus COVID-19, but it will be a much milder form of the disease and that the administration of the 3rd dose (booster) was also important.

The safety and efficacy of this new vaccine is a very debated topic, therefore in the questionnaires addressed to the patients, there was a special section dedicated to their opinions about the safety/perceived possible risks of the vaccine. One previously known concern is that mRNA vaccine technology is new and long-term adverse effects in humans are unknown (Hitti & Weissman, 2021). Indeed, more than 50% of the participants did not know if the mRNA vaccine against Covid-19 can alter the structure of their DNA or not. One out of two participants did not know what to believe regarding the risk for pregnant women and fetus, while two-thirds were not sure about the effects of fertility, showing that even not clear misconceptions were present among many of the participants, several uncertainties could be noticed among many of them.

Similar with other studies, several attitudes were associated with the vaccination or intention to get vaccinated. People who thought the vaccine provoked sterility for women were less likely to get vaccinated and those who were more convinced about the efficacy and safety of vaccine and its importance for getting back to normality were more likely to get vaccinated. At the same time, people who considered that the vaccine was not useful were less convinced that they would get vaccinated, while those more convinced about the importance of the vaccine for getting back to the normality were more likely to declare intention for vaccination.

Among vaccinated participants the most popular reasons for getting vaccinated were the contribution for the recovery of the society and its return to normality and for the protection of their own health and of their family members, while the most alleged reasons for not getting vaccinated among those who did not get the vaccine were that the vaccine is still insufficiently tested and studied and because people feared the possible side effects. As well as previous studies showed, the vaccination process is influenced by the people’s confidence in the effectiveness of vaccination and their trust in the medical staff that cares and advises them (Dhama et al., 2021). Some other studies showed the same main reasons: the people who accept the vaccination do so to protect themselves and the people close to them against infection with COVID-19, and those who refuse the inoculation of the vaccine do so because of the fear of adverse effects and the insufficient study of this type of vaccine regarding its safety (Wang et al., 2021). In the present study, more than 20% of the unvaccinated patient said there is nothing that would make them change their mind and accept the vaccine.

As it can be seen in a systematic review, with thirty articles included, realized following the PRISMA guidelines, during the first year of pandemic the overall vaccination intention was observed to be between 27.7% to 93.3%; differences were stood out regarding the following aspects: socio-demographic membership, vaccine features and the way the risks related to vaccination are perceived (Al-Amer et al., 2022). It was also noted that the intention to vaccinate is also related to political aspects, conservatives being less willing to accept vaccination, being more frequently exposed to discussions with conservative colleagues and less exposed to liberal news (Jiang et al., 2022). There were also noticed in different studies the relationship between personal motivation of population to get vaccinated and external factors (Cirnatu et al., 2023).

Regarding the vaccination campaign in Romania, there were many challenges that had to be overcome, challenges that were posed by the socioeconomic, cultural, historical and religious context. The effects of the onset of the pandemic on the Romanian medical system were quickly and acutely felt; already present problems have become obvious and unacceptable: shortage of medical staff, inappropriate equipment, the impossibility of properly creating isolation zones due to the limited capacity of hospitals in the country and lack of trust in the competent authorities. Then, after the start of the vaccination campaign, new problems were noticed: the transport and adequate storage of vaccine doses, the prioritization of certain population categories, the acceptance of vaccination and the fight against widespread false information (Dascalu et al., 2021). The problem of accepting the vaccine generated the beginning of several studies, to see what is being done right or wrong in this direction. Some of these showed that belonging to the urban environment, the female gender and the profession of medical doctor are associated with a higher rate of acceptance of the vaccine (Manolescu et al., 2022). The present study showed that were no age, gender or educational level differences regarding vaccination status and intention to vaccinate.

This study is subject of several limitations. First, the participants were selected from those who have presented themselves to the family doctor for several issues, hence people more aware and more interested in their own health and implicitly in the COVID-19 pandemic and vaccination process could have come. Second, we have to keep in mind the acceptance rate of completing the questionnaire of 71%, there is a possibility that it is precisely the unvaccinated patients who refused to complete the questionnaire. Third, the study was performed only among patients from one city of Romania and it was an exploratory study, without a prior validation of the questionnaire. Nevertheless, the study was performed during a very difficult time of COVID-19 pandemic in Romania, with many cases of infections and lockdown in place, the contact of different population groups in order to participate in these types of surveys being very limited.

Despite these limitations, the data gathered by the study have the strengths of being collected in a country with a lower vaccination rate than other countries from European Union during a strong wave of COVID-19 pandemic and several limitations in place, contributing to the data collected in Romania and other countries with diverse evolution of epidemiological COVID-19 pandemics during different periods of time and targeting different population groups. Another strength is based on the fact that printed questionnaires were used (not on-line questionnaires), making possible and encouraging in this way the participation of older age groups, too, which in Romania have less skills and acceptance of using digital tools and online questionnaires.

Conclusions

The study gives insights into attitudes, behavior and intention related to COVID-19 vaccination among Romanian adults during a challenging period of COVID-19. The results have implications for public health, organization of health communication campaigns and pandemic management in order to increase the trust of the population in the medical personnel and in the state institutions, the organization by the public health departments of more convincing actions and more understandable vaccination related messages for different population groups. If we were to think of some more specific public health strategies to combat vaccination hesitancy, we consider that the use of social media could represent an important information channel; this aspect can be achieved by disseminating correct information and in a language that is as easy to understand as possible for the general population, related to the importance of vaccination, through appropriate platforms and websites of state institutions. Considering that the vaccination process of an individual starts from an early age, an important aspect that must be followed is the medical education of the parents; all medical personnel who have contact with children and implicitly with parents should be trained in such a way that they can convince parents that vaccination is a beneficial thing, through relevant, updated information, easily accessible to them, and proven by studies (Hotopf et al., 2024).

The present study’s findings have the potential to inform public health strategies not only in Romania, but in other contexts facing similar challenges, allowing to learn from the past and get ready for future community health challenges.