The National Institute of Public Health (INSP) and the WHO Country Office in Romania presented the results of a qualitative study on barriers to vaccination conducted in late 2024 with caregivers and health-care providers in rural and semi-urban areas of Brașov, Timiș and Covasna counties.
The study aimed to uncover the reasons behind vaccination gaps among children in low socioeconomic and ethnically diverse settings so they can be addressed. It was led by WHO with support from the EU4Health programme of the European Commission’s Directorate-General for Health and Food Safety.
“Vaccination saves lives, but providing this protection to everyone requires trust, correct information and equitable access,” explained Dr Simona Parvu, General Director of the INSP. “Only through a joint effort – involving WHO, the INSP, local authorities, health-care professionals, civil society organizations, economic entities, media and citizens – can we ensure the protection of every child, adult and older person in Romania.”
Background
The WHO European Region saw a resurgence of measles in 2024 with over 127 000 reported cases – more than double the 2023 total and the highest since 1997.
Coverage with the first dose of measles-containing vaccine remained steady at 94% for the Region as a whole from 2022 through 2024, with some considerable differences both between and within countries. Romania, for example, experienced a decline in coverage with the first dose of measles-mumps-rubella (MMR) vaccine from 83% in 2022 to 78% in 2024, according to estimates by WHO and the United Nations Children’s Fund (UNICEF).
In addition, only 62% of Romanian children received the second dose of MMR vaccine in 2024, well below the 95% recommended by WHO. These trends underscore the urgency of tailored, effective interventions to increase coverage.
Key findings of the study
While numbers capture the scale of the problem, the study’s report offers insights into the human experiences behind them.
For example, parents interviewed across the 3 counties frequently cited missed reminders as a key barrier. Many said they relied entirely on notifications from clinics and family doctors to know when to bring their children for vaccination. While an automated text message system does exist, it does not send out additional notifications in the case of missed appointments, and health-care staff do not always follow up with a direct call. This is a particularly significant barrier in communities with low levels of health literacy, where trust and human interaction matter most.
The study also identified a need for accessible, easy-to-understand information on vaccination. Many health professionals reported a lack of visual materials adapted for caregivers with low levels of literacy. While community health mediators and nurses often improvise with verbal explanations or simple leaflets, general practitioners have fewer tools and less training on how to impart information in an empathic manner.
Another critical barrier is the perception of stigma and discrimination, particularly among Roma families. Some parents described feeling unwelcome at clinics or judged for their circumstances, which led them to disengage. Others reported practical challenges such as the lack of identity documents or difficulties registering children with a family doctor. These obstacles impede access to vaccines and health care in general.
Community health workers and mediators play a crucial role in building trust and reaching families
The study also uncovered multiple examples of good practice. In Covasna County, outreach activities by community health mediators inspire trust and contribute to higher vaccination rates. In addition, many clinics and family doctors allow walk-ins and offer vaccinations outside of set appointments. These strategies build trust and improve accessibility for families with irregular work schedules or transport difficulties.
Dr Caroline Clarinval, WHO Representative in Romania, pointed out, “Behind every unvaccinated child is a story of distance, doubt or disconnection. This study brings those voices to the forefront and reminds us that rebuilding trust starts with listening. Vaccination is not just a medical act; it is a social commitment.”
In response to these findings, the report proposes immediate actions such as:
- phone outreach to supplement automated text messages for vaccination reminders;
- development of visual and inclusive information materials on vaccination;
- training on empathetic communication for primary health-care providers; and
- strengthened partnerships with community leaders and social services to address broader determinants of health.
The full report is pending publication on the WHO/Europe website.