1. Introduction
The COVID-19 pandemic, caused by the SARS-CoV-2 virus, began in late 2019 and rapidly spread worldwide, resulting in significant impacts on global health systems, economies, and day-to-day life [
1,
2,
3]. While the immediate effects of the virus on respiratory health are evident, its indirect repercussions on other aspects of public health, such as sexual and reproductive health, are similarly important to address [
4,
5,
6,
7]. During the COVID-19 pandemic, Romania experienced significant challenges, including high infection and mortality rates, particularly in waves that overwhelmed the healthcare system [
5]. The country’s vaccination rates were lower than the European average due to factors like vaccine hesitancy and logistical issues, which contributed to the public health struggle [
8,
9,
10]. Economic disruptions and societal changes, such as shifts to online education, were among the broader impacts of the pandemic [
11].
Teenagers and young adult women represent a vital segment of the population, whose reproductive health needs require particular attention [
12,
13]. Their access to contraceptive information, products, and services is crucial in determining the trajectories of their lives, with implications for educational attainment, economic stability, and overall health and well-being [
14]. In Romania, reproductive and sexual health has been a subject of concern, particularly when examining indicators related to unwanted births and pregnancies among minors [
15]. According to Eurostat data, Romania has consistently had one of the highest rates of teenage pregnancies in the European Union [
16]. In previous years, the country recorded rates considerably higher than the EU average for live births per 1000 women aged 15–19 that reached 35% [
17]. This higher incidence of teenage pregnancies often translates into a significant number of unwanted births, given the limited access to comprehensive sex education in schools and barriers to contraceptives for young women. Additionally, Romanian health reports indicate that abortions, which can sometimes be a proxy for unintended pregnancies, have remained prevalent, despite a decrease since the 1990s [
18].
Between the years 1985 and 2022, Romania documented a total of 26,791 cases of HIV infection. This number comprised 10,053 cases in children and 16,738 cases in adults. Throughout the same timeframe, there were 8293 fatalities associated with the disease [
19]. Several factors, some of which may not be fully understood, contribute to the deficiency of sexual education in Romania. A principal factor is the omission of sexual education classes from school curricula, a decision that reflects the priorities of the educational authorities. While not explicitly prohibited, these classes have not been deemed essential by policymakers.
Nevertheless, there is growing evidence that the disruptions caused by the pandemic, such as lockdowns, changes in routine health service provision, and widespread economic downturns, may have impeded access to contraception and related education [
20,
21,
22]. This is particularly concerning given that unplanned pregnancies, especially among younger women, can have long-term implications at both individual and societal levels [
23,
24]. Moreover, contraception measures are important to be taught early to prevent sexually transmitted diseases and the spread of human papilloma virus (HPV), with a growing concern in the sexually active population due to its known contribution towards the development of cervical, anal, and oropharyngeal cancer [
25,
26].
Moreover, the pandemic has amplified mental health issues worldwide. Isolation, economic instability, and fear of the virus are just some factors that have contributed to increased rates of anxiety and depression [
27,
28,
29]. For teenagers and young adult women, these challenges may be compounded by hormonal fluctuations, concerns about reproductive health, and the stress of navigating early adulthood amidst a global crisis.
In Romania, the interplay between mental health and reproductive education among young women has become increasingly significant in the context of the COVID-19 pandemic [
30,
31]. With reported rises in anxiety and depression, the well-being of this group is under strain, not only due to general pandemic-related stressors but also due to the challenges of navigating reproductive health amidst a landscape where sex education is often inadequate. The national sex education system has faced scrutiny for not sufficiently equipping young women with essential knowledge about contraception, leading to gaps in awareness and safe practices. Moreover, within the family environment, the process of sexual socialization can be fraught with reticence and cultural taboos, adding layers of complexity to these young adults’ understanding and management of their sexual health. Recognizing these challenges is vital for developing strategies to improve mental health services and sexual health education, thereby enhancing the overall well-being of young Romanian women during and beyond the pandemic era.
To date, few studies have provided a comprehensive analysis of the impact of the pandemic on both contraceptive awareness and mental well-being within the Balkan and Eastern European region [
32]. Moreover, understanding the evolution of these effects over years provides a nuanced insight into the adaptive strategies employed, resilience, or exacerbation of challenges over time. Thus, it is essential to fill this gap by conducting a cross-sectional analysis focusing on contraception awareness and associated mental health outcomes among teenagers and young adult women.
It is hypothesized that the COVID-19 pandemic has led to a decline in contraceptive awareness and has adversely affected mental well-being in our target demographic across the years studied. The primary objectives are to ascertain levels of contraception awareness over the three years, assess associated anxiety and depression levels using standardized surveying tools, and to determine any correlations between the two domains.
3. Results
In the three-year cross-sectional analysis focusing on the impact of the COVID-19 pandemic on contraception awareness and mental well-being, various background characteristics of the participants were assessed (
Table 1). In 2020, 2021, and 2022, the samples included 59, 56, and 60 participants, respectively. The mean age in 2020 was 20.3 years (SD = 6.6), slightly increasing to 21.5 years (SD = 6.4) in 2021, and then slightly decreasing to 20.8 years (SD = 6.9) in 2022; this variation was not statistically significant (
p = 0.624, ANOVA test). When examining age distribution, the largest proportion of participants in all three years fell within the 23–25 age bracket, accounting for 55.9% in 2020, 44.6% in 2021, and 61.7% in 2022. However, age distribution differences across the years were not statistically significant (
p = 0.480).
The prevalence of current smokers in the study population increased from 22.0% in 2020 to 36.7% in 2022, yet this trend was not statistically significant (p = 0.187). The proportions of alcohol and substance use among participants remained relatively stable across the three years, with p-values of 0.684 and 0.584, respectively. The majority of participants hailed from urban areas, and this remained relatively constant, without significant yearly variations (p = 0.241).
Educational backgrounds showed that university attendance was highest in 2020 at 42.4% but decreased to 30.4% in 2021 and rebounded slightly to 35.0% in 2022. The observed variations in educational distribution over the three years were not statistically significant (p = 0.548). Of note, there was a significant increase in COVID-19 vaccination rates from 2021 (16.1%) to 2022 (36.7%), and this was statistically significant (p = 0.012). Regarding reproductive health, the majority of participants across the three years reported having one pregnancy, with rates of 71.2%, 66.1%, and 66.7% for 2020, 2021, and 2022, respectively (p = 0.852). The majority had not given birth, with rates ranging from 55.4% to 61.0% across the three years (p = 0.632). In terms of abortions, in 2020, 40.7% had no abortions, 37.3% had one abortion, and 22.0% had two or more. In 2022, these proportions shifted to 48.3%, 40.0%, and 11.7%, respectively, yet the differences across the years were not statistically significant (p = 0.263).
Significant findings emerged when participants assessed the pandemic’s effect on their access to contraceptive education or counseling. A score of 7.1 (±3.3) in 2020 slightly rose to 7.9 (±2.6) in 2021, but then decreased to 6.4 (±3.0) in 2022 (p = 0.029). This suggests that participants felt more challenged in accessing such resources as the pandemic progressed. Similarly, feelings of overwhelming anxiety (excluding work or academic causes) during the pandemic rose slightly from 7.4 (±4.1) in 2020 to 7.7 (±3.2) in 2021 and then markedly dropped to 6.0 (±3.4) in 2022, with the variance between years being statistically significant (p = 0.025). When assessing the overall influence on their mental well-being since the pandemic’s start, scores indicated a peak in 2021 at 7.6 (±3.6) and a substantial drop to 5.5 (±4.1) by 2022, which was statistically significant (p = 0.017).
Participants believed that the pandemic played an increasing role in shaping their perspectives on reproductive health and contraception, with scores showing a significant jump from 6.1 (±4.0) in 2020 to 7.7 (±3.7) in 2022 (
p = 0.049). Lastly, belief in COVID-19 potentially influencing future fertility witnessed a significant decrease across the three years, from 64.4% in 2020, to 51.8% in 2021, and down to 35.0% in 2022 (
p = 0.005), as seen in
Table 2.
The SF-36 survey, which evaluates health-related quality of life, is divided into two primary domains: Physical and Mental, with the total score serving as an overall measure of health status and quality of life. Notably, higher scores in this survey indicate better health status and quality of life. In 2020, the mean physical health score stood at 52.1 (±6.3). This score experienced a statistically significant rise over the subsequent years, registering at 55.9 (±7.0) in 2021 and further increasing to 56.5 (±6.8) in 2022 (p < 0.001). This suggests that the participants perceived an improvement in their physical health and quality of life across the years examined.
Similarly, the mental health domain of the survey exhibited an upward trend over the three years. The mean score in 2020 was 51.4 (±7.2), modestly elevating to 52.8 (±6.8) in 2021, and then reaching 55.0 (±6.9) in 2022. The observed increase in scores was statistically significant with a p-value of 0.019, indicating a perceived betterment in mental well-being across the years studied.
Furthermore, the total score of the SF-36, representing the combined influence of both physical and mental health domains, also showed a progressive increase. It began at 53.6 (±7.9) in 2020, rose to 55.3 (±7.7) in 2021, and peaked at 57.5 (±8.0) in 2022, as presented in
Table 3. This overall increment over the three years was statistically significant with a
p-value of 0.027, signifying a positive shift in the general health status and quality of life among the respondents throughout the duration of the COVID-19 pandemic.
The WHOQOL-BREF survey, a globally recognized tool, evaluates the quality of life in four primary domains: Physical, Mental, Social, and Environmental. In this assessment, higher scores indicate better perceived quality of life. For the Physical domain, a steady increase in mean scores was observed across the three years. In 2020, participants reported an average score of 62.9 (±16.3). This score experienced a boost in the subsequent years, rising to 66.0 (±17.5) in 2021 and further elevating to 68.3 (±18.0) in 2022. Although there is a noticeable upward trend, the changes across the years were not statistically significant, as indicated by the p-value of 0.235.
Regarding the Mental domain, the findings mirrored a similar pattern of enhancement. The mean score started at 60.7 (±17.0) in 2020, made a slight rise to 61.3 (±16.8) in 2021, and then showed a more pronounced increase to 66.5 (±15.9) in 2022. Yet, the overall difference between the years did not attain statistical significance, with a p-value of 0.114.
The Social domain, on the other hand, experienced a significant upward trajectory. The initial score in 2020 was 53.6 (±18.2). This increased to 58.2 (±18.9) in 2021 and further to 63.0 (±20.5) in 2022. The elevation across the three years was statistically significant, with a p-value of 0.030, highlighting a meaningful improvement in participants’ perceptions of their social quality of life.
Lastly, the Environmental domain scores exhibited a varied trend. After beginning at 60.4 (±15.6) in 2020, a minor decrease to 59.3 (±18.1) was observed in 2021. However, the scores bounced back in 2022, reaching 64.1 (±16.9), as presented in
Table 4. Despite these fluctuations, the differences across the years did not show statistical significance, as evinced by the
p-value of 0.274.
Regarding the GAD-7 results, which assess anxiety symptoms, there was a discernible decline in mean scores over the three studied years. In 2020, participants recorded an average score of 7.9 (±2.6), indicating moderate levels of anxiety. This score decreased to 6.8 (±3.1) in 2021 and further dropped to 6.5 (±3.3) in 2022. The downward trajectory in GAD-7 scores across the three years was statistically significant, as highlighted by the p-value of 0.031. This suggests a gradual alleviation in anxiety symptoms among participants as the pandemic years progressed.
Transitioning to the PHQ-9 scores, which quantify depression symptoms, a similar decreasing trend was observed. The mean score in 2020 was 4.8 (±2.2), placing the group in the minimal depression range. The score showed a subtle decline to 4.3 (±3.4) in 2021 and reached 3.9 (±2.8) in 2022. However, unlike the GAD-7 findings, the differences in PHQ-9 scores over the years did not achieve statistical significance, as evidenced by the
p-value of 0.224, as presented in
Table 5. Thus, while there was a slight reduction in depression symptoms over time, the changes were not conclusively indicative of a genuine trend when considering statistical rigor.
In examining the connection between contraception awareness and mental well-being, as quantified by the SF-36, our analysis unearthed a positive and meaningful relationship. Contraception awareness bore a correlation coefficient (Rho) of 0.324, signifying a moderate association with mental well-being. The statistical significance of this correlation was established with a p-value of 0.015, reinforcing the likelihood that enhanced awareness about contraception is linked with better mental well-being among the participants. Regarding the Mental Domain of the WHOQOL-BREF, contraception awareness presented a Rho of 0.298, denoting a comparable positive correlation. This relation was statistically significant at the 0.05 level, thereby underscoring the potential influence of contraception awareness on the mental quality of life.
Conversely, anxiety levels, as measured by the GAD-7, exhibited a negative correlation with contraception awareness, with a Rho of −0.412. This suggests that higher contraception awareness may be associated with lower levels of anxiety among the study participants. The correlation was strongly significant, with a
p-value of 0.001, indicating a robust inverse relationship. Similarly, depression levels, as gauged by the PHQ-9, were inversely correlated with contraception awareness, as reflected by a Rho of −0.389, as described in
Table 6. This also denotes a significant association, where greater awareness correlates with reduced depression symptoms, a finding bolstered by a
p-value of 0.001. It appears that increased knowledge and awareness of contraceptive methods could potentially have played a role in mitigating anxiety and depression during the pandemic.