Theta-burst stimulation as a therapeutic tool in neurological pathology: a systematic review.

TBS (theta-burst stimulation) is a novel therapeutic approach in a wide range of neurological diseases. The present systematic review aims to identify the various protocols used in the last years, to assess study quality and to offer a general overview of the current state of the literature. The systematic review was conducted according to the Preferred Reporting Item for Systematic Review and Meta-Analyses (PRISMA) guidelines. We applied the following inclusion criteria: (1) population over 18 years old with diagnosed neurological disorders, (2) patients treated with sessions of theta-burst stimulation, (3) randomized-controlled clinical trials, (4) articles in the English language, and (5) studies that report response and score reduction on a validated scale of the investigated disorder or remission rates. We included in the final analysis 56 randomized controlled trials focusing on different neurological pathologies (stroke, Parkinson`s disease, multiple sclerosis, tinnitus, dystonia, chronic pain, essential tremor and tic disorder), and we extracted data regarding study design, groups and comparators, sample sizes, type of coil, stimulation parameters (frequency, number of pulses, intensity, stimulation site etc.), number of sessions, follow-up, assessment through functional connectivity and neurological scales used. We observed a great interstudy heterogenicity that leads to a difficulty in drawing plain conclusions. TBS protocols have shown promising results in improving various symptoms in patients with neurological disorders, but larger and more coherent studies, using similar stimulation protocols and evaluation scales, are needed to establish guideline recommendations.

Pregnancy experiences of women in rural Romania: understanding ethnic and socioeconomic disparities.

Women in rural Romania face significant health disadvantages. This qualitative pilot study describes the structural disadvantage experienced during pregnancy by women in rural Romania, focusing on the lived experiences of Roma women. We explore how women in rural communities experience pregnancy, their interactions with the healthcare system, and the role that ethnic and social factors play in pregnancy and childbearing. We conducted 42 semi-structured interviews with health and other professionals, seven narrative interviews with Roma and non-Roma women and a focus group with Roma women. Data were analysed using thematic analysis. We identified intersectional factors associated with women's pregnancy experiences: women perceiving pregnancy as both unplanned and wanted, joyful, and normal; women's and professionals' differing prenatal care perceptions; transport and cost related barriers to care; socioeconomic and ethnic discrimination; and facilitators to care such as social support, having a health mediator and having a doctor. Talking directly with professionals and Roma and non-Roma women helped us understand these many factors, how they are interconnected, and how we can work towards improving the pregnancy experiences of Roma women in rural Romania.

Integrating research evidence and physical activity policy making-REPOPA project.

Evidence shows that regular physical activity is enhanced by supporting environment. Studies are needed to integrate research evidence into health enhancing, cross-sector physical activity (HEPA) policy making. This article presents the rationale, study design, measurement procedures and the initial results of the first phase of six European countries in a five-year research project (2011-2016), REsearch into POlicy to enhance Physical Activity (REPOPA). REPOPA is programmatic research; it consists of linked studies; the first phase studied the use of evidence in 21 policies in implementation to learn more in depth from the policy making process and carried out 86 qualitative stakeholder interviews. The second, ongoing phase builds on the central findings of the first phase in each country; it consists of two sets of interventions: game simulations to study cross-sector collaboration and organizational change processes in the use of evidence and locally tailored interventions to increase knowledge integration. The results of the first two study phases will be tested and validated among policy makers and other stakeholders in the third phase using a Delphi process. Initial results from the first project phase showed the lack of explicit evidence use in HEPA policy making. Facilitators and barriers of the evidence use were the availability of institutional resources and support but also networking between researchers and policy makers. REPOPA will increase understanding use of research evidence in different contexts; develop guidance and tools and establish sustainable structures such as networks and platforms between academics and policy makers across relevant sectors.

Exploring the use of research evidence in health-enhancing physical activity policies.

BACKGROUND: The gaps observed between the use of research evidence and policy have been reported to be based on the different methods of using research evidence in policymaking by researchers and actual policymakers. Some policies and policymaking processes may therefore be particularly well informed by research evidence compared to others. The aims of the present article are to explore the use of research evidence in health-enhancing physical activity (HEPA) policies, identify when research evidence was used, and find what other types of evidence were employed in HEPA policymaking. METHODS: Multidisciplinary teams from six EU member states analysed the use of research evidence and other kinds of evidence in 21 HEPA policies and interviewed 86 key policymakers involved in the policies. Qualitative content analysis was conducted on both policy documents and interview data. RESULTS: Research evidence was mostly used to justify the creation of HEPA policies and, generally, implicitly without citation. The policies analysed used many types of evidence other than citable research. The evidence used in HEPA policies was found to fall into the following categories: societal framework, media, everyday knowledge and intuition, research evidence, and other types of evidence. CONCLUSIONS: Research evidence seems to be the only type of evidence used in policymaking. Competition between the use of other types of evidence and research evidence is constant due to the various sources of information on the Internet and elsewhere. However, researchers need to understand their role in translating research evidence into policymaking processes.

Gender differences in the magnitude of the associations between eating disorders symptoms and depression and anxiety symptoms. Results from a community sample of adolescents.

BACKGROUND: Studies reporting comorbidities of eating disorders (EDs) with depression and anxiety disorders during adolescence used clinical samples of female adolescents with few attempts to present the magnitude of these associations in population-based samples and to assess gender differences in the strength of these associations. AIMS: This study assesses significant gender differences in the association of anorexia nervosa (AN) and bulimia nervosa (BN) symptoms with depression and generalized anxiety symptoms in a community sample of adolescents. METHOD: We collected anonymous self-reported data from 235 adolescent boys and 471 adolescent girls, through an online platform. To identify correlations between symptoms of AN and BN, and symptoms of depression and generalized anxiety, we used the Mann-Whitney U test. To identify differences between independent correlation coefficients, we converted each correlation coefficient into a z-score using Fisher's r-to-z transformation and, making use of the sample size employed to obtain each coefficient, we compared the z-scores. RESULTS: The magnitude of the associations between EDs symptomatology and depression and anxiety symptomatology was similar in adolescent boys and girls. CONCLUSION: Our results show an urgent need to address EDs prevention in adolescent girls and boys from the community.

Maternal smoking during pregnancy and birth outcomes in a sample of Romanian women.

Smoking during pregnancy is causally associated with reduced birth weight and is strongly related to preterm birth. Smoking cessation in early pregnancy seems to reduce these risks, although the research evidence is limited. In a sample of Romanian women, differences in birth outcomes were assessed between non-smokers and women who continued to smoke during pregnancy and non-smokers and women who stopped smok- ing when they found out about the pregnancy. Pregnant women were recruited in two urban clinics (N= 474). A baseline questionnaire collected information on their smoking status, depressive symptoms, stress, demographics, and other characteristics at recruitment. The women reported the newborn weight and birth term by phone in the first weeks following birth. Descriptive statistics and multivariate regressions were used to ana- lyze the relationship between smoking status during pregnancy and birth outcomes. Over 61% (N = 290) women were non-smokers, 15% (N= 72) smoked during pregnancy, and 24% (N= 112) quit smoking when they found out about the pregnancy. Compared to non-smokers, continuous smokers delivered babies 165 grams lighter (95% CI -313, -17). Women who stopped smoking when they ascertained the pregnancy had higher odds of delivering a newborn who was small for gestational age compared to non-smokers (OR= 2.16, 95% CI 1.05, 4.43). Elevated maternal stress was associated with reduced birth weight (-113 grams, 95% CI -213, -11), and higher odds of a preterm birth (OR=2.8, 95% CI 1.17, 6.76). In a predominantly urban sample of Romanian women, continuous maternal smoking during pregnancy was a risk factor for restricted foetal growth. Smoking cessation when the pregnancy was ascertained did not seem to reduce this risk. Smoking prevention efforts should therefore begin before pregnancy and should integrate psychological components, addressing maternal stress in particular.

Exploring students' perception of subjective food literacy: A model of educational practice.

Introduction: Latest research showed that lower levels of food literacy led to poorer health outcomes and highlighted the importance of nutrition education to improve food literacy for the population. Although evidence at the global level exists, the scientific literature on food literacy in Romania is scarce; therefore, this article aims to explore the perception of subjective food literacy as an outcome of an educational model in a sample of university students from Romania. Methods: The present study used a qualitative inductive approach using focus groups to explore the results from an educational "learning-by-doing" model regarding the perception of subjective food literacy. The sample consisted of 64 second-year students who participated in a class taught by one of the authors between October 2019 and February 2020 and later agreed to participate in the focus groups. All focus groups were audiotaped following participants' permission and transcribed verbatim. Data was analyzed with the QSR Nvivo 12 Pro software package using an inductive thematic analysis. Results: Several themes and sub-themes emerged from the focus groups discussing prior information of participants regarding nutrition, change in nutrition knowledge (information about plant protein, information about soy and soy products, information about sugar and its effects on health, and additional nutrition information), modified perception of nutrition and food, dietary habits, short-term behavior changes, and aspects that helped them to have more information about nutrition (construction of the health campaign, pre-testing materials, and support offered by the professors). All participants reported acquiring new information about food and nutrition, modified perceptions about nutritional habits, and even reported short-term behavioral change as an outcome of the educational model. Conclusions: Educational models using a learning-by-doing approach and combining formal and non-formal education can potentially affect students' subjective food literacy. Future research should explore university students' food literacy using evidence-based educational models.

Cerebrolysin and repetitive transcranial magnetic stimulation (rTMS) in patients with traumatic brain injury: a three-arm randomized trial.

Introduction: Traumatic brain injury (TBI) is a major public health problem affecting millions worldwide. Despite significant advances in medical care, there are limited effective interventions for improving cognitive and functional outcomes in TBI patients. Methods: This randomized controlled trial investigated the safety and efficacy of combining repetitive transcranial magnetic stimulation (rTMS) and Cerebrolysin in improving cognitive and functional outcomes in TBI patients. Ninety-three patients with TBI were randomized to receive either Cerebrolysin and rTMS (CRB + rTMS), Cerebrolysin and sham stimulation (CRB + SHM), or placebo and sham stimulation (PLC + SHM). The primary outcome measures were the composite cognitive outcome scores at 3 and 6 months after TBI. Safety and tolerability were also assessed. Results: The study results demonstrated that the combined intervention of rTMS and Cerebrolysin was safe and well-tolerated by patients with TBI. Although no statistically significant differences were observed in the primary outcome measures, the descriptive trends in the study support existing literature on the efficacy and safety of rTMS and Cerebrolysin. Discussion: The findings of this study suggest that rTMS and Cerebrolysin may be effective interventions for improving cognitive and functional outcomes in TBI patients. However, limitations of the study, such as the small sample size and exclusion of specific patient populations, should be considered when interpreting the results. This study provides preliminary evidence for the safety and potential efficacy of combining rTMS and Cerebrolysin in improving cognitive and functional outcomes in TBI patients. The study highlights the importance of multidisciplinary approaches in TBI rehabilitation and the potential for combining neuropsychological measurements and interventions to optimize patient outcomes. Conclusion: Further research is needed to establish these findings' generalizability and identify the optimal dosages and treatment protocols for rTMS and Cerebrolysin.

Pediatric poisonings and risk markers for hospital admission in a major emergency department in Romania.

To identify the prevalence, characteristics, and risk markers for childhood poisonings treated in the emergency department of a large Romanian hospital. Trauma registry data using ICD-10 codes and case summaries were studied to identify poisonings among children aged 0-18. Multivariate logistic regression identified factors associated with hospital admission. Between 1999 and 2003, 1,173 pediatric trauma cases were seen in the emergency department; 437 (37.3%) were treated for poisoning, including medication (35%), alcohol (26%), chemical products (19%), and carbon monoxide (14%). Half of all poisonings were unintentional, primarily affecting children < 10 years. Half were intentional, mainly affecting children 10-18. Females were three times more likely than males to have documented suicidal intent (P < .0001). Over 30% of suicide attempts were among children ages 10-14 (P < .0001). We report significantly increased adjusted odds ratios (P < .05) of hospital admission for children 10-18, and for chemical substance poisoning, and suicidal intent. Pediatric poisoning is a serious public health issue in Romania, and we suggest these findings are relevant across other eastern European countries with limited resources. Poisonings result in morbidity and hospital admissions, yet there are few prevention resources available. Health education programs and consumer product safety policies are needed in Romania and eastern Europe.

Does co-morbid depression impact diabetes related costs? Evidence from a cross-sectional survey in a low-income country.

AIMS OF THE STUDY: The economic implications of co-morbid depression in patients with chronic medical disorders have been studied mainly in high-income countries. However, the applicability of such findings in developing countries cannot be assumed. In the present study we estimate diabetes related costs and explore the link between depression and diabetes related costs in Romania. In this former communist country, the general perception of practitioners and policy-makers is that psychological issues are far less important than medical concerns for patients with diabetes, a perception that may lead to the misallocation of already scarce resources. METHODS: Data related to costs of diabetes care and to co-morbid depression were collected from a sample of 1,171 diabetes patients at the Nutrition and Diabetes Center in Cluj-Napoca, Romania, using the Diabetes Costs Questionnaire (DCQ) and the Patient Health Questionnaire 9 (PHQ9). The gathered data were subjected to a bivariate analysis of the depression-cost relationship, as well as a regression analysis in order to isolate the effect of depression on diabetes related costs from the effect of covariates. RESULTS: Direct and indirect diabetes related costs equally contributed to the total costs. The repartition of the cost burden between the public system and private agents is nearly equal as well. The bivariate analysis of the depression-cost relationship reveals statistically significant larger diabetes related costs for patients with major depression than for patients with minor depression, and the latter have larger diabetes related costs than patients free of depression symptoms. When the pure effect of depression on diabetes related costs was isolated by means of regression techniques, the provisional diagnosis of major depression was found to significantly increase diabetes related costs. DISCUSSION: The equal distribution of diabetes related costs between direct and indirect measures, as well as the cost burden equally split between the public system and private agents can be explained by the costs of medication and the costs associated with time lost by the non-compensated caregivers. Consistent with Romanian cultural traditions, most of the patients rely on their relatives in an informal diabetes caregiving market for assistance. Alongside depression, the multivariate analysis revealed that factors such as Hungarian ethnicity, income, and number of years since diagnosis also significantly contribute to diabetes related costs. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Findings that depression increases diabetes related costs bear potential implications for health policies and health care provision (i.e., the effect of depression on costs can be minimized by adequate recognition and treatment). As such, screening and treatment of co-occurring depression in diabetes patients should become part of the diabetes treatment protocol, not only in Romania but in other Central and Eastern European countries as well.

Measuring Health Literacy in Romania: Validation of the HLS-EU-Q16 Survey Questionnaire.

Objective: Empirical data on health literacy (HL) for Romania is almost inexistent. The present study aimed to validate the HLS-EU-Q16 questionnaire for the Romanian population and explore the predictors of HL in the North-West Region of the country. Methods: A non-experimental, cross-sectional study was conducted between March and November 2019 on a representative, stratified random sample of 1,622 participants from the North-Western Region of Romania. Exploratory Factor Analysis (EFA), Principal component analysis (PCA), Pearson correlations, and Chronbach's Alpha were used to validate the scale. Linear regressions were conducted to assess the determinants of health literacy. Results: Results obtained for the HL scale support its factorial component and reliability, with a Cronbach's alpha of α = 0.84. Age, gender, education and self-reported health status were identified as determinants of HL. Conclusion: Study findings indicate that the Romanian version of HLS-EU-Q16 is psychometrically sound and comparable to the original version. These results provide the first validated tool to measure HL in Romanian and the first population level data for Romania.

Prospects of COVID-19 Vaccination in Romania: Challenges and Potential Solutions.

The rapid advancement in vaccine development represents a critical milestone that will help humanity tackle the COVID-19 pandemic. However, the success of these efforts is not guaranteed, as it relies on the outcomes of national and international vaccination strategies. In this article, we highlight some of the challenges that Romania will face and propose a set of solutions to overcome them. With this in mind, we discuss issues such as the infrastructure of vaccine storage and delivery, the deployment and administration of immunisations, and the public acceptance of vaccines. The ways in which Romanian society will respond to a national COVID-19 vaccination campaign will be contingent on appropriate and timely actions. As many of the problems encountered in Romania are not unique, the proposed recommendations could be adapted and implemented in other countries that face similar issues, thereby informing better practices in the management of the COVID-19 pandemic.

Validation and Performance of Chronic Liver Disease Questionnaire (CLDQ-RO) in the Romanian Population.

BACKGROUND AND AIMS: Health-related quality of life is an essential part of managing chronically ill patients, including patients with chronic liver disease. Various methods are used to try to assess the quality of life ranging from generic to disease-specific questionnaires. Some of the results may reveal a novel connection to the disease's evolution, which is observed directly by the patient. This study aimed to validate and assess the chronic liver disease questionnaire (CLDQ-RO) performance in the Romanian population. METHODS: A two-phase study was designed. The first phase consisted of linguistic validation of CLDQ-RO (translation and piloting), while in the second phase, the questionnaire was applied to patients with various chronic liver diseases. Statistical validation (reliability, structural, and construct validity) was performed using SPSS v20.0, and statistical significance was considered p<0.05. RESULTS: The CLDQ-RO was applied to 231 patients with chronic liver disease (14.3% with chronic hepatitis, 35.5% with compensated cirrhosis, and 50.2% with decompensated cirrhosis). The questionnaire showed excellent overall reliability (Cronbach's alpha=0.93) and good structural and construct validity, with most of the items in CLDQ-RO fitting in the domains of the original version of the questionnaire. There was a significant decrease in the overall score of the CLDQ-RO with the progression of disease (p<0.001), indicating a substantial impact of the decompensation event on health-related quality of life. Regarding the type of decompensation, ascites accurately predicted a lower quality of life (p=0.004). CONCLUSIONS: The CLDQ-RO is a valid and disease-specific method for assessing patients' health-related quality of life with liver disease. Among the decompensation events, it seems that ascites seriously impacts the quality of life.

Promoting health in rural Transylvania, Romania. a descriptive analysis of health promotion activities.

Even though efforts are made to reduce health disparities, promote health for all social groups and improve health outcomes, inconsistencies still exist. Existing evidence shows that lack of funding, lack of properly trained workforce, as well as heavy workload on health care workers, are the most employed explanations for the limited number of health promotion interventions in the area. This paper presents the results of a descriptive study that pursues to render a comprehensive image of health promotion efforts undertaken in rural Transylvania, Romania. This descriptive analysis is conducted on data extracted from a larger dataset, obtained through a study which pursues a cross-sectional design, with a quantitative strategy of inquiry on access to health information in rural Transylvania. The instrument used for data collection is a questionnaire administered by telephone to a sample of medical doctors working in rural medical offices in the studied area (n = 226). Results show overall low rates of health promotion activities in the area, as well as low levels of collaboration with other local actors. In the context of behavioral risk factors, this study clearly shows the need of targeted health promotion activities in rural Transylvania in order to improve health outcomes and mitigate health disparities.

Educational Interventions to Improve Safety and Health Literacy Among Agricultural Workers: A Systematic Review.

Health and safety education for farmers has the potential to increase the level of health, safety literacy, and thereby improve farmers' health and quality of life. The aim of this paper is to provide a systematic review of the published literature documenting different educational interventions for agricultural workers that have the improvement of health and/or safety literacy as an outcome. A systematic search was conducted in PubMed, Embase, Scopus and PsycINFO databases for articles focusing on educational interventions for farmers' health and safety. From the 3357 initial hits, 36 unduplicated records met the inclusion criteria. The articles included in the review used educational interventions for farmers with the purpose of preventing farm-induced diseases and injuries, increasing the health and well-being of farmers, and promoting good manufacturing practices. The educational approaches considered varied from lectures, videos, newsletters, games, and community fairs, to involving the community in designing the intervention and training farmers to deliver the intervention to the community. Interventions that used evidence-based theories, which took into account cultural aspects and individual factors, used biomarkers as a behavior change measurement, and involved the community in the development of the intervention had the best results in terms of behavior change. The strategies of educational interventions identified in this review that produced good results have the potential to inform future researchers and policy makers in the design and implementation of public health interventions, programs and policies to improve the health of farmers and their families.

Nutritional composition of the food supply: a comparison of soft drinks and breakfast cereals between three European countries based on labels.

BACKGROUND/OBJECTIVES: Monitoring of processed products at the brand level was implemented in Austria, France and Romania on the basis of the Oqali methodology during the Joint Action on Nutrition and Physical Activity (JANPA) to compare the nutritional quality of the food offering. The objective of this paper is to present the results obtained during this study. SUBJECTS/METHODS: Collected data were those available on product packaging. In total, 2155 soft drinks and 943 breakfast cereals were classified in a standardised list of product families and analysed in a harmonised way. For each product family, mean values for sugar, fat, saturated fat, salt and dietary fibres were compared between countries. Common products across countries were also studied. RESULTS: For all the studied nutrients, significant differences were observed between countries, with a higher sugar content for Romania in regular carbonated and non-carbonated beverages containing fruits, regular lemonades and regular tonics and bitters (together with Austria for tonics), for France in fruit beverages with more than 50% fruit, and for Austria in low-sugar beverages containing tea. For France, higher nutrient contents were also observed for sugar in chocolate-flavoured cereals, filled cereals and cornflakes, and other plain cereals (at a similar level as Romania for cornflakes), and for saturated fats in honey/caramel cereals and crunchy mueslis. These differences were explained by a different food offering in the three countries, but also by differences in nutrient contents for common products. This study also showed high variability of the nutrient content within a product family, suggesting a real potential for product reformulation. CONCLUSIONS: National tools, at the branded products level, are essential to monitor the nutritional quality of the food offering, and to follow up on processed food reformulations.

Use and effectiveness of behavioural economics in interventions for lifestyle risk factors of non-communicable diseases: a systematic review with policy implications.

AIM: There is limited evidence on what behavioural economics strategies are effective and can be used to inform non-communicable diseases (NCDs) public health policies designed to reduce overeating, excessive drinking, smoking, and physical inactivity. The aim of the review is to examine the evidence on the use and effectiveness of behavioural economics insights on reducing NCDs lifestyle risk factors. METHODS: Medline, Embase, PsycINFO, and EconLit were searched for studies published between January 2002 and July 2016 and reporting empirical, non-pharmacological, interventional research focusing on reducing at least one NCDs lifestyle risk factor by employing a behavioural economics perspective. RESULTS: We included 117 studies in the review; 67 studies had a low risk of bias and were classified as strong or very strong, 37 were moderate, and 13 were weak. We grouped studies by NCDs risk factors and conducted a narrative synthesis. The most frequent behavioural economics precepts used were incentives, framing, and choice architecture. We found inconclusive evidence regarding the success of behavioural economics strategies to reduce alcohol consumption, but we identified several strategies with policy-level implications which could be used to reduce smoking, improve nutrition, and increase physical activity. CONCLUSION: Most studies targeting tobacco consumption, physical activity levels, and eating behaviours from a behavioural economics perspective had promising results with potential impact on NCDs health policies. We recommend future studies to be implemented in real-life settings and on large samples from diverse populations.

Smoking and quitting smoking during pregnancy: A qualitative exploration of the socio-cultural context for the development of a couple-based smoking cessation intervention in Romania.

INTRODUCTION: Smoking during pregnancy has negative effects on the mother and the unborn infant. Barriers to and facilitators of smoking cessation during pregnancy are context-dependent and multifaceted. This qualitative research explored pregnant women's experiences with smoking and cessation in Romania, and informed the development of a couple-focused smoking cessation intervention. METHODS: Semi-structured, in-depth interviews were conducted via telephone, with 15 pregnant women who smoked during pregnancy or had quit smoking upon learning about the pregnancy or shortly before. A hybrid inductive-deductive approach to thematic analysis was used, to identify patterns in the data and explore women's narratives, in relation to smoking and smoking cessation. RESULTS: Three main themes emerged from the data, which shaped the socio-cultural adaptation of the intervention to the local context: 1) Access to and mixed messages from the healthcare system that describe an inconsistent discourse from the healthcare system regarding smoking during pregnancy with some physicians not emphasizing the need for cessation, 2) Cessation as individual or team effort with variations in partner dynamics and difficulty in quitting that have important roles in perceptions about team efforts, and 3) Transition to motherhood and motivation to quit for the health of the pregnancy and infant, although in isolated cases women felt less connected with the pregnancy and such motivators. CONCLUSIONS: Pregnant women in Romania face systemic, interpersonal, and individual-level barriers that can be responsively integrated in smoking cessation interventions, by culturally adapting them to the local context.

A couples-focused intervention for smoking cessation during pregnancy: The study protocol of the Quit Together pilot randomized controlled trial.

Tobacco smoking remains the leading global cause of preventable disease and death. Preconception and pregnancy smoking are high in Central and Eastern Europe. Quit Together is a partnership between a US university and a Romanian university, obstetrics and gynecology clinics in Romania, and other community partners in Romania. The objective of the Quit Together pilot study is to adapt, enhance and test the implementation feasibility and initial efficacy of an evidence-based pregnancy and postnatal couple intervention for smoking cessation in Romania. Quit Together builds on the Motivation and Problem Solving (MAPS) approach, enhanced by targeting the couples' smoking behavior and focusing on dyadic efficacy for smoking cessation. The study is an ongoing randomized controlled trial of 120 Romanian pregnant smokers and their partners. Participants are randomized to: 1) an intervention arm consisting, typically, of up to 8 prenatal and postnatal telephone counseling calls for the women and 4 for their partners, combining motivational strategies and problem-solving/coping skills to encourage the woman to quit smoking and the partner to support her decision; and 2) a control arm (usual care). The primary outcome is maternal biochemically verified smoking abstinence at 3 months postpartum. Quit Together has the potential to identify effective strategies to increase maternal smoking cessation during pregnancy and smoking abstinence after birth. If effective, Quit Together is expected to have a sustainable positive impact on the health of the child, mother and partner, and potentially reduced health system costs.