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Eka Burkadze,1 Ketevan Axobadze,1 Nino Chkhaberidze,1 Nino Chikhladze,1 Madalina Adina Coman,2 Diana Dulf,2 Corinne Peek-Asa3 1Department of Public Health, Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi, Georgia; 2Department of Public Health, College of Political, Administrative and Communication Sciences, Babes-Bolyai University, Cluj-Napoca, Romania; 3Department of Occupational and Environmental Health, College of Public Health, University of Iowa, Iowa City, IA, USACorrespondence: Eka BurkadzeDepartment of Public Health, Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, 1 Chavchavadze Ave, Tbilisi, 0179, GeorgiaTel +995 591 11 80 90Email eka.burkadze@tsu.gePurpose: Traumatic brain injury (TBI) is one of the major causes of morbidity and mortality worldwide, disproportionally affecting low- and middle-income countries (LMICs). Epidemiological characteristics of TBI at a national level are absent for most LMICs including Georgia. This study aimed to establish the registries and assess causes and outcomes in TBI patients presenting to two major trauma hospitals in the capital city –Tbilisi.Patients and Methods: The prospective observational study was conducted at Acad. O. Gudushauri National Medical Center and M. Iashvili Children’s Central Hospital from March, 1 through August, 31, 2019. Patients of all age groups admitted to one of the study hospitals with a TBI diagnosis were eligible for participation. Collected data were uploaded using the electronic data collection tool –REDCap, analyzed through SPSS software and evaluated to provide detailed information on TBI-related variables and outcomes using descriptive statistics.Results: Overall, 542 hospitalized patients were enrolled during the study period, about 63% were male and the average age was 17.7. The main causes of TBI were falls (58%) and struck by or against an object (22%). The 97% suffered from mild TBI (GCS 13– 15). Over 23% of patients arrived at the hospital more than 1 hour after injury and 25% after more than 4-hours post-injury. Moderate and severe TBI were associated with an increased hospital length of stay. Mortality rate of severe TBI was 54%.Conclusion: This study provides important information on the major epidemiological characteristics of TBI in Georgia, which should be considered for setting priorities for injury management.Keywords: traumatic brain injury, injury epidemiology, registry, Georgia

Background The World Health Organization predicts a striking rise in the burden of traumatic brain injury (TBI) burden in the next decades. A disproportionately large increase is predicted in low- and middle-income countries, which have brain injury rates 3 times higher than high-income countries. The aim of this study was to identify current TBI practices and treatment capacity in 3 low- and middle-income countries: Republic of Armenia, Georgia, and Republic of Moldova. Methods After a national inventory of hospitals treating TBI, a situational analysis was conducted in the highest volume adult and pediatric hospital in each country. The situational analysis included key informant interviews with content analysis and a quantitative checklist of treatment resources. Results All 3 countries follow international, national, and hospital protocols for TBI treatment, and the in-hospital management of patients with TBI is similar to international standards in all 3 countries. Although health care specialists were well trained, however, lack of proper equipment, a scant number of hospitals outside the capital region, lack of specialized personnel in regional areas, and lack of rehabilitation services were mentioned as difficulties in interviews from all 3 countries. Conclusions Particular gaps were found in pre-hospital and rehabilitative care, as well as national leadership and data collection. Surveillance and standardized data collection are important measures to fill treatment gaps and reduce the burden of TBI.

The Republic of Moldova has one of the European region’s highest road traffic injury rates and also has an increase in motorization and exposure of children as vehicle passengers. This study describes child restraint use, and parents’ knowledge and attitudes toward child restraint based on observations in Chisinau, the country’s capital and largest city. The study aims to describe the use of child restraints and to compare data with existing standards of good practice. An observational study on child safety restraint use was conducted in 2018. Observational sites included 22 early education institutions, where drivers (n = 611) and child passengers (n = 710) were observed. Observations were conducted as motor vehicles parked or pulled to a stop near the early education institutions and included a driver survey on knowledge and attitudes toward restraint legislation and child safety behavior. Of the 710 child passengers observed, 462 (65.1%) were appropriately restrained, 145 (20.4%) were seated in restraints inappropriate for the child and 103 (14.5%) of children were unrestrained. Younger children (0-3 year-old) were 7 times more likely to be properly restrained compared with children with ages between 4 and 6 (OR 1.92, 95% CI 1.15 to 3.22). Two-thirds out of 609 observed drivers with full study data, N = 431 (70,8%), knew about the mandatory legislation on using child safety restraints in the Republic of Moldova. The drivers using child safety restraints responded that they used them because of their safety features, and the major reason for nonuse was high price/affordability. This study, the first to document child safety restraint use among children, indicates that much progress has been made, in that the majority of children are restrained and most drivers of children are aware of safety policies. However, progress can be made to increase knowledge and motivation to safely transport children, and to ensure safety seats are affordable and available. These data will be an important foundation on which to advocate for increased safety activities, child restraint policies, educational approaches in Moldova and to monitor progress over time.

The purpose of the current study was to identify the existing practices and policies on TBI treatment and rehabilitation in the Republic of Moldova. Methods:Qualitative face-to-face interviews were conducted with health care professionals from two major emergency hospitals in Chisinau Municipality in 2018.An interview guide was modeled according to a standard operation procedure with a set of concrete questions. Results:Participants underlines important issues in the health care management of TBI for different medical levels: pre-hospital careambulance system and definitive care work,acute care focused on the existing frameworks for treatment and care of TBI patients in hospitals, rehabilitationcare, treatment, prevention gaps, and country-level resources. The main gaps in the prevention and treatment of traumatic injuries were identified to be related to road accidents, alcohol-related injuries, home injuries, and long arriving times of ambulance, lack of medical equipment both at pre-hospital and acute care and low salaries of medical staff. Conclusion:Our results suggested the need for health promotion and health education campaigns, police interventions, state support, acquiring financial support and modern equipment. &nbsp

Highlights • Media attitude towards underpinning policy with evidence influences policy decision makers. • Individual skills, attitudes, values of policy makers impact the extent evidence use. • A solid research infrastructure is facilitating but not sufficient for evidence use. • Factors that impact evidence use in policy making differ by country and policy context. • Interventions connecting policy makers and researchers in the policy context seem most promising., The knowledge-practice gap in public health is widely known. The importance of using different types of evidence for the development of effective health promotion has also been emphasized. Nevertheless, in practice, intervention decisions are often based on perceived short-term opportunities, lacking the most effective approaches, thus limiting the impact of health promotion strategies. This article focuses on facilitators and barriers in the use of evidence in developing health enhancing physical activity policies. Data was collected in 2012 by interviewing 86 key stakeholders from six EU countries (FI, DK, UK, NL, IT, RO) using a common topic guide. Content analysis and concept mapping was used to construct a map of facilitators and barriers. Barriers and facilitators experienced by most stakeholders and policy context in each country are analysed. A lack of locally useful and concrete evidence, evidence on costs, and a lack of joint understanding were specific hindrances. Also users’ characteristics and the role media play were identified as factors of influence. Attention for individual and social factors within the policy context might provide the key to enhance more sustainable evidence use. Developing and evaluating tailored approaches impacting on networking, personal relationships, collaboration and evidence coproduction is recommended.

Objective Pedestrian fatalities due to collisions with motor vehicles are a large public health problem in Romania, ranking them among the highest in Eastern Europe. The purpose of this study was to gain a better understanding of crash factors by examining how roadway and environmental characteristics contribute to pedestrian distraction and risky behaviours at pedestrian MVC (PMVC) locations in Cluj County, Romania. Methods A sample of PMVC locations was selected from the 2010 Cluj County police reported crash database for on-site examination. A total of 100 sites were visited to collect details on site characteristics and typical pedestrian and driver behaviours. Variable distributions were examined and rate ratios of pedestrian distraction and risky behaviours were calculated. Results Pedestrian distraction and risky behaviours were observed at rates of 6.3 and 24.3 per 100 observed pedestrians. The majority of distractions were related to electronic device use. Risky behaviours were evenly split between unpredictable, partial use of a crosswalk and midblock illegal crossings. Distractions and risky behaviours decreased as the number of pedestrians and average vehicle speeds at a site increased. RR of distraction was higher at intersections and locations with crosswalks. Conclusions Pedestrian distraction was highly correlated with pedestrian risky behaviours at PMVC locations in Romania. Higher pedestrian volume was protective against pedestrian distraction and risky behaviours. Locations with painted crosswalks had increased distraction. Targeted distraction prevention, particularly at intersections and crosswalk locations, may contribute to the prevention of PMVCs.

Introduction Injury rates are highest among LMICs. Many of the leading injury causes are increasing disproportionately in LMICs compared with high income countries. Although medical and public health education in each of these countries has been growing over the last several years, injury and violence prevention has not yet been recognized as a priority. The iCREATE project aims to create a critical mass of injury researchers from multiple disciplines and to engage agencies and stakeholders in conducting high impact research that reduces the burden of injuries and violence in the LMICs of Armenia, Georgia, and Rep. of Moldova. Progress Based on priority needs in our partner countries and the expertise of the training team, the project focuses on: road traffic injury prevention, prevention of violence against women and children and acute care. Although it is the first project of capacity building in injury research implemented in these countries, the partnership builds on and translates existing successful infrastructure. The lead of the project (University of Iowa) has conducted similar projects in other countries from Eastern Europe and one of the training sites (Babes-Bolyai University) is currently a partner in the project. Activities include skill-building workshops; summer classes; long-term degree-based and professional development training; focused exploratory research projects; and collaborative data infrastructure projects. The focus is on long-term MPH and PhD training in order to build research and leadership skills focused on injury prevention in the partner institutions. Some results of the first three project years are implementation of Injury prevention Curricula in three medical universities from the partner countries, and a Center of Injury and Violence Prevention established in Armenia. Furthermore, 33 trainees were trained, 8 hospitals implemented injury registries and 12446 registry records were collected so far across 3 countries.

BackgroundUse of seat belts and car seats for children are among the most effective interventions to reduce injury severity when a crash occurs. The use should be enforced in order to have an increase in wearing these restraints. Romania has the lowest rate of using seatbelts in the backseat, 16%. The purpose of the study is to describe the use of child safety restraints and compare it with existing standards of good practice.MethodsAn observational study on child safety restraint was conducted in Cluj-Napoca, Romania, between 2013 and 2014. Observational sites included 38 schools and kindergartens and three commercial areas, where drivers (n=768) and child passengers (n=892) were observed. Observations were conducted as vehicles parked or pulled to a stop and were followed by driver surveys on knowledge and attitudes towards restraint legislation and child safety behaviour as car occupants.ResultsThe proportion of observed child motor vehicle occupants wearing some type of restraint was 67.4% (n=601). The majority of children (82.6%) were in the back seat, and 14.2% of infants were in a rear-facing child seat. The proportion of restrained children declined with age, with children 5 years old or younger being almost five times more likely to be properly restrained (OR 4.87, 95% CI 2.93 to 8.07) when compared with older children.ConclusionsAlthough minimum legal requirements of child motor vehicle occupant safety were in place in Romania at the time of the study, the rates of using children restraints was low compared with other middle-income and high-income countries.

Background Motorization growth worldwide is increasing children’s exposure to motor vehicle occupant crash injury. The use of child safety seats and seat belts, as appropriate for a child’s age and development, is one of the most effective ways to reduce child occupant injury in a crash. However, child safety seat use varies throughout the world. Objective Compare children’s occupant protection use, driver knowledge, and barriers to use in three countries: one with a comprehensive policy (Iowa City, United States), one with a partial policy (Cluj-Napoca, Romania) and one with no policy (Shantou, China) at the time of data collection. Methods Using a standardized protocol, child occupant protection use was observed and driver surveys were conducted. More than 7 000 children in vehicles were observed, and of these more than 65% of drivers were interviewed. Results For children aged 0 to 3, who should be in a safety seat, 95.9% of children in the US were properly restrained, compared with 49.6% in Romania and 0.1% in China. For children aged 4–12, who should be in booster seats, 65% of children in the US, 34.6% in Romania, and 1.5% of children in China were properly restrained. For children aged 13–17, 82.7% of children in the US, 65.0% in Romania, and 25.2% in China were wearing seat belts. Driver seat belt use was 90.6% in the US, 66.8% in Romania, and 58.3% in China. In China, 26.8% of drivers reported that they did not know about safety seats. In Romania, 68.4% were aware that some type of law was in place. Barriers were similar and included lack of knowledge or awareness, expense, and choosing not to use one. Conclusion Prevalence of child occupant restraint was highly correlated with the country’s policy status, although barriers to use were similar.

Police crash reports are often the main source for official data in many countries. However, with the exception of fatal crashes, crashes are often underreported in a biased manner. Consequently, the countermeasures adopted according to them may be inefficient. In the case of bicycle crashes, this bias is most acute and it probably varies across countries, with some of them being more prone to reporting accidents to police than others. Assessing if this bias occurs and the size of it can be of great importance for evaluating the risks associated with bicycling.This study utilized data collected in the COST TU1101 action "Towards safer bicycling through optimization of bicycle helmets and usage". The data came from an online survey that included questions related to bicyclists´ attitudes, behaviour, cycling habits, accidents, and patterns of use of helmets. The survey was filled by 8655 bicyclists from 30 different countries. After applying various exclusion factors, 7015 questionnaires filled by adult cyclists from 17 countries, each with at least 100 valid responses, remained in our sample.The results showed that across all countries, an average of only 10% of all crashes were reported to the police, with a wide range among countries: from a minimum of 0.0% (Israel) and 2.6% (Croatia) to a maximum of a 35.0% (Germany). Some factors associated with the reporting levels were type of crash, type of vehicle involved, and injury severity. No relation was found between the likelihood of reporting and the cyclist´s gender, age, educational level, marital status, being a parent, use of helmet, and type of bicycle.The significant under-reporting - including injury crashes that do not lead to hospitalization - justifies the use of self-report survey data for assessment of bicycling crash patterns as they relate to (1) crash risk issues such as location, infrastructure, cyclists´ characteristics, and use of helmet and (2) strategic approaches to bicycle crash prevention and injury reduction. Fil: Shinar, D.. Ben Gurion University of the Negev; Israel Fil: Valero-Mora, P.. Universidad de Valencia; España Fil: van Strijp-Houtenbos, M.. Institute For Road Safety Research, Netherlands; Países Bajos Fil: Haworth, N.. Queensland University Of Technology Qut; Australia Fil: Schramm, A.. Queensland University Of Technology Qut; Australia Fil: de Bruyne, G.. Universiteit Antwerp; Bélgica Fil: Cavallo, V.. Ifsttar - French Institute Of Science And Technology For Transport, Development And Networks; Fil: Chliaoutakis, J.. Technologiko Ekpaideutiko Idrima, Kritis; Fil: Dias, J.. Instituto Superior Tecnico; Portugal Fil: Ferraro, O.E.. Universita Degli Studi Di Pavia; Fil: Fyhri, A.. Transportokonomisk Institutt; Fil: Sajatovic, A. Hursa. University Of Zagreb, Faculty Of Textile Technology; Fil: Kuklane, K.. Lund University; Suecia Fil: Ledesma, Ruben Daniel. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Mascarell, O.. Ben Gurion University of the Negev; Israel Fil: Morandi, A.. Universita Degli Studi Di Pavia; Fil: Muser, M.. Working Group On Accident Mechanics; Fil: Otte, D.. Medizinische Hochschule Hannover (mhh); Fil: Papadakaki, M.. Technologiko Ekpaideutiko Idrima, Kritis; Fil: Sanmartín, J.. Universidad de Valencia; España Fil: Dulf, D.. Universitatea Babes-bolyai Din Cluj-napoca; Fil: Saplioglu, M.. Suleyman Demirel Universitesi; Fil: Tzamalouka, G.. Technologiko Ekpaideutiko Idrima, Kritis

Background: Facilitating and enhancing interaction between stakeholders involved in the policymaking process to stimulate collaboration and use of evidence, is important to foster the development of effective Health Enhancing Physical Activity (HEPA) policies. Performing an analysis of real-world policymaking processes will help reveal the complexity of a network of stakeholders. Therefore, the main objectives were to unravel the stakeholder network in the policy process by conducting three systems analyses, and to increase insight into the similarities and differences in the policy processes of these European country cases.Methods: A systems analysis of the local HEPA policymaking process was performed in three European countries involved in the 'REsearch into POlicy to enhance Physical Activity' (REPOPA) project, resulting in three schematic models showing the main stakeholders and their relationships. The models were used to compare the systems, focusing on implications with respect to collaboration and use of evidence in local HEPA policymaking. Policy documents and relevant webpages were examined and main stakeholders were interviewed.Results: The systems analysis in each country identified the main stakeholders involved and their position and relations in the policymaking process. The Netherlands and Denmark were the most similar and both differed most from Romania, especially at the level of accountability of the local public authorities for local HEPA policymaking. The categories of driving forces underlying the relations between stakeholders were formal relations, informal interaction and knowledge exchange.Conclusions: A systems analysis providing detailed descriptions of positions and relations in the stakeholder network in local level HEPA policymaking is rather unique in this area. The analyses are useful when a need arises for increased interaction, collaboration and use of knowledge between stakeholders in the local HEPA network, as they provide an overview of the stakeholders involved and their mutual relations. This information can be an important starting point to enhance the uptake of evidence and build more effective public health policies.