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Abstract Background Women in precarious conditions in their countries of origin, especially those who have left the country as refugees, may have been victims of serious mental and physical violence. These potentially traumatic experiences may threaten women’s reproductive health. This study examines the prevalence of potentially traumatic experiences pre-migration and female genital mutilation/cutting (FGM/C) and their associations with adverse reproductive outcomes among migrant women of Somali- and Kurdish-origin who have been pregnant in Finland. Methods Survey and register data of the participants of the Finnish Migrant Health and Wellbeing Study (Maamu), conducted in 2010–2012, were used. Women of 18 to 64 years of age, 185 Somali- and 230 Kurdish-origin, who had at least one pregnancy or birth in Finland were included in the analysis. The survey data were linked to the Finnish Medical Birth Register, the Register of Induced Abortions, and the Care Register for Health Care until 2018. For each outcome, logistic regression was used and adjusted for age, body mass index, time lived in Finland, and the number of births. Results A total of 67% of Somali-origin and 71% of Kurdish-origin women had experienced potentially traumatic experiences pre-migration and 64% of Somali- and 32% of Kurdish-origin women had also undergone FGM/C. In Kurdish-origin women, complications during pregnancy (e.g. bleeding in the first trimester, known or suspected fetal abnormality, signs of fetal hypoxia, death of the fetus and other problems) were significantly more common among women without potentially traumatic experiences (70%) than among women with potentially traumatic experiences (48%) (p-value 0.005). No associations between potentially traumatic experiences or FGM/C and other adverse reproductive outcomes were observed among Somali- or Kurdish-origin women. Conclusion Past trauma is common among Somali- and Kurdish-origin women and this needs to be evaluated in maternity care. However, we found no association between potentially traumatic experiences pre-migration and adverse reproductive outcomes.

Abstract Background Reliable information on the use of health services is important for health care planning, monitoring and policy. It is critical to assess the validity of the sources used for this purpose, including register and survey-based data. Studies on foreign-born populations’ health care use have usually implemented either survey or register data. The concordance of such data among groups of different cultural background remains largely unknown. In this study, we presented an approach to examine routinely how survey and register-related characteristics may explain disagreement found between the two information sources. Methods We linked register- and survey-based data pertaining to the Finnish Register of Primary Health Care general physician visits and the Survey on Well-Being among Foreign Born Population (FinMonik, 2018–2019), a nationally representative survey. The sample comprised n = 5,800 informants for whom registered general physician visits were tracked in the 12-month period preceding their participation in the survey. Cohen’s kappa was used as measure of multisource concordance, hierarchical loglinear models for the association between single predictors and multisource discrepancy, and a logistic regression model for examining source-related predictors of source discrepancy. Survey weights were used in all sample analyses. Results Source concordance was poor. When dichotomizing general physician visits (zero vs one or more), 35% of informants had reported one or more visits while none were found from register. Both register- and informant-related predictors were associated to this discrepancy (i.e. catchment area, private health care use, inability to work, region of origin and reason for migration). Conclusions We found high discrepancy between the reported and the registered physician visits among the foreign-born population in Finland, with a particularly high number of reported physician visits when none were found in the register. There was a strong association between the specific catchment area and mismatch, indicating that both register under-coverage and survey over-report are plausible and may coexist behind the discrepancy. However, associations of informant’s characteristics and mismatch were less pronounced. Implications on the validity of medical information sources are discussed.

Abstract Background Guidelines highlight the importance of an individualized approach to treatment initiation for Parkinson’s disease. Our aim was to investigate initiation of anti-Parkinson medication in Australia from 2013–2018, and to determine factors predicting choice of initial treatment. Methods Cohort of new-users (N = 4,887) of anti-Parkinson medication aged ≥ 40 years were identified from a 10% random representative sample of national medication dispensing data from July-2013 to June-2018. Changes in treatment initiation were examined across the whole cohort and stratified by age and sex. Results Treatment initiation was most frequent with levodopa followed by non-ergot dopamine agonists (DAs) and anticholinergics. Two thirds initiated with levodopa across the study period. Initiation with non-ergot DAs increased from 22 to 27% (rate ratio, RR 1.23, 95% confidence interval, CI 1.02–1.47) and initiation with anticholinergics decreased from 6.9% to 2.4% (RR 0.34, 95% CI 0.21–0.55) from 2013–2018. Among persons aged ≥ 65 years, one third of women and one fourth of men initiated on levodopa. Among women aged

Abstract Background Although cardio- and cerebrovascular diseases are common among people with Alzheimer’s disease (AD), it is unknown how the prevalence of oral anticoagulant (OAC) use changes in relation to AD diagnosis. We investigated the prevalence of OAC use in relation to AD diagnosis in comparison to a matched cohort without AD. Methods Register-based Medication use and Alzheimer’s disease (MEDALZ) cohort includes 70 718 Finnish people with AD diagnosed between 2005–2011. Point prevalence of OAC use (prescription register) was calculated every three months with three-month evaluation periods, from five years before to five years after clinically verified diagnosis and compared to matched cohort without AD. Longitudinal association between AD and OAC use was evaluated by generalized estimating equations (GEE). Results OAC use was more common among people with AD until AD diagnosis, (OR 1.17; 95% CI 1.13–1.22), and less common after AD diagnosis (OR 0.87; 95% CI 0.85–0.89), compared to people without AD. At the time of AD diagnosis, prevalence was 23% and 20% among people with and without AD, respectively. OAC use among people with AD began to decline gradually two years after AD diagnosis while continuous increase was observed in the comparison cohort. Warfarin was the most common OAC, and atrial fibrillation was the most common comorbidity in OAC users. Conclusion Decline in OAC use among people with AD after diagnosis may be attributed to high risk of falling and problems in monitoring. However, direct oral anticoagulants (DOACs) that are nowadays more commonly used require less monitoring and may also be safer for vulnerable people with AD.

Abstract Background Type 2 diabetes is common in persons with Alzheimer’s disease (AD). Management of diabetes in persons with AD is challenging due to changing goals of care and susceptibility to adverse drug events including hypoglycemia. The aim of this study was to investigate the prevalence of diabetes drug use from 5 years before to 5 years after the time of AD diagnosis among persons with and without AD. Methods This was a nationwide register-based study of persons with and without AD and diabetes in Finland. We analyzed data from the Medication Use and Alzheimer’s disease (MEDALZ) study that included 70,718 community-dwelling people diagnosed with AD from 2005 to 2011. The study population included 8418 persons with AD and 6666 matched persons without AD who were diagnosed with diabetes 5 years before AD diagnosis (index date). We defined the prevalence of diabetes drug use in three-month evaluation periods from 5 years before until 5 years after the index date. Results Nearly all people with diabetes (94% in both cohorts) used one or more diabetes drugs on the index date. The most prevalent drug metformin was used by 60.9% of people with AD and 59.1% of people without AD. The next most prevalent drugs were sulfonylureas and insulin. The prevalence of diabetes drug use was similar in people with and without AD but began to decline 1 year after AD diagnosis in the AD cohort compared to non-AD cohort. Conclusions The decline in diabetes drug use after AD diagnosis may be attributed to clinicians and patients seeking to avoid serious adverse drug events including hypoglycemia. In addition, the findings may reflect personalized glycemic control and unintentional weight loss in persons with AD reducing the need for diabetes drugs.

Abstract Background Health indicators are used to monitor the health status and determinants of health of the population and population sub-groups, identify existing or emerging health problems which would require prevention and health promotion activities, help to target health care resources in the most adequate way as well as for evaluation of the success of public health actions both at the national and international level. The quality and validity of the health indicator depends both on available data and used indicator definition. In this study we will evaluate existing knowledge about comparability of different data sources for definition of health indicators, compare how selected health indicators presented in different international databases possibly differ, and finally, present the results from a case study from Finland on comparability of health indicators derived from different data sources at national level. Methods For comparisons, four health indicators were selected that were commonly available in international databases and available for the Finnish case study. These were prevalence of obesity, hypertension, diabetes, and asthma in the adult populations. Our evaluation has three parts: 1) a scoping review of the latest literature, 2) comparison of the prevalences presented in different international databases, and 3) a case study using data from Finland. Results Literature shows that comparability of estimated outcomes for health indicators using different data sources such as self-reported questionnaire data from surveys, measured data from surveys or data from administrative health registers, varies between indicators. Also, the case study from Finland showed that diseases which require regular health care visits such as diabetes, comparability is high while for health outcomes which can remain asymptomatic for a long time such as hypertension, comparability is lower. In different international health related databases, country specific results differ due to variations in the used data sources but also due to differences in indicator definitions. Conclusions Reliable comparison of the health indicators over time and between regions within a country or across the countries requires common indicator definitions, similar data sources and standardized data collection methods.

Abstract Background Rising prevalence of type 2 diabetes (T2D), also among younger adults, constitutes a growing public health challenge. According to the person-centred Chronic Care Model, proactive care and self-management support in combination with community resources enhance quality of healthcare and health outcomes for patients with T2D. However, research is scarce concerning the importance of person-centred care and community resources for such outcomes as empowerment, and the relative impact of various patient support sources for empowerment is not known. Moreover, little is known about the association of age with these variables in this patient-group. This study, carried out among patients with T2D, examined in three age-groups (27–54, 55–64 and 65–75 years) whether person-centred care and diabetes-related social support, including community support and possibilities to influence community health issues, are associated with patient empowerment, when considering possible confounding factors, such as other quality of care indicators and psychosocial wellbeing. We also explored age differentials in empowerment and in the proposed correlates of empowerment. Method Individuals from a register-based sample with T2D participated in a cross-sectional survey (participation 56%, n = 2866). Data were analysed by descriptive statistics and multivariate logistic regression analyses. Results Respondents in the youngest age-group were more likely to have low empowerment scores, less continuity of care, and lower wellbeing than the other age-groups, and to perceive less social support, but a higher level of person-centred care than the oldest group. Community support, including possibilities to influence community health issues, was independently and consistently associated with high empowerment in all three age-groups, as was person-centred care in the two older age-groups. Community support was the social support variable with the strongest association with empowerment across age-groups. Moreover, vitality was positively and diabetes-related distress negatively associated with high empowerment in all age-groups, whereas continuity of care, i.e. having a family/regular nurse, was independently associated in the youngest age-group only. Conclusion Person-centred care and community support, including possibilities to influence community health issues, supports empowerment among adults with T2D. Findings suggest that age is related to most correlates of empowerment, and that younger adults with T2D have specific healthcare needs.

Abstract Background Alzheimer’s disease (AD) is related to higher mortality but it is not entirely evident which causes of death explain this. The objective of this study was to assess the causes of death in a nationwide cohort of clinically verified AD cases and compare the causes to a matched comparison cohort without AD. Methods Cohort of all community-dwellers with clinically verified AD residing in Finland on 31 December 2005 (n = 27,948) and a matched comparison cohort without AD (n = 27,948). Mortality (2006–2012, n = 30,641, 54.8%) and causes of death were obtained from register. Cause of death was ascertained with clinical examination (87.3% of deaths), forensic (8.0%) or medical autopsy (4.7%). Results In AD cohort, the most common causes were diseases of the nervous system (49.9%), circulatory system (31.7%) and neoplasms (7.7%), while diseases of circulatory system (53.5%), neoplasms (19.1%) and mental and behavioral disorders (7.3%) contributed for majority of deaths in the comparison cohort. There were no sex-wise differences. People with AD were over 20 times more likely to die due to diseases of the nervous system (OR, 95% CI 22.06, 19.87–24.25) than the comparison cohort, while other causes, e.g., diseases of the circulatory system (0.40, 0.38–0.42), neoplasms (0.35, 0.33–0.38), mental and behavioral disorders (0.27, 0.24–0.30) and external causes of morbidity and mortality (0.72, 0.62–0.81) were less common in the AD cohort. Conclusions Although half of the people with AD died due to diseases of the nervous system, cancers and especially cardio/cerebrovascular diseases were still important contributors to the overall mortality among them. This should be acknowledged when planning their terminal care.

Abstract Background Hospital length of stays (LOS) for incident of hip fracture are decreasing, but it is unknown if these changes have negative impacts on vulnerable older patient populations, like those with Alzheimer’s disease (AD). We aimed to assess if persons with and without AD have different hospital LOS for hip fracture, and is the LOS associated with hospital readmissions. Methods Utilizing register-based data for a matched cohort study nested in the Medication use and Alzheimer’s disease study (MEDALZ), we collected all community-dwelling persons in Finland diagnosed with AD during 2005–2012, had incident of first hip fracture between 2005 and 2015 after AD diagnosis, and were discharged alive from an acute care hospital. Hospital LOS and hospital readmissions within 30-days and 90-days were compared between those with and without AD and risk of readmission was assessed using binary logistic regression analysis. Results In this matched cohort study of 12,532 persons (mean age 84.6 years (95% CI: 84.5–84.7), 76.8% women), the median LOS in an acute care hospital was 1 day shorter for those with AD (median 4 days, IQR 3–7) than those without AD (median 5 days, IQR 3–7) (P

Abstract Background Emissions from road traffic are under constant discussion since they pose a major threat to human health despite the increasingly strict emission targets and regulations. Although the new passenger car regulations have been very effective in reducing the particulate matter (PM) emissions, the aged car fleet in some EU countries remains a substantial source of PM emissions. Moreover, toxicity of PM emissions from multiple new types of bio-based fuels remain uncertain and different driving conditions such as the sub-zero running temperature has been shown to affect the emissions. Overall, the current literature and experimental knowledge on the toxicology of these PM emissions and conditions is scarce. Methods In the present study, we show that exhaust gas PM from newly regulated passenger cars fueled by different fuels at sub-zero temperatures, induce toxicological responses in vitro. We used exhaust gas volume-based PM doses to give us better insight on the real-life exposure and included one older diesel car to estimate the effect of the new emissions regulations. Results In cars compliant with the new regulations, gasoline (E10) displayed the highest PM concentrations and toxicological responses, while the higher ethanol blend (E85) resulted in slightly lower exhaust gas PM concentrations and notably lower toxicological responses in comparison. Engines powered by modern diesel and compressed natural gas (CNG) yielded the lowest PM concentrations and toxicological responses. Conclusions The present study shows that toxicity of the exhaust gas PM varies depending on the fuels used. Additionally, concentration and toxicity of PM from an older diesel car were vastly higher, compared to contemporary vehicles, indicating the beneficial effects of the new emissions regulations.

Abstract Background Health interview and examination surveys provide valuable information for policy, practice and research purposes. Appropriate use of high-quality, representative and timely population data can indirectly help the citizens to live healthier and longer lives. The aim of this study was to review how health survey data have supported health policy making, health research and everyday health care in Finland. Methods Data were collected by focused interviews with ten Finnish senior experts from the Ministry of Social Affairs and Health, political parties, National Institute for Health and Welfare, universities, and health associations. Results Most interviewees agreed that health surveys have positively affected the health of the population over the past 50 years - through health strategies, care guidelines, legislation, research, prevention programs, risk calculators, and healthier products on the market. There is also a need for further development: the latest research results should be provided in a nutshell for politicians, and effective tools should be developed more for health care professionals’ use. The coverage of health information on children, adolescents, oldest old, disabled persons, migrants and ethnic minorities should be improved. Conclusions Sound health policy and its successful implementation require extensive national cooperation and new communication strategies between policy makers, researchers, health care professionals, health service providers - and citizens. The future health information system in Finland should better cover all population groups. To obtain more comprehensive health information, the possibilities for register linkages should be secured and register data should be further evaluated and developed to serve health monitoring purposes.

Abstract Background Little is known about the exposure levels and adverse health effects of occupational exposure to airplane emissions. Diesel exhaust particles are classified as carcinogenic to humans and jet engines produce potentially similar soot particles. Here, we evaluated the potential occupational exposure risk by analyzing particles from a non-commercial airfield and from the apron of a commercial airport. Toxicity of the collected particles was evaluated alongside NIST standard reference diesel exhaust particles (NIST2975) in terms of acute phase response, pulmonary inflammation, and genotoxicity after single intratracheal instillation in mice. Results Particle exposure levels were up to 1 mg/m3 at the non-commercial airfield. Particulate matter from the non-commercial airfield air consisted of primary and aggregated soot particles, whereas commercial airport sampling resulted in a more heterogeneous mixture of organic compounds including salt, pollen and soot, reflecting the complex occupational exposure at an apron. The particle contents of polycyclic aromatic hydrocarbons and metals were similar to the content in NIST2975. Mice were exposed to doses 6, 18 and 54 μg alongside carbon black (Printex 90) and NIST2975 and euthanized after 1, 28 or 90 days. Dose-dependent increases in total number of cells, neutrophils, and eosinophils in bronchoalveolar lavage fluid were observed on day 1 post-exposure for all particles. Lymphocytes were increased for all four particle types on 28 days post-exposure as well as for neutrophil influx for jet engine particles and carbon black nanoparticles. Increased Saa3 mRNA levels in lung tissue and increased SAA3 protein levels in plasma were observed on day 1 post-exposure. Increased levels of DNA strand breaks in bronchoalveolar lavage cells and liver tissue were observed for both particles, at single dose levels across doses and time points. Conclusions Pulmonary exposure of mice to particles collected at two airports induced acute phase response, inflammation, and genotoxicity similar to standard diesel exhaust particles and carbon black nanoparticles, suggesting similar physicochemical properties and toxicity of jet engine particles and diesel exhaust particles. Given this resemblance as well as the dose-response relationship between diesel exhaust exposure and lung cancer, occupational exposure to jet engine emissions at the two airports should be minimized.

Abstract Background Short-term controlled exposure to diesel exhaust (DE) in chamber studies have shown mixed results on lung and systemic effects. There is a paucity of studies on well-characterized real-life DE exposure in humans. In the present study, 29 healthy volunteers were exposed to DE while sitting as passengers in diesel-powered trains. Exposure in electric trains was used as control scenario. Each train scenario consisted of three consecutive days (6 h/day) ending with biomarker samplings. Results Combustion-derived air pollutants were considerably higher in the passenger carriages of diesel trains compared with electric trains. The concentrations of black carbon and ultrafine particles were 8.5 μg/m3 and 1.2–1.8 × 105 particles/cm3 higher, respectively, in diesel as compared to electric trains. Net increases of NOx and NO2 concentrations were 317 μg/m3 and 36 μg/m3. Exposure to DE was associated with reduced lung function and increased levels of DNA strand breaks in peripheral blood mononuclear cells (PBMCs), whereas there were unaltered levels of oxidatively damaged DNA, soluble cell adhesion molecules, acute phase proteins in blood and urinary excretion of metabolites of polycyclic aromatic hydrocarbons. Also the microvascular function was unaltered. An increase in the low frequency of heart rate variability measures was observed, whereas time-domain measures were unaltered. Conclusion Exposure to DE inside diesel-powered trains for 3 days was associated with reduced lung function and systemic effects in terms of altered heart rate variability and increased levels of DNA strand breaks in PBMCs compared with electric trains. Trial registration ClinicalTrials.Gov (NCT03104387). Registered on March 23rd 2017

Abstract Background Persons of African and Middle-Eastern origin living in European countries have a high prevalence of type 2 diabetes, accompanied by high prevalence of obesity among women but not always among men. The aim of this study was to examine whether there are differences in the association between anthropometric measures and glucose levels measured with glycated haemoglobin and fasting blood glucose among persons of migrant origin in Finland. Methods Cross-sectional population-based data of the 30–64 year-old participants in the health examination of the Migrant Health and Wellbeing Study was used, selecting persons without diabetes (Russian origin n = 293, Somali origin n = 184, Kurdish origin n = 275). The reference group were non-diabetic participants in the Health 2011 Survey (n = 653), representative of the general Finnish population. Anthropometric measures included body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR) and waist-to-hip ratio (WHR, available for Maamu Study participants only). Results Depending on whether continuous or categorical anthropometric measures were used, age, sex and anthropometrics explained 13–18% of variation in HbA1c among persons of Russian origin, 5–10% among persons of Somali origin, 1–3% among persons of Kurdish origin and 11–13% among the general population. Also depending on whether continuous or categorical anthropometric measures were used, age, sex and anthropometrics explained 13–19% of variation in fasting blood glucose among persons of Russian origin, 15–20% among persons of Somali origin, 13–17% among persons of Kurdish origin and 16–17% among the general population. With exception for BMI, strength of the association between continuous anthropometric measures and HbA1c was significantly lower among persons of Kurdish origin compared with the general Finnish population (p = 0.044 for WC and p = 0.040 for WHtR). Conclusions A low degree of association between anthropometric measures and HbA1c was observed among persons of Kurdish origin. Findings of this study suggest caution is warranted when using HbA1c as a screening tool for glucose impairment among persons without diabetes in populations of diverse origin.

Abstract Background Previous findings indicate that in utero exposure to nanoparticles may affect the reproductive system in male offspring. Effects such as decreased sperm counts and testicular structural changes in F1 males have been reported following maternal airway exposure to carbon black during gestation. In addition, a previous study in our laboratory suggested that the effects of in utero exposure of nanoparticles may span further than the first generation, as sperm content per gram of testis was significantly lowered in F2 males. In the present study we assessed male fertility parameters following in utero inhalation exposure to carbon black in four generations of mice. Results Filter measurements demonstrated that the time-mated females were exposed to a mean total suspended particle mass concentration of 4.79 ± 1.86 or 33.87 ± 14.77 mg/m3 for the low and high exposure, respectively. The control exposure was below the detection limit (LOD 0.08 mg/m3). Exposure did not affect gestation and litter parameters in any generation. No significant changes were observed in body and reproductive organ weights, epididymal sperm parameters, daily sperm production, plasma testosterone or fertility. Conclusion In utero exposure to carbon black nanoparticles, at occupationally relevant exposure levels, via maternal whole body inhalation did not affect male-specific reproductive, fertility and litter parameters in four generations of mice.

Abstract Background Engineered nanoparticles are smaller than 100 nm and designed to improve or creating even new physico-chemical properties. Consequently, toxicological properties of materials may change as size reaches the nm size-range. We examined outcomes related to the central nervous system in the offspring following maternal inhalation exposure to nanosized carbon black particles (Printex 90). Methods Time-mated mice (NMRI) were exposed by inhalation, for 45 min/day to 0, 4.6 or 37 mg/m3 aerosolized carbon black on gestation days 4–18, i.e. for a total of 15 days. Outcomes included maternal lung inflammation (differential cell count in bronchoalveolar lavage fluid and Saa3 mRNA expression in lung tissue), offspring neurohistopathology and behaviour in the open field test. Results Carbon black exposure did not cause lung inflammation in the exposed females, measured 11 or 28–29 days post-exposure. Glial fibrillary acidic protein (GFAP) expression levels were dose-dependently increased in astrocytes around blood vessels in the cerebral cortex and hippocampus in six weeks old offspring, indicative of reactive astrogliosis. Also enlarged lysosomal granules were observed in brain perivascular macrophages (PVMs) in the prenatally exposed offspring. The number of parvalbumin-positive interneurons and the expression levels of parvalbumin were decreased in the motor and prefrontal cortices at weaning and 120 days of age in the prenatally exposed offspring. In the open field test, behaviour was dose-dependently altered following maternal exposure to Printex 90, at 90 days of age. Prenatally exposed female offspring moved a longer total distance, and especially males spent significantly longer time in the central zone of the maze. In the offspring, the described effects were long-lasting as they were present at all time points investigated. Conclusion The present study reports for the first time that maternal inhalation exposure to Printex 90 carbon black induced dose-dependent denaturation of PVM and reactive astrocytes, similarly to the findings observed following maternal exposure to Printex 90 by airway instillation. Of note, some of the observed effects have striking similarities with those observed in mouse models of neurodevelopmental disorders.

Abstract Background Since reproductive health is often considered a highly sensitive topic, underreporting in surveys and under coverage of register data occurs frequently. This may lead to inaccurate information about the reproductive health. This study compares the proportion of women having births and induced abortions among migrant women of Russian, Somali and Kurdish origin in Finland to women in the general Finnish population and examines the agreement between survey- and register-based data. Methods The survey data from the Migrant Health and Wellbeing Study conducted in 2010–2012 and data from the Health 2011 Survey with corresponding information on women in the general population were used in this study. The respondents were women aged 18–64: 341 Russian, 176 Somali and 228 Kurdish origin women and 630 women in the general population. The survey data were linked to the Finnish Medical Birth Register and the Register of Induced Abortions. Results In the combined (survey and register) data, migrant groups aged 30–64 had a higher proportion (89–96%) compared to the general population (69%) of women with at least one birth. Under-coverage of registered births was observed in all study groups. Among women aged 18–64, 36% of the Russian group and 24% of the Kurdish group reported more births in the survey than in the register data. In the combined data, the proportions of Russian origin (69%) and Kurdish origin (38%) women who have had at least one induced abortion in their lifetime are higher than in the general population (21%). Under-reporting of induced abortions in survey was observed among Somali origin women aged 18–29 (1% vs. 18%). The level of agreement between survey and register data was the lowest for induced abortions among the Somali and Russian groups (− 0.01 and 0.27). Conclusion Both survey- and register-based information are needed in studies on reproductive health, especially when comparing women with foreign origin with women in the general population. Culturally sensitive survey protocols need to be developed to reduce reporting bias.

Abstract Background To meet the challenges of the rising prevalence of chronic diseases, such as type 2 diabetes, new approaches to healthcare delivery have been initiated; among these the influential Chronic Care Model (CCM). Valid instruments are needed to evaluate the public health impact of these frameworks in different countries. The Patient Assessment of Chronic Illness Care (PACIC) is a 20-item quality of care measure that, from the perspective of the patient, measures the extent to which care is congruent with the CCM. The aim of this study was to evaluate the psychometric properties of the Finnish translation of the PACIC questionnaire, in terms of validity and reliability, in a large register-based sample of patients with type 2 diabetes. Method The PACIC items were translated into Finnish in a standardized forward-backward procedure, followed by a cross-sectional survey among patients with type 2 diabetes (response rate 56%; n = 2866). We assessed the Finnish version of the PACIC scale for the following psychometric properties: content validity, internal consistency reliability, convergent and construct validity. We also present descriptive data on total scale as well as predetermined subscale levels. Results The item-response on the PACIC scale was high with only small numbers of missing data (0.5–1.1%). Ceiling effects were low (0.3–5.3%) whereas floor effects were over 20% for two of the predetermined subscales (problem solving and follow-up/coordination). The total PACIC scale showed a reasonable distribution and excellent internal consistency (alpha 0.94) while the internal consistency of the subscales were at least acceptable (0.74–0.86). The principal component analysis identified a two- or three-factor solution instead of the proposed five-dimensional. In other respects, the PACIC scale showed the hypothesized relationships with quality of care and outcome measures, thus demonstrating convergent and construct validity. Conclusion A Finnish version of the PACIC scale is now validated in the primary care setting among patients with type 2 diabetes. The findings suggest comparable psychometric properties of the Finnish scale as of the original English instrument and earlier translations, and reasonable levels of validity and reliability.

Abstract Background Representative and reliable data on health and health determinants of the population and population sub-groups are needed for evidence-informed policy making; planning and evaluation of prevention programmes; and research. Health examination surveys (HESs) including questionnaires, objective health measurements and analysis of biological samples, provide information on many health indicators that are available not at all or less reliably or completely through administrative registers or health interview surveys. Methods Standardized cross-sectional HESs were already conducted in the 1980’s and 1990’s, in the framework of the WHO MONICA Project. The methodology was developed and finally, in 2010–2012, a European Health Examination Survey (EHES) Pilot Project was conducted. During this pilot phase, an EHES Coordinating Centre (EHES CC, formerly EHES Reference Centre) was established. Standardized protocols, guidelines and quality control procedures were prepared and tested in 12 countries which conducted pilot surveys, demonstrating the feasibility of standardized HES data collection in the European Union (EU). Currently, the EHES CC operates at the National Institute for Health and Welfare (THL), Finland. Its activities include maintaining and developing the standardized protocols, guidelines and training programme; maintaining the EHES network; providing professional support for countries planning and organizing their national HESs; external quality assessment for surveys organized in the EU Member States; and development of a centralized database and joint reporting system for HES data. Results An increasing number of EU Member States are conducting national HESs, demonstrating a strong need for such surveys as part of the national health monitoring systems. Standardization of the data collection is essential to ensure that HES data are comparable across countries and over time. The work of the EHES CC helps to ensure the quality and comparability of HES data across the EU. Conclusions HES data have been used for health monitoring and identifying public health problems; to develop health and prevention programmes; to support health policies and preparation of health-related legislation and regulations; and to develop clinical treatment guidelines and population reference values. HESs have also been utilized to prepare health measurement tools and diagnostic methods; in training and research and to increase health awareness among population.

Abstract Background Substance use is a well-known public health problem, but population-based research on migrants’ substance use in Europe is limited. Factors related to the cultural background and current life situation might influence substance use among migrants. Here, the prevalence of substance use in Russian, Somali and Kurdish migrants in Finland is reported in comparison with the general population, and the associations between substance use and socio-economic and migration-related background factors among migrants are analysed. Methods Cross-sectional data from the Finnish Migrant Health and Wellbeing Study (Maamu) and comparison group data of the general Finnish population (n = 1165) from the Health 2011 Survey were used. The survey participants were of Russian (n = 702), Somali (n = 512), and Kurdish (n = 632) origin. Substance use included self-reported alcohol use within previous 12 months (AUDIT-C questionnaire), current and lifetime daily smoking and lifetime use of cannabis and intravenous drugs. Results Binge drinking was less prevalent among all migrant groups than in the general Finnish population (Russian men 65%, p

Abstract Background Cervical cancer is currently ranked as the fourth commonly diagnosed cancer in women globally. A higher incidence has been reported in low- and-middle-income countries, and the disease poses significant public health challenges. Evidence suggests that this disease is preventable by means of regular screening using the Papanicolaou (Pap) test. However, limited knowledge exists about disparities in cervical screening participation among immigrants compared with non-immigrants, in countries with universal cervical screening programmes. We aimed to examine disparities in cervical screening participation among women of Russian, Somali, and Kurdish, origin in Finland, comparing them with the general Finnish population (Finns). We controlled for differences in several socio-demographic and health-related variables as potential confounders. Methods We employed data from the Finnish Migrant Health and Well-being Study 2010–2012 and the National Health 2011 Survey. Data collection involved face-to-face interviews. Data on screening participation in the previous five years from women aged 29–60 were available from 537 immigrants (257 Russians, 113 Somalis, 167 Kurds) and from 436 Finns. For statistical analyses, we used multiple logistic regression. Results Age-adjusted screening participation rates were as follows: Russians 79% (95% CI 72.9–84.4), Somalis 41% (95% CI 31.4–50.1), and Kurds 64% (95% CI 57.2–70.8), compared with 94% (95% CI 91.4–95.9) among Finns. After additionally adjusting for socio-demographic and health-related confounders, all the immigrant groups showed a significantly lower likelihood of screening participation when compared with Finns. The Odds Ratios were as follows: Russians 0.32 (95% CI 0.18–0.58), Somalis 0.10 (95% CI 0.04–0.23), and Kurds 0.17 (95% CI 0.09–0.35). However, when additionally accounting for country of origin-confounder interactions, such differences were attenuated. Conclusions Our results indicate disparities in screening participation among these immigrants and a lower likelihood of screening participation compared with the general Finnish population. To improve equity in cervical cancer screening participation, appropriate culturally tailored intervention programmes for each immigrant group might be beneficial.

Abstract Background Long QT syndrome (LQTS) is an inherited cardiac disorder predisposing to sudden cardiac death (SCD). We studied factors affecting the clinical course of genetically confirmed patients, in particular those not receiving β-blocker treatment. In addition, an attempt was made to associate risk of events to specific types of KCNQ1 and KCNH2 mutations. Methods A follow-up study covering a mean of 18.6 ± 6.1 years was conducted in 867 genetically confirmed LQT1 and LQT2 patients and 654 non-carrier relatives aged 18–40 years. Cox regression models were used to evaluate the contribution of clinical and genetic risk factors to cardiac events. Results In mutation carriers, risk factors for cardiac events before initiation of β-blocker included LQT2 genotype (hazard ratio [HR] = 2.1, p = 0.002), female gender (HR = 3.2, p G and other KCNQ1 mutation carriers after adjusting for gender, QTc duration, and cardiac events before age 18. KCNH2 c.453delC, L552S and R176W mutations associated with lower risk (HR = 0.11–0.23, p

Abstract Background Migrants are considered a key population at risk for sexually transmitted and blood-borne diseases in Europe. Prevalence data to support the design of infectious diseases screening protocols are scarce. We aimed to estimate the prevalence of hepatitis B and C, human immunodefiency virus (HIV) infection and syphilis in specific migrant groups in Finland and to assess risk factors for missed diagnosis. Methods A random sample of 3000 Kurdish, Russian, or Somali origin migrants in Finland was invited to a migrant population-based health interview and examination survey during 2010–2012. Participants in the health examination were offered screening for hepatitis B and C, HIV and syphilis. Notification prevalence in the National Infectious Diseases Register (NIDR) was compared between participants and non-participants to assess non-participation. Missed diagnosis was defined as test-positive case in the survey without previous notification in NIDR. Inverse probability weighting was used to correct for non-participation. Results Altogether 1000 migrants were screened for infectious diseases. No difference in the notification prevalence among participants and non-participants was observed. Seroprevalence of hepatitis B surface antigen (HBsAg) was 2.3%, hepatitis C antibodies 1.7%, and Treponema pallidum antibodies 1.3%. No cases of HIV were identified. Of all test-positive cases, 61% (34/56) had no previous notification in NIDR. 48% of HBsAg, 62.5% of anti-HCV and 84.6% of anti-Trpa positive cases had been missed. Among the Somali population (n = 261), prevalence of missed hepatitis B diagnosis was 3.0%. Of the 324 Russian migrants, 3.0% had not been previously diagnosed with hepatitis C and 2.4% had a missed syphilis diagnosis. In multivariable regression model missed diagnosis was associated with migrant origin, living alone, poor self-perceived health, daily smoking, and previous diagnosis of another blood-borne infection. Conclusions More than half of chronic hepatitis and syphilis diagnoses had been missed among migrants in Finland. Undiagnosed hepatitis B among Somali migrants implies post-migration transmission that could be prevented by enhanced screening and vaccinations. Rate of missed diagnoses among Russian migrants supports implementation of targeted hepatitis and syphilis screening upon arrival and also in later health care contacts. Coverage and up-take of current screening among migrants should be evaluated.

Abstract Background In most reported cases of lung trauma with water proofing products, volatile organic compounds (VOC) have a prominent role. Here we report on a case involving ten workers exposed to a sprayed product containing nanoparticles in a water solution with only a few percent VOC. Case presentation Ten workers suffered from respiratory symptoms following spray impregnation of hardwood furniture using a waterproofing product that contained positively charged fluorinated acrylate copolymer solid cores with a median diameter of 70 nm (1.3 w%) in aqueous suspension with 3.3 w% VOC and 0.3 w% quaternary ammonium. The worker who applied one liter of the product in a wood workshop, using an air mix spray gun, did not report any health complaints. Another worker, who entered the workshop 3 h later and had rolled and smoked two cigarettes, was hospitalized with severe chemical pneumonitis. A chest X-ray (CXR) showed bilateral infiltrative impairment in the lower lobe regions. On the next day a second CXR showed increased patchiness marking in all fields. A high-resolution Computer Tomography (CT)-scan demonstrated extensive bilateral areas of ground-glass opacities predominantly in the lower regions of the upper lobes, the right middle lobe and the apical regions of the lower lobes, compatible with severe chemical pneumonitis. On the following morning, nine workers in an adjacent workplace in the same building, experienced dry cough, chest tightness and substernal pain upon physical exercise. Reconstruction of the spray application in a climate chamber confirmed trimethyl silanol, glycol ethers and fluoroalkenes in the gas phase. Immediately after the spray application, aerosols were observed at a maximum concentration of 6.3 × 104 cm−3. Mass concentrations were 0.095 and 10 mg/m3 in the size ranges 5.6-560 nm and 0.22-30 μm, respectively, decreasing to less than 10 μg/m3 in both size ranges after 15 h. Conclusion The hospitalized worker had smoked cigarettes contaminated with fluoropolymers which is a plausible explanation for the lung trauma. Respiratory symptoms in the nine workers may be caused by inhalation of particles that became airborne by resuspension from surfaces when workers entered the adjacent workplace the next day. A contribution from VOC appears less likely because measurements and modelling showed that concentrations in the mg/m3 range could have occurred only if the building was assumed to be completely airtight.

Abstract Background Firefighters have increased risk of cardiovascular disease and of sudden death from coronary heart disease on duty while suppressing fires. This study investigated the effect of firefighting activities, using appropriate personal protective equipment (PPE), on biomarkers of cardiovascular effects in young conscripts training to become firefighters. Methods Healthy conscripts (n = 43) who participated in a rescue educational course for firefighting were enrolled in the study. The exposure period consisted of a three-day training course where the conscripts participated in various firefighting exercises in a constructed firehouse and flashover container. The subjects were instructed to extinguish fires of either wood or wood with electrical cords and mattresses. The exposure to particulate matter (PM) was assessed at various locations and personal exposure was assessed by portable PM samplers and urinary excretion of 1-hydroxypyrene. Cardiovascular measurements included microvascular function and heart rate variability (HRV). Results The subjects were primarily exposed to PM in bystander positions, whereas self-contained breathing apparatus effectively abolished pulmonary exposure. Firefighting training was associated with elevated urinary excretion of 1-hydroxypyrene (105%, 95% CI: 52; 157%), increased body temperature, decreased microvascular function (−18%, 95% CI: -26; −9%) and altered HRV. There was no difference in cardiovascular measurements for the two types of fires. Conclusion Observations from this fire extinction training show that PM exposure mainly occurs in situations where firefighters removed the self-contained breathing apparatus. Altered cardiovascular disease endpoints after the firefighting exercise period were most likely due to complex effects from PM exposure, physical exhaustion and increased core body temperature.

Abstract Background Antidepressant use has been associated with an increased risk of falling, but no studies have been conducted on whether antidepressant use is associated with an increased risk of head injuries which often result from falling among older persons. The objective of this study was to investigate the risk of head and brain injuries associated with antidepressant use among community-dwelling persons with Alzheimer’s disease. Methods A matched cohort study was conducted by comparing new antidepressant users (n = 10,910) with two matched nonusers (n = 21,820) in the MEDALZ study cohort. The MEDALZ cohort includes all community-dwelling persons newly diagnosed with Alzheimer’s disease between 2005 and 2011 in Finland. Incident antidepressant users were identified based on register-based dispensing data from the Prescription register with a 1-year washout period for antidepressant use. Nonusers were matched with users based on age, gender, and time since Alzheimer’s disease diagnosis. The outcome events were defined as any head injuries and traumatic brain injuries based on diagnoses in Hospital Discharge and Causes of Death registers. Propensity score adjusted Cox proportional hazard models were utilized. Sensitivity analyses with case-crossover design were conducted. All registers are linkable with unique personal identification numbers assigned for each resident. Results Antidepressant use was associated with an increased risk of head injuries (age-adjusted event rate per 100 person-years 2.98 (95% confidence interval (CI) 2.49–3.06) during use and 2.43 (95% CI 2.06–2.35) during nonuse, adjusted hazard ratio (HR) 1.35, 95% CI 1.20–1.52) and traumatic brain injuries (age-adjusted event rate per 100 person-years 1.33 (95% CI 1.13–1.53) during use and 1.10 (95% CI 1.00–1.20) during nonuse, adjusted HR 1.26, 95% CI 1.06–1.50). The risk was highest during the first 30 days of use (HR 1.71, 95% CI 1.10–2.66 for head injuries; HR 2.06, 95% CI 1.12–3.82 for traumatic brain injuries) and remained at an elevated level for head injuries for over 2 years of use. In case-crossover analyses, antidepressant use was consistently associated with a higher risk of head injuries. Conclusions Antidepressant use was associated with an increased risk of the most severe outcomes, head and brain injuries, in persons with Alzheimer’s disease. Antidepressant use should be carefully considered and the association confirmed in future studies.

Abstract Background Older adults with hearing difficulties face problems of communication which may lead to underuse of health services. This study investigated the association of hearing loss and self-reported hearing difficulty with the use of health services and unmet health care needs in older adults. Methods Data on persons aged 65 and older (n = 2144) drawn from a population-based study, Health 2000, were analyzed. Hearing loss was determined with screening audiometry (n = 1680). Structured face-to-face interviews were used to assess self-reported hearing difficulty (n = 1962), use of health services (physician and nurse visits, health examinations, mental health services, physical therapy, health promotion groups, vision test, hearing test, mammography, PSA test) and perceived unmet health care needs. Multivariable logistic regression analyses were used. Results After adjusting for socio-economic and health-related confounders, persons with hearing loss (hearing level of better ear 0.5–2 kHz > 40 dB) were more likely to have used mental health services than those with non-impaired hearing (OR = 3.2, 95 % CI 1.3–7.9). Self-reported hearing difficulty was also associated with higher odds for mental health service use (OR = 2.1 95 % CI 1.2–3.5). Hearing was not associated with use of the other health services studied, except presenting for a hearing test. Persons with self-reported hearing difficulty were more likely to perceive unmet health care needs than those without hearing difficulty (OR = 1.7, 95 % CI 1.4–2.1). Conclusions Older adults with hearing loss or self-reported hearing difficulty are as likely to use most health services as those without hearing loss. However, self-reported hearing difficulty is associated with experiencing unmet health care needs. Adequate health services should be ensured for older adults with hearing difficulties.

Abstract Background Many ethnic minority populations have poorer health than the general population. However, there is limited knowledge on the possible ethnic gap in physical mobility. We aim to examine the prevalence of mobility limitations in working-age Russian, Somali and Kurdish origin migrants in comparison to the general population in Finland. We also determine whether the association between ethnic group and mobility limitation remains after taking into account socio-economic and health-related factors. Methods We used data from the Finnish Migrant Health and Wellbeing Study (Maamu) and the Finnish Health 2011 Survey. The participants comprised 1880 persons aged 29–64 years. The age-adjusted prevalence of difficulties in various mobility tasks was calculated using predictive margins. Logistic regression analysis was used to examine the association between socio-economic, health- and migration-related factors and mobility limitation (self-reported difficulty in walking 500 m or stair climbing). The association between ethnic group and mobility limitation was calculated using logistic regression analysis. Results Mobility limitations were much more prevalent among Somali origin women (46 %) and Kurdish origin men (32 %) and women (57 %) compared to men and women in the general Finnish population (5–12 %). In Russian origin men and women, the prevalence of mobility limitation (7–17 %) was similar to the general Finnish population. Socio-economic and health-related factors, but not migration-related factors (time lived in Finland and language proficiency in Finnish or Swedish), were found to be associated with mobility limitation in the studied populations. Somali and Kurdish origin migrants were found to have increased odds for mobility limitation compared to the general Finnish population, even after adjusting for socio-economic and health-related factors (Somalis odds ratio [OR] 3.61; 95 % confidence interval [CI] 2.07–6.29, Kurds OR 7.40; 95 % CI 4.65–11.77). Conclusions This study demonstrates a functional disadvantage in Somali and Kurdish origin populations compared to the general Finnish population, even after adjusting for socio-economic and health-related factors. The high prevalence of mobility limitation among Somali origin women and Kurdish origin men and women in Finland demonstrates an acute need to promote the health and functioning of these populations.

Background: Type 1 diabetes is associated with increased risk of cardiovascular diseases and altered metabolism of cholesterol. We studied whether the markers of arterial stiffness reflecting preclinical atherosclerosis are related to markers of cholesterol metabolism in type 1 diabetes. Methods: In eighteen type 1 diabetes subjects aged from 20 to 56 years, serum squalene and non-cholesterol sterols were measured with gas–liquid chromatography, and carotid arterial stiffness (elastic and Young’s modulus, beta index, distensibility, and compliance), intima-media thickness (IMT), and brachial artery endothelial function (flow-mediated dilatation, FMD) were measured with ultrasound imaging. Results: Variables of arterial stiffness were not related to serum lipids or HbA1c except Young’s modulus and compliance to triglycerides (r = 0.541 and r = −0.552, p < 0.05 for both, respectively). Stiffness of carotid artery was related to mean blood pressure (elastic modulus r = 0.590, distensibility r = −0.486, p < 0.05 for both). Stiffness of carotid artery was associated with serum desmosterol concentration, marker of cholesterol synthesis (e.g. compliance r = −0.600, p < 0.01), and with markers of cholesterol absorption (e.g. distensibility and sitosterol to cholesterol ratio r = 0.628, p < 0.01), and the associations between absorption markers and arterial stiffness remained significant after adjustment on age and mean blood pressure. Conclusions: Carotid arterial stiffness was associated with markers of cholesterol metabolism, but not with serum lipid levels. Low absorption-high synthesis of cholesterol was related to increased arterial stiffness. Cholesterol metabolism seems to play a role in vascular health beyond serum lipids in type 1 diabetes.

Abstract Background There is a lack of knowledge on the influence of different levels of physical activity (PA) on unintentional injuries among those with depressive symptoms (DS). The aim of this study was to evaluate the relationship between PA categories and unintentional injuries among participants with and without DS based on a cross-sectional population–based FIN-D2D survey conducted in 2007. Methods Out of 4500, 2682 participants (60%) aged 45–74 years attended in this study. The unintentional injuries over the past year were captured in a questionnaire. DS were determined with the Beck Depression Inventory (≥ 10 points) and PA with the International Physical Activity Questionnaire. The statistical significance between DS and unintentional injury categories was evaluated by using t-test, chi-square test, or permutation test, analysis of covariance, or regression models. The factors related to unintentional injuries were estimated by univariate and multivariate logistic regression models. Results The proportion of subjects with unintentional injuries was higher among those with DS (17%) compared to those without DS (10%) (age- and gender-adjusted p = 0.023). The median (range) number of activity-loss days after injury was 22 (0–365) in participants with DS and 7 (0–120) in participants without DS ( p = 0.009). The percentage of subjects with unintentional injuries was not significantly different between PA categories in participants with DS and without DS. A stepwise multivariate logistic regression analysis showed that DS, functional ability, and musculoskeletal diseases were related to unintentional injuries. Conclusions PA level was not related to unintentional injuries, whereas those with DS had a higher prevalence of unintentional injuries and prolonged activity-loss after injury. These results underline the importance of injury prevention, especially among those who have DS and additional risk factors.

Abstract Background Little is known of how the toxicity of nanoparticles is affected by the incorporation in complex matrices. We compared the toxic effects of the titanium dioxide nanoparticle UV-Titan L181 (NanoTiO2), pure or embedded in a paint matrix. We also compared the effects of the same paint with and without NanoTiO2. Methods Mice received a single intratracheal instillation of 18, 54 and 162 μg of NanoTiO2 or 54, 162 and 486 μg of the sanding dust from paint with and without NanoTiO2. DNA damage in broncheoalveolar lavage cells and liver, lung inflammation and liver histology were evaluated 1, 3 and 28 days after intratracheal instillation. Printex 90 was included as positive control. Results There was no additive effect of adding NanoTiO2 to paints: Therefore the toxicity of NanoTiO2 was reduced by inclusion into a paint matrix. NanoTiO2 induced inflammation in mice with severity similar to Printex 90. The inflammatory response of NanoTiO2 and Printex 90 correlated with the instilled surface area. None of the materials, except of Printex 90, induced DNA damage in lung lining fluid cells. The highest dose of NanoTiO2 caused DNA damage in hepatic tissue 1 day after intratracheal instillation. Exposure of mice to the dust from paints with and without TiO2 was not associated with hepatic histopathological changes. Exposure to NanoTiO2 or to Printex 90 caused slight histopathological changes in the liver in some of the mice at different time points. Conclusions Pulmonary inflammation and DNA damage and hepatic histopathology were not changed in mice instilled with sanding dust from NanoTiO2 paint compared to paint without NanoTiO2. However, pure NanoTiO2 caused greater inflammation than NanoTiO2 embedded in the paint matrix.

Abstract Background Excessive gestational weight gain and postpartum weight retention may predispose women to long-term overweight and other health problems. Intervention studies aiming at preventing excessive pregnancy-related weight gain are needed. The feasibility of implementing such a study protocol in primary health care setting was evaluated in this pilot study. Methods A non-randomized controlled trial was conducted in three intervention and three control maternity and child health clinics in primary health care in Finland. Altogether, 132 pregnant and 92 postpartum women and 23 public health nurses (PHN) participated in the study. The intervention consisted of individual counselling on physical activity and diet at five routine visits to a PHN and of an option for supervised group exercise until 37 weeks' gestation or ten months postpartum. The control clinics continued their usual care. The components of the feasibility evaluation were 1) recruitment and participation, 2) completion of data collection, 3) realization of the intervention and 4) the public health nurses' experiences. Results 1) The recruitment rate was slower than expected and the recruitment period had to be prolonged from the initially planned three months to six months. The average participation rate of eligible women at study enrolment was 77% and the drop-out rate 15%. 2) In total, 99% of the data on weight, physical activity and diet and 96% of the blood samples were obtained. 3) In the intervention clinics, 98% of the counselling sessions were realized, their contents and average durations were as intended, 87% of participants regularly completed the weekly records for physical activity and diet, and the average participation percentage in the group exercise sessions was 45%. 4) The PHNs regarded the extra training as a major advantage and the high additional workload as a disadvantage of the study. Conclusion The study protocol was mostly feasible to implement, which encourages conducting large trials in comparable settings. Trial registration Current Controlled Trials ISRCTN21512277

Abstract Background Evaluating complex interventions in health services faces various difficulties, such as making practice changes and costs. Ways to increase research capacity and decrease costs include making research an integral part of health services and using routine data to judge outcomes. The purpose of this article is to report the feasibility of a pilot trial relying solely on routinely collected register data and being based on ordinary health services. Methods The example intervention was education to public health nurses (PHN) (childbirth classes) to reduce caesarean section rates via pre-delivery considerations of pregnant women. 20 maternity health centers (MHC) were paired and of each 10 pairs, one MHC was randomly allocated to an intervention group and the other to a control; 8 pairs with successful intervention were used in the analyses (1601 mothers). The women visiting to the study maternity centers were identified from the Customer Register of Helsinki City. A list of the study women was made using the mother's personal identification number, visit date, the maternity center code, birth date and gestation length. The mode of delivery and health outcomes were retrieved from the Finnish Medical Birth Register (MBR). Process data of the intervention are based on observations, written feedback and questionnaires from PHNs, and project correspondence. Results It took almost two years to establish how to obtain permissions and to actually obtain it for the trial. Obtaining permissions for the customer and outcome data and register linkages was unproblematic and the cluster randomization provided comparable groups. The intervention did not succeed well. Had the main aim of the trial been to cause a change in PHNs behavior, we would have very likely intensified the intervention during the trial. Conclusion Our experiences encourage the use of trials that obtain their outcomes from registers. Changing the behavior of ordinary health service providers is a challenging intervention. Trial registration number not registered (see Results)