Cohort Profile: The International Mobility In Aging Study (IMIAS)

Mobility, the ability to move in one’s environment, is an essential feature of human functioning.1 Among older adults, mobility disability is more frequent in women than in men and differences are largely unexplained. Results from the Established Populations Epidemiologic Study of the Elderly (EPESE) showed that the prevalence of mobility disability in women increased from 22% at age 70 to 62% at age 80, whereas in men disability reached only 15% and 38% at comparable ages.2 This gender gap in mobility disability in old age was narrower and had decreased in recent decades in Sweden.3 In less industrialized countries, gender mobility disability differences are larger. Using data from the SABE surveys (SAlud BienEstar, or Health and Wellbeing) on older people in seven Latin America and Caribbean (LAC) cities,4 we found a mobility disability prevalence odds ratio for women compared with men of 2.4, when controlling for life course exposures and health factors.5 The International Mobility In Aging Study (IMIAS) study was designed by researchers from the Université de Montréal and Queen’s University in Canada, Universidade Federal do Rio Grande do Norte in Natal, Brazil, Universidad de Caldas in Manizales, Colombia, and researchers affiliated with the Albanian School of Public Health in Tirana, in a close collaboration between social and biomedical scientists. The main objective of IMIAS is to increase knowledge oof the effects of gender differences on mobility disability (prevalence, incidence and recovery) in ageing and on the impact of potentially modifiable risk factors, with detailed hypotheses on the pathways linking life course exposure to violence, poverty, social isolation and reproductive history with mobility disability in old age. We use an interdisciplinary approach to conduct research on gender differences in mobility across societies at different stages of the epidemiological transition. Herein, the term ‘gender’ emcompasses the biological and social differences between men and women. IMIAS is a population-based, longitudinal, prospective cohort, multicentre, multidisciplinary study conducted in five cities: Tirana (Albania), Natal (Brazil), Manizales (Colombia), Kingston (Ontario, Canada) and Saint-Hyacinthe (Quebec, Canada). It examines the prevalence, incidence of and recovery from mobility disability and associated risk factors in n = 2002 community-dwelling men and women aged 65–74 years at baseline. Participants were followed to establish the baseline prevalence and the 4-year incidence of and recovery from mobility disability, allowing for the study of both cross-sectional and longitudinal relationships between risk factors and mobility disability. Inclusion of five research sites allowed analyses of the impact of the diversity of environments in terms of life course past and current living social and economic conditions, gender roles and current neighborhood environments on mobility disability. IMIAS included communities that differed in their social, cultural, socioeconomic and geographical environments and in their health care systems (Table 1). Country profiles: demographic, health and economic indicators GNP, gross national product. United Nations Development Program. Human Development Reports 2015. [https://esa.un.org/unpd/wpp/DataQuery/]. WHO Health Statistics 2010. [http://www.who.int/whosis/whostat/2010/en/]. WHO 2015. [http://www.who.int/gho/ncd/risk_factors/overweight_obesity/obesity_adults/en/]. WHO 2015. Universal Health Coverage Portal. [http://apps.who.int/gho/cabinet/uhc-service-coverage.jsp]. UNDP 2016 Human Development Report. Table 5. Gender Inequality Index. [http://hdr.undp.org/en/composite/GII]. Country profiles: demographic, health and economic indicators GNP, gross national product. United Nations Development Program. Human Development Reports 2015. [https://esa.un.org/unpd/wpp/DataQuery/]. WHO Health Statistics 2010. [http://www.who.int/whosis/whostat/2010/en/]. WHO 2015. [http://www.who.int/gho/ncd/risk_factors/overweight_obesity/obesity_adults/en/]. WHO 2015. Universal Health Coverage Portal. [http://apps.who.int/gho/cabinet/uhc-service-coverage.jsp]. UNDP 2016 Human Development Report. Table 5. Gender Inequality Index. [http://hdr.undp.org/en/composite/GII]. The sample was stratified by sex, with the aim to recruit 200 men and 200 women registered at community health clinics and through public health insurance databases. The sample in Natal was randomly drawn from the registers of the Family Health programme at three low-income and two middle-income areas of the city. The Manizales sample was randomly drawn from the Public Health Insurance database. At Tirana, participants were randomly selected from the population registered at two neighbourhood health centres in one middle class area of the city. In the Canadian research sites, the ethics committees did not allow direct contact with the potential participants. Thus in Kingston and Saint-Hyacinthe, potential participants were invited by letter from their primary care physicians to contact our field coordinator in order to participate in the study. In Saint-Hyacinthe, the sample was stratified by neighbourhoods. In Kingston this stratification was not possible because the Ethics Board requested that invitation letters be sent directly by the participating clinics to avoid knowledge of the addresses of the potential participants among the research team. At baseline, participants with scores lower than 4 (severe cognitive impairment) in the orientation scale of the Leganes Cognitive Test were excluded from the study because they were considered unable to answer the questionnaire and to complete the physical function tests, as well as freely consent to the study.6 The numbers of excluded people were zero in Kingston, one in Saint-Hyacinthe and Tirana, two in Manizales and five in Natal. Ethical approval for this project was obtained from the ethics review committees of the research centres of the University of Montreal Hospitals (CR-CHUM), Queen’s University (Kingston), the Albanian Institute of Public Health, the Federal University of Rio Grande do Norte (Brazil) and the University of Caldas (Colombia). The first data collection (baseline) took place in 2012. Before fieldwork, research and field staff were trained in all aspects of data collection, questionnaire administration and physical measurements. Cohort members underwent biennual home follow-up visits. The first follow-up assessments were conducted in 2014 and the second in 2016. IMIAS has expanded its collaborative efforts with nested sub-studies. At all sites, study procedures were carried out by a trained interviewer at the participant’s home unless the participant requested otherwise. Interviewers at each site received standard training based on protocol instructions and data entry forms. Assessments in Tirana were done by public health professionals and graduate students, in Natal by physiotherapists, in Manizales by local nurses, in Saint-Hyacinthe by retired high school teachers and in Kingston by lay people with university degrees. The principal investigators and the study coordinator trained all interviewers at each site in the 5 days preceding fieldwork, using the study manual of procedures and role playing. Retraining took place a few weeks later during data collection. Training and retraining sessions were repeated in 2014 and 2016. The questionnaires, all data collection documents and manuals of procedures were available in the local languages: Albanian, Spanish, Portuguese, English and French. Questionnaires and manuals of procedures are available upon request. The main scales were validated in pilot studies conducted in Brazil, Colombia and Quebec.6,7–12 In Tirana, translation into Albanian and adaptation to the local population were also carried out, although no pilot study was conducted at Tirana. Box 1 presents the variables included in the interview questionnaire, functional tests and biomarkers from blood and saliva analysis. The questionnaire included sections on demographic and socioeconomic variables, self-reported chronic conditions, depressive symptoms, medications currently used, falls and fear of falling, disability, life course history of socioeconomic conditions, exposure to domestic violence, reproductive history, physical activity, smoking and alcohol and illegal drug use, quality of life, neighbourhood social, economic and physical characteristics, social networks and support, social participation, gender roles, decision making power, financial autonomy and life space assessment. New variables were included in the second wave interviews: housing quality, driving experience, resilience,13 personal mastery,14 pain, urinary incontinence and an additional disability scale: the Late Life Disability Index.15 Summary of variables collected in IMIAS Demographic data Household membership Living arrangements Marital status Education Income and assets Earnings Sources of income Occupation Employment situation Economic hardship Migration history Physical health Self-rated health Chronic conditions (SABE) Medication use Vision test (ETDRS Tumbling E chart) Falls/balance Falls Efficacy Scale International (FES I) Functional limitations (Nagi questionnaire) Disability, mobility and activities of daily living Mobility Assessment Tool (MAT) videos Reproductive history (only for women) Access and use of health care services Behavioural health Smoking/smoking history Alcohol consumption Physical activity: IPAQ Mental health Cognitive function: MoCA/Leganes Cognitive Test (LCT) CES-D depression scale Social and civic participation Social activities Neighbourhood physical and social environment Friends-family networks and support Life-space assessment Psychosocial factors Gender roles: Bem Sex roles inventory Decision autonomy Victimization and fear of victimization Early life circumstances (first 15 years) and childhood adversity. Violence Hurt, insulted, threaten and scream (HITS) Two questions from Canadian Health Questionnaire Physical examination and performance Height and weight; waist circumference Blood pressure Grip strength Short Physical Performance Battery (SPPB): balance, gait speed and chair stands Blood assays Haemoglobin and haematocrit Glycated haemoglobin Albumin Total, LDL, HDL cholesterol and triglycerides High sensitivity C-reactive protein (HS-CRP) Interleukin 6 (IL-6) Demographic data Household membership Living arrangements Marital status Education Income and assets Earnings Sources of income Occupation Employment situation Economic hardship Migration history Physical health Self-rated health Chronic conditions (SABE) Medication use Vision test (ETDRS Tumbling E chart) Falls/balance Falls Efficacy Scale International (FES I) Functional limitations (Nagi questionnaire) Disability, mobility and activities of daily living Mobility Assessment Tool (MAT) videos Reproductive history (only for women) Access and use of health care services Behavioural health Smoking/smoking history Alcohol consumption Physical activity: IPAQ Mental health Cognitive function: MoCA/Leganes Cognitive Test (LCT) CES-D depression scale Social and civic participation Social activities Neighbourhood physical and social environment Friends-family networks and support Life-space assessment Psychosocial factors Gender roles: Bem Sex roles inventory Decision autonomy Victimization and fear of victimization Early life circumstances (first 15 years) and childhood adversity. Violence Hurt, insulted, threaten and scream (HITS) Two questions from Canadian Health Questionnaire Physical examination and performance Height and weight; waist circumference Blood pressure Grip strength Short Physical Performance Battery (SPPB): balance, gait speed and chair stands Blood assays Haemoglobin and haematocrit Glycated haemoglobin Albumin Total, LDL, HDL cholesterol and triglycerides High sensitivity C-reactive protein (HS-CRP) Interleukin 6 (IL-6) HDL, high-density lipoprotein; LDL, low-density lipoprotein; ETDRS, Early Treatment Diabetic Retinopathy Study; FES I, Falls Self-Efficacy Scale; IPAQ, International Physical Activity Questionnaire; CES, Center for Epidemiologic Studies Scale-Depression; Summary of variables collected in IMIAS Demographic data Household membership Living arrangements Marital status Education Income and assets Earnings Sources of income Occupation Employment situation Economic hardship Migration history Physical health Self-rated health Chronic conditions (SABE) Medication use Vision test (ETDRS Tumbling E chart) Falls/balance Falls Efficacy Scale International (FES I) Functional limitations (Nagi questionnaire) Disability, mobility and activities of daily living Mobility Assessment Tool (MAT) videos Reproductive history (only for women) Access and use of health care services Behavioural health Smoking/smoking history Alcohol consumption Physical activity: IPAQ Mental health Cognitive function: MoCA/Leganes Cognitive Test (LCT) CES-D depression scale Social and civic participation Social activities Neighbourhood physical and social environment Friends-family networks and support Life-space assessment Psychosocial factors Gender roles: Bem Sex roles inventory Decision autonomy Victimization and fear of victimization Early life circumstances (first 15 years) and childhood adversity. Violence Hurt, insulted, threaten and scream (HITS) Two questions from Canadian Health Questionnaire Physical examination and performance Height and weight; waist circumference Blood pressure Grip strength Short Physical Performance Battery (SPPB): balance, gait speed and chair stands Blood assays Haemoglobin and haematocrit Glycated haemoglobin Albumin Total, LDL, HDL cholesterol and triglycerides High sensitivity C-reactive protein (HS-CRP) Interleukin 6 (IL-6) Demographic data Household membership Living arrangements Marital status Education Income and assets Earnings Sources of income Occupation Employment situation Economic hardship Migration history Physical health Self-rated health Chronic conditions (SABE) Medication use Vision test (ETDRS Tumbling E chart) Falls/balance Falls Efficacy Scale International (FES I) Functional limitations (Nagi questionnaire) Disability, mobility and activities of daily living Mobility Assessment Tool (MAT) videos Reproductive history (only for women) Access and use of health care services Behavioural health Smoking/smoking history Alcohol consumption Physical activity: IPAQ Mental health Cognitive function: MoCA/Leganes Cognitive Test (LCT) CES-D depression scale Social and civic participation Social activities Neighbourhood physical and social environment Friends-family networks and support Life-space assessment Psychosocial factors Gender roles: Bem Sex roles inventory Decision autonomy Victimization and fear of victimization Early life circumstances (first 15 years) and childhood adversity. Violence Hurt, insulted, threaten and scream (HITS) Two questions from Canadian Health Questionnaire Physical examination and performance Height and weight; waist circumference Blood pressure Grip strength Short Physical Performance Battery (SPPB): balance, gait speed and chair stands Blood assays Haemoglobin and haematocrit Glycated haemoglobin Albumin Total, LDL, HDL cholesterol and triglycerides High sensitivity C-reactive protein (HS-CRP) Interleukin 6 (IL-6) HDL, high-density lipoprotein; LDL, low-density lipoprotein; ETDRS, Early Treatment Diabetic Retinopathy Study; FES I, Falls Self-Efficacy Scale; IPAQ, International Physical Activity Questionnaire; CES, Center for Epidemiologic Studies Scale-Depression; Two tests of cognitive function were used. The Leganes Cognitive Test (LCT), originally developed to screen for dementia in populations with low education and used previously in cognitive ageing research,6 was administered to all IMIAS participants. The Montreal Cognitive Assessment (MoCA) was used only in the Canadian sample, since during pilot testing of MoCA we documented its lack of validity in Manizales.8 Vision assessment, blood pressure, grip strength, physical performance based on assessments of gait speed, balance and chair stands [the Short Physical Performance Battery (SPPB)], see: [http://www.grc.nia.nih.gov/branches/leps/sppb/index.htm], were also carried out.16 Participants from all five sites underwent fasting blood tests. A total of 1728 participants out of the 2002 total sample provided blood (86%). Blood samples were taken by nurses or a trained phlebotomist. Conventional blood analyses were done at the local hospitals. Inflammatory markers were analysed as follows: serum from Saint-Hyacinthe and Kingston was analysed at Kingston General Hospital, affiliated with Queen’s University, serum from Manizales at the University Hospital of the Caldas and serum from Natal at a certified local commercial laboratory. Inflammatory markers at Tirana were not determined. Salivary cortisol was collected from a subsample of 309 participants, instructed to collect saliva on two consecutive days at awakening, 30 min and 60 min after awakening, at 15.00 h and before bedtime. All information was collected on laptops, using WILLIAM (WilliamMD MultiSpectra Inc.), resulting in more efficient interviews and greater ease in producing databases. Baseline response rates in Manizales, Natal and Tirana were higher than 90%. Response rates in Canada were low; these low rates were induced by the procedures by the ethics review at the Canadian research of people received the invitation letter from their primary care our research field and of to participate in the an response of The samples were at Kingston, at Saint-Hyacinthe, at Tirana, at Manizales and at Natal. The the sample of were to the of with the Canadian data on education that participants in Kingston were more than the population of that age in that whereas participants in Saint-Hyacinthe had of education close to the data for that age in In whereas the of participants with more than high school education was in our Kingston sample, this was in the Canadian for the Kingston In Saint-Hyacinthe, these were and between the baseline data collection and the follow-up in 2016 was was in Kingston, in Saint-Hyacinthe, in Tirana, in Manizales and in Natal. At 4 of the not to in the follow-up assessment The of interviews in of in and not to was at Kingston and at Saint-Hyacinthe, at Tirana, at Manizales and at Natal. The first IMIAS objective was to the of the gender gap in mobility disability and to increase of gender differences in life course exposures to of self-reported mobility disability or a of and activities of daily living disability in across a and to the were higher in women than in men in all sites for physical performance by an was more frequent in women than in men in Manizales, Natal and Tirana, the three Among few differences in physical mobility or disability were across Among mobility and disability were for Manizales, Natal and Tirana compared with support for our that gender physical performance and mobility and disability gap is to gender in less IMIAS showed of the of social and economic in physical performance during old low physical performance was associated with childhood social and economic living and income in later Early social was associated with high of in old and in old age was associated with low physical All these between life course and physical performance were in men and women. IMIAS provided the that the risk of chronic and physical limitations in older after for study childhood economic and women at a age had odds ratio for physical function compared with women after years of Gender roles to health and health and be by environment and the research has not the between gender roles and physical of a of the Bem Sex we into and cross-sectional and longitudinal between these gender role and physical performance and pathways between and physical and gender roles are risk factors for mobility disability and low physical higher of physical Gender roles health in to chronic conditions and of lower physical was frequent in the life of older in all five with in women compared with physical in the 6 was both from the and from members was and was associated with low support from and Family was more frequent in In the Canadian subsample of risk factors associated with both current and a of an between members in and quality relationships with and In life course was to be a risk for both self-reported mobility and physical chronic conditions, depression and lack of physical were to pathways between domestic violence, and mobility disability and physical chronic conditions are factors for mobility disability and physical and our they are between socioeconomic gender roles and domestic violence, and mobility disability and low physical we of our research to the prevalence and of chronic conditions in our research We our research on depression and since these are conditions with and available and prevalence from in Saint-Hyacinthe to in Tirana. than of participants were of their in Saint-Hyacinthe to in women were more than of of their were between and physical and from were among participants was in Tirana and Natal. and physical were associated with The prevalence of falls in the was with site from in Kingston to in of mobility disability was associated with fear of and associated with in life space in all sites of the using and we a to falls in primary care based on three fear of falling, of falls and to complete five chair We social socioeconomic status and environment factors as potential factors in the of the of falls among older of depression to and was higher in women than in living chronic conditions and physical performance were all associated with depression prevalence in all and the gender role was associated with low prevalence of depression of biological We socioeconomic in drug use among IMIAS participants. was between socioeconomic and drug use in Canada, whereas in Latin America greater use was associated with high education and The prevalence rates of in Natal, Manizales and Tirana were 22% and The of an care in the past in Natal, Manizales and Tirana were and factors for were older a a low income and physical from a associated with an care in the past included a more years of in a higher income and history of physical from a the IMIAS has provided for research on cortisol and physical social and The main of the IMIAS IMIAS on the function gap by ageing populations living in societies from and low-income countries, using and study and data collection and used physical and cognitive function validated in the IMIAS samples from five research sites in countries, in life course exposures and health and disability The sample of 2002 men and women is to social and reproductive history on allowing for The of across a of physical and health and in this older age All and were pilot in Canada, Colombia and in preceding and are available in the five study The study researchers from a of and public and across a of in different This has allowed the to be well an of factors demographic, social and that to the health status of participants. Early that the study by Response rates in The baseline response rates were low in Canada, these low rates are by the by the human committees at the Canadian research of data on education that participants in Kingston are more than the population in that whereas participants in of education that are with Mobility disability in the Canadian sites are close to in the Canadian on Disability, used a comparable for women and of men older than and in the 65–74 age with no differences between for that age The sample was to participants aged 65–74 The participants were adults, and do not a age of older This age was by our in mobility in populations at an age when mobility is with high rates of In we to by the study to a of the on of we that our samples do not all community-dwelling older in Brazil, Canada and All collected data are and at the IMIAS in the Universidade Federal do Rio Grande do information be found at the study in collaborative are invited to contact the IMIAS as at the in a IMIAS is a population-based, longitudinal, prospective cohort, multicentre, multidisciplinary study conducted in five cities: Tirana (Albania), Natal (Brazil), Manizales (Colombia), Kingston (Ontario, Canada) and Saint-Hyacinthe (Quebec, Canada). It examines the prevalence, incidence of and recovery from mobility disability and associated risk factors in 2002 community-dwelling men and women aged years at baseline. Participants were followed to establish the baseline prevalence and the 4-year incidence of and recovery from mobility disability, allowing for the study of both cross-sectional and longitudinal relationships between risk factors and mobility disability. The first data collection (baseline) took place in 2012. The first follow-up assessments were conducted in 2014 and the second in 2016. between the baseline data collection and the follow-up in 2016 was was in Kingston, in Saint-Hyacinthe, in Tirana, in Manizales and in Natal. At 4 of the not to in the follow-up assessment A of information was collected questionnaires, physical and biological in the five for collaboration are and researchers are invited to contact at the study IMIAS was by the Canadian of Health Institute of Mobility in Aging Gender differences in we mobility in old This was by the Canadian for Health Mobility in Aging of

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