Aging, Education, and Equity: How Social and Economic Support Can Improve Health

Above. Lindsay Kobayashi leads a group of students from the University of the Witwatersrand during a data workshop on socioeconomic conditions and healthy aging at Wits Rural Facility, South Africa

The cumulative effects of daily life on your health status—both advantages and disadvantages—become clearer with time. The older you get, the clearer those effects become.

“Aging and cognitive aging have always fascinated me because it is later in life where we see more and more variation in people’s physical and cognitive health,” says Center member Lindsay Kobayashi. “Over the course of a lifetime, inequities can be observed more clearly than in younger individuals.”

Kobayashi is the John G. Searle Assistant Professor of Epidemiology in the Center for Social Epidemiology and Population Health (CSEPH), and her research focuses on how and why our minds age.

“Cognitive aging is fundamentally about equity. Things that support good cognitive health in later life are connected clearly to education and early childhood socioeconomic advantage. The brain functions with what we call cognitive reserve—the ability to ‘use it or lose it’—and this builds up across a lifetime and is fundamentally socially influenced,” Kobayashi says.

Health Sciences Are Social Sciences

While Kobayashi is trained in epidemiology and public health, much of her work is built on disciplines in the social sciences.

“To inform my work on cognitive health, I read broadly—including in psychology and sociology—because we have to understand each other across the broad fields of population health sciences and other fields that can inform our work,” she states.

Kobayashi’s work requires that she have fundamental understandings of South African history, culture, and economics, as well as functional understandings of technical areas of human health such as trauma theory.

Cognitive aging is fundamentally about equity. Things that support good cognitive health in later life are connected clearly to education and early childhood socioeconomic advantage.
—Lindsay Kobayashi

She also incorporates into her work on aging and equity the biopsychosocial theory of weathering, the idea developed by Arline Geronimus—professor of Health Behavior and Health Education at the School of Public Health—that social exclusion leads to health deterioration an earlier age than would be expected for an individual.

Understanding prevailing theories about the accelerated aging of bodily systems, including the technical biochemical evidence supporting those theories, is fundamentally related to work on socioeconomic equity and cognitive aging, says Kobayashi. “It means we have a better understanding of the phenomena we’re observing in our study populations. And with a more comprehensive perspective, we can do better science.”

Where social, political, and environmental landscapes interact to affect human health is the complex, creative work of social epidemiology. “Epidemiology is fundamentally about understanding humans and how the world around us works,” posits Kobayashi.

Aging and Social Support in Rural South Africa

For the past six years, Kobayashi has been collaborating with partners in South Africa on the study Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI), engaging with communities in the Agincourt sub-district of Mpumalanga, a rural area in northeast South Africa.

A majority of South Africa’s older population lived through Apartheid, a formal system of racial segregation that ended only in the early 1990s. “Apartheid affected individual health, including mental health, and had broad impacts on community life and social factors affecting health,” Kobayashi notes. “We want to understand how people’s life course histories affect cognitive aging in communities that were heavily affected by Apartheid.”

Kobayashi and her partners are asking what chronological age means in different settings, paying close attention to the wide variations in cognitive aging within and between populations around the globe. “What is the health status of a sixty-year-old in the US compared with someone the same age in South Africa? Is their physical health alone a good way to conceptualize their overall health? Probably not.”

In the older populations of Mpumalanga province, lives continue to be shaped by the legacy of Apartheid well beyond physical health. With partners in the School of Public Health at the University of the Witwatersrand and the Wits Rural Public Health and Health Transitions Research Unit in Agincourt, Kobayashi is working to identify social and economic influences from early- and mid-life that affect cognitive health and dementia risk in later life.

Chodziwadziwa Kabudula, senior researcher and data scientist with the Wits Rural Public Health and Health Transitions Research Unit in Agincourt, South Africa, presenting at a data workshop with local students at the Wits facility.
 

Since September 2020, Kobayashi has been collaborating with the Wits Research Unit on an NIH R01 grant-funded project looking at income, cash transfers, government social policy, and dementia risk in Agincourt. The team recently investigated how improvements in the socioeconomic welfare of households in Agincourt since the early 2000s may have led to improved cognitive health of older adults in the region. They are also examining how direct cash transfers and eligibility expansions to the South African Old Age Pension and Child Support Grant may impact cognitive and other health outcomes among older adults in Agincourt.

The rural research site in Agincourt is operated jointly with the University of Witwatersrand and the local public health agency. They have conducted the Agincourt Health and Socio-Demographic Surveillance System since the early 1990s, set up to monitor health circumstances in the region as socioeconomic and political contexts shifted dramatically with the end of Apartheid.

Kobayashi says the high participation rates in the study and the high quality of the data have a lot to do with an effective local public health office, including community engagement and good communication. “This ongoing surveillance system is essentially a regional census. It has very strong ties to local communities and is one of the major employers in the region.”

Education and Equity

Ideally, evidence from the team’s research will inform the development or redesign of government social policies to best support the health of South Africa’s rapidly aging older population. By scrutinizing the type, timing, and delivery of social grants that involve direct cash payments to households, they hope to inform policy that optimizes population health across the country.

“If our work can support the design of social policies that provide economic improvement to households, that would be my dream for this work,” says Kobayashi.

Connections between the old and the young is a big piece of household health in South Africa. “With generous government support of older people in communities where most households are intergenerational,” Kobayashi notes, “these grants become a big support to an entire household.”

The study team from the University of Michigan, Indiana University, and the University of the Witwatersrand.

How can we advance health equity around the world? Pay attention to proven ways of optimizing healthy cognitive aging, such as education.

“Cognitive aging in populations like South Africa’s, where access to education has been low, demonstrates the importance of basic social benefits,” notes Kobayashi. “Socioeconomic conditions in the household during early-life can be a big influence on whether adolescents and young adults stay in school. If social grants from the government can promote education among the youngest population members, this would have long-term positive effects for their health and well-being as they grow older.”

In the US, we have high-quality early childhood education and a strong educational system across the country. “Nearly the entire population goes to school and becomes literate. That’s not the case in many places around the world,” says Kobayashi. “Because education is one of the strongest protective factors as we age, access to education is a health equity issue on a global scale.”

—Josh Messner

More about Kobayashi

Kobayashi has followed a winding academic path toward this body of research, highlighted by a commitment to health equity. As an undergraduate student at Queen’s University in Canada, she took elective courses in epidemiology, discovering that population health allowed her to merge her passions for biology and medicine with a rich social understanding of how the world around us shapes our health.

After earning an MS in epidemiology at Queen’s University, Kobayashi followed her dream to study literacy as a social determinant of healthy aging outcomes at University College London, where she completed a PhD in epidemiology and public health. Over time, she turned her focus towards studying cognitive aging in low literacy contexts where epidemiologic evidence could be impactful in improving the social determinants of health. Kobayashi became involved with the HAALSI cohort during her postdoctoral studies at the Harvard T.H. Chan School of Public Health.

Kobayashi has committed her career to understanding the social and economic determinants of cognitive aging in South Africa and across diverse global regions since then. She says she pursued epidemiology to “improve human health and health equity with science while approaching science in new and creative ways, including through good communication.”