Health Statuses of People in Poverty Receiving Public Assistance in Japan: A Scoping Review

Abstract

Background: Promoting health and well-being is essential to ensure dignified lives of the entire population, including those living in poverty. Guaranteeing the human right to health is a critical responsibility of social security policies. To address emerging issues associated with poverty, the Japanese government has implemented a welfare program known as public assistance―seikatsu-hogo. However, financial welfare programs may not fully mitigate health risks due to the complex impact of poverty on health. Although a global systematic review of the health status of public and social assistance recipients has been conducted, it did not include any studies from Japan. Furthermore, evidence for the development of health support strategies for Japanese recipients remains scarce. This scoping review aims to identify the current situation and potential issues concerning the health of recipients.

Methods: PubMed was searched for articles published before November 2023. Of the 357 articles identified, 56 were included. Among those included, 35 used the individual status of receiving public assistance as an exposure variable, 13 considered public assistance recipients as the study population, and 8 used the prefectural proportion of the population receiving public assistance as an environmental predictor.

Results: We found that public assistance recipients tend to have more disadvantageous health and well-being statuses than the general population, as reported in the global systematic review. Health inequalities were also observed among recipients based on their sociodemographic characteristics. In Japan, public assistance recipients face several health risks and are at a disadvantage compared with the general population.

Conclusions: The distribution of risks is heterogeneous among recipients, despite the minimum income protection and financial benefits in health and long-term care use. Further studies to identify the effects of public assistance policy on the health of the impoverished population, evidence-based discussions, and reform of social security policies are warranted.

Key words: Poverty, Public assistance, Scoping review, Japan

Introduction

Promoting health and well-being are prerequisites for the dignified lives of the entire population, and guaranteeing the human right to health for the people is one of the important roles and responsibilities of society and social security policies ^{(1), (2), (3)}. However, global evidence has recently indicated that people’s social backgrounds and contexts certainly inhibit their health-promoting activities and healthy lifestyles, resulting in health inequalities across their socioeconomic statuses ^{(4), (5)}. Poverty is known to be a major, but unmet, social determinant of health. People living in poverty have insufficient resources to meet their health needs, which can impede cognitive function, resulting in difficulty making reasonable health investments and leading to adverse health outcomes ^{(6), (7)}. Thus, it is imperative to reform the social security system to address the negative health effects of poverty.

In recent decades, Japan has been facing emerging issues associated with poverty. For example, Japan’s poverty rate was reported to be 15.4% in 2021, which is higher than the average among member nations of the Organization for Economic Cooperation and Development ⁽⁸⁾. In particular, the poverty rate among children living with single parents has been raised as a serious problem. Approximately half of children living with single parents live below the poverty line. The Constitution of Japan Article 25 stipulates that “All people shall have the right to maintain the minimum standards of wholesome and cultured living” and that “In all spheres of life, the state shall use its endeavors for the promotion and extension of social welfare, security, and public health ⁽⁹⁾.” As a measure to embody this clause, a governmental welfare program called public assistance―seikatsu-hogo―exists, which can benefit households living below the poverty line. The Municipal Welfare Office conducts rigorous means tests and determines whether people will receive benefits ⁽¹⁰⁾. Approximately 1.6% of the entire population in Japan was receiving public assistance in 2021. Households receiving public assistance can benefit from monthly minimum income benefits and are fully exempt from payments for healthcare and long-term care utilization ⁽¹⁰⁾.

Considering the potential influence of multidimensional poverty ⁽¹¹⁾, financial welfare programs may not fully compensate for socioeconomic health risks. A previous review by Shahidi et al. reported that the health status of public and social assistance recipients in high-income countries is not better than that of nonrecipients ⁽¹²⁾. From the review, public or social assistance recipients have poorer subjective health; a higher prevalence of mental illness, including anxiety and depression, diabetes, and obesity; and a higher mortality rate than the general population not receiving public or social assistance. Furthermore, public and social assistance recipients have been reported to be more likely than nonrecipients to engage in high-risk health behaviors, such as smoking, problematic drinking, and frequent visits to healthcare institutions. Shahidi et al. summarized these findings and suggested that public and social assistance programs may not sufficiently protect the health of recipients.

Since the fiscal year 2021, from the perspectives of promoting health and optimizing medical assistance costs for public assistance recipients, a health support program for public assistance recipients―kenko-kanri-shien-jigyo―has been mandated in municipal offices. This program emphasized the importance of a data-driven approach. However, because public and social assistance systems vary across countries and the review by Shahidi et al. did not include any Japanese evidence ⁽¹²⁾, the generalizability of the evidence was unclear. In addition, quantitative data on health support strategies for recipients of public assistance in Japan remain sparse. Summarizing the existing evidence to develop evidence-based health support policies for recipients is urgently needed.

In this study, we aimed to conduct a literature review of existing peer-reviewed research that has dealt with the health and health behaviors of public assistance recipients in Japan. Considering the findings of this review, we further aimed to organize the evidence and summarize emerging issues that can contribute to the discussion of effective interventions to support health among recipients.

Materials and Methods

Study design

A scoping review.

Eligibility criteria

We used the population, concept, and context framework to define the inclusion criteria. All published studies using public assistance recipients in Japan, both as an exposure variable and study population, were eligible. We reviewed the existing literature describing the health and well-being of public assistance recipients as an outcome measure. We restricted our search to English-language and peer-reviewed publications. We excluded gray literature, working papers, and peer-reviewed commentaries lacking direct empirical tests.

Search strategy

We conducted a search on PubMed using the term ((“public assistance” [MESH] or “public assistance”) AND (Japan)) on November 7, 2023. We supplemented our electronic search by searching the reference lists of all the included literature and related review articles.

Study selection

The studies were independently selected by two researchers (HK and DN). The two researchers compared their lists, and any differences in opinions were resolved through discussion.

Data extraction and analytic strategy

Data were extracted by the authors using standard data extraction forms, including the PMID, title, author names, and publication year of the articles. Whether public assistance was used as an exposure variable or as a study population was coded. If a study utilized public assistance as an exposure variable, we extracted the study design, setting, reference group information, study participants, sample size, study outcomes, and study findings. If the study utilized public assistance recipients as the entire study population, the study design, setting, sample size, and findings were extracted.

Results

A total of 357 articles were identified in the search, of which 52 met the eligibility criteria of this review ^{(13), (14), (15), (16), (17), (18), (19), (20), (21), (22), (23), (24), (25), (26), (27), (28), (29), (30), (31), (32), (33), (34), (35), (36), (37), (38), (40), (41), (42), (43), (44), (45), (46), (47), (48), (49), (50), (51), (52), (53), (54), (55), (56), (57), (58), (59), (60), (61), (62), (63), (64)}. From the review, four eligible studies were additionally included ^{(65), (66), (67), (68)}. Finally, 56 articles were included. The selection process of the study is illustrated in Figure 1. There have been no randomized controlled trials on this study design.

Figure 1. Flow diagram of the scoping review.

» Full size image

Studies using public assistance as an exposure variable

A total of 35 studies utilized public assistance status as the exposure variable ^{(13), (14), (15), (16), (17), (18), (19), (20), (21), (22), (23), (24), (25), (26), (27), (28), (29), (30), (31), (32), (33), (34), (35), (36), (37), (38), (39), (40), (41), (42), (43), (44), (65), (66), (67)}. Among them, seven used public data obtained from national or local governments ^{(17), (21), (22), (23), (27), (32), (38)}. One study used registry data obtained from medical institutes ⁽³⁵⁾. Majority of the studies used data collected from medical records and/or administered surveys through questionnaires or interviews with healthcare providers at medical institutes. A higher mortality ⁽⁶⁷⁾, prevalence of infections ⁽²⁴⁾, chronic diseases (diabetes complications ^{(19), (36)} and heart diseases ^{(30), (31), (35)}), and adverse health outcomes of surgeries ⁽¹⁵⁾ were observed. Unpreferable health behaviors were also prevalent among public assistance recipients such as smoking ⁽³¹⁾, frequent medical visits ^{(25), (26), (38), (65)}, polypharmacy ^{(40), (41)}, less vaccine uptake ⁽⁴²⁾, and refraining from necessary healthcare-seeking behaviors ^{(16), (27), (44)}. However, several studies have also demonstrated an association or no association between receiving public assistance and favorable health outcomes/behaviors ^{(14), (17), (18), (28), (32), (34)}. In a multicenter prospective cohort study, Kaneko et al. investigated that the receipt of public assistance was inversely associated with all-cause mortality among patients who had started receiving regular physician-led health care at home or at nursing homes ⁽²⁸⁾. Furthermore, among patients who were diagnosed with methamphetamine use disorder, those who received public assistance were more likely to remain in treatment at 3 months than those who did not (Table 1) ⁽¹⁴⁾.

Studies using public assistance as an entire study population

A total of 13 studies used public assistance recipients as their study population ^{(45), (46), (47), (48), (49), (50), (51), (52), (53), (54), (55), (56), (68)}. Among them, one study used data from the Japanese national database, which identified regional differences in the prevalence of admission length in psychiatric hospital ⁽⁴⁵⁾ by public assistance recipients and its predictors. Furthermore, eight studies used data from public assistance databases of the welfare offices of local governments ^{(46), (48), (49), (50), (51), (53), (55), (56)}. Among the public assistance recipients, several characteristics were associated with undesirable health statuses and behaviors. For example, those living alone or unemployed were more likely to have diabetes and frequently attend medical consultations ^{(46), (49), (51), (53)}. Four studies used data obtained from a self-questionnaire social survey ^{(47), (52), (54), (68)}. The health behavior scale of older recipients living alone, who have the most disadvantageous health risks among recipients, was developed ⁽⁴⁷⁾ and examined for validity ⁽⁵⁴⁾. This scale is reportedly useful in predicting the health behaviors of older recipients living alone, such as health checkup ^{(47), (54)}. High activity of daily living and social capital were found to be associated with the initiation and termination of public assistance (Table 2) ^{(52), (68)}.

Studies using the proportion of the population receiving public assistance as an environmental predictor in ecological studies

Eight studies used the proportion of the population receiving public assistance as a variable to express environmental factors across prefectures. Among these studies, only one used the proportion of the population receiving public assistance as a community-level economic factor in a cohort study ⁽⁶⁰⁾. This study demonstrated that among men, the risk of cancer-related death was significantly higher with an increase in the proportion of households receiving public assistance. Seven were ecological studies ^{(57), (58), (59), (61), (62), (63), (64)}. Considering the nature of ecological studies, it is inappropriate to apply the evidence to individual public assistance recipients, as people living in prefectures with a higher proportion of the population receiving public assistance tend to have unfavorable health conditions. Yoshikawa et al. reported that the COVID-19 incidence and mortality rates were higher in prefectures with a high proportion of the population receiving public assistance (Table 3) ⁽⁶³⁾.

Discussion

To the best of our knowledge, this was the first review to describe the health status of impoverished individuals receiving public assistance in Japan. The review included 56 studies, and we elucidated that the available evidence on the health status of public assistance recipients was based on observational data, including national and governmental data, social surveys, and hospital-based registration data. We found that public assistance recipients tended to have a more disadvantageous health and well-being statuses than the general population and that the prevalence of health outcomes varied across prefectures among the recipients. Focusing on people receiving public assistance, sociodemographic inequalities in health outcomes across recipients’ characteristics, such as household composition and employment status, were found. The proportion of the population receiving public assistance may be available as a prefectural monitoring measure or as an adjustment measure of community-level economic factors in public health studies in Japan.

As mentioned, descriptions of the health statuses of public and social assistance recipients have globally accumulated in recent years. Global evidence, excluding the Japanese population, has indicated that recipients have poorer health outcomes and problematic health behaviors than the general population not receiving public or social assistance ^{(12), (69), (70)}. The present review identified that the health status of public assistance recipients in Japan was consistent with previous global evidence; thus, global evidence may also be applicable to these recipients. Shahidi et al. suggested that the use of public/social assistance programs may not be sufficiently protective for the health of impoverished individuals ^{(12), (69)}. From the perspective of multidimensional poverty ⁽¹¹⁾, additional social support beyond financial support for public assistance recipients in Japan may also be necessary to maintain the health of recipients.

The studies included in this review have several strengths and limitations. First, studies that utilized public assistance as an exposure variable focused on marginalized populations in which ordinary social surveys could not have been sufficiently outreached. However, these studies could only capture potential associations between the receipt of public assistance and health outcomes. Second, evidence based on studies using public assistance as a study population that used national and local governmental data had the strength of analyzing complete demographic data with few missing data; however, there were limitations in the generalizability of the findings due to the limited number of municipalities included in the review. Furthermore, the evidence included in this study indicates that public assistance recipients have more undesirable health risks than the general population, and a missing link regarding the mechanism that produces health inequality across the population remains unknown. When compared between public assistance recipients and nonrecipients, several studies have shown controversial results, with inverse or no association for health outcomes ^{(14), (17), (18), (28), (32), (34)}. This may be due to the effect of the public assistance as social security on access to health care and the effect of social welfare support related to the public assistance system. However, each study is specific to its target population, and the results are extremely limited, requiring further studies with diverse population to address the underlying mechanisms. In addition, as public assistance recipients differ from the general population in their characteristics and the social context leading to their receipt of public assistance, studies that remove these biases and estimate causal relationships are needed.

More detailed socioeconomic status information on the daily lifestyles of public assistance recipients and longitudinal observations are needed to elucidate the mechanisms underlying the health problems of recipients. This may enable us to make more precise causal inferences regarding the modifying effects of public assistance on the relationship between poverty and health.

This review had several strengths and limitations. The results of this review were based on currently available robust evidence from peer-reviewed papers following a comprehensive literature search. However, we restricted our search to English-language publications. English-language publications have mainly been published in the last decade, and evidence may not have been sufficiently accumulated. Furthermore, the authors acknowledge the importance of reviewing Japanese-language publications; Japanese-language publications that quantitatively described the health and well-being statuses of the recipients were sparse ^{(71), (72), (73), (74), (75)}. However, evidence from Japanese publications was consistent with the findings of this review and did not alter our conclusions.

In conclusion, public assistance recipients in Japan face more health risks than the general population, and the distribution of the risks is heterogeneous among recipients despite the minimum income protection and financial benefits in health and long-term care use. Further studies are warranted to identify the effect of public assistance policies on the impoverished population and to strategize effective support for recipients’ health. Evidence-based discussions and reforms of social security policies are imperative to protect individuals’ healthy lives, even when they fall into poverty.

Article Information

This article is based on the study, which received the Medical Research Encouragement Prize of The Japan Medical Association in 2023.

Conflicts of Interest

None

Sources of Funding

This work was supported by [the Japan Society for the Promotion of Science KAKENHI] grant number [22K17404] and the [Health Labor Sciences Special Research Grant] grant number [23CA2001]. This work was supported by the Medical Research Encouragement Prize of The Japan Medical Association.

Acknowledgement

We thank Editage (www.editage.com) for the English language editing.

Author Contributions

KH and DN conceptualized and designed the study. Both authors searched relevant literature and prepared the manuscript. All authors contributed equally to this study and approved the final version of the manuscript.

Approval by Institutional Review Board (IRB)

Not applicable.

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