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

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.


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.

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.

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 condi- tions.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, Okumura Y, et al. (45) 2019 Cross-sectional study All PA recipients hospitalized in psychiatric hospitals

National database 46,559 Age-sex-standardized claim ratio of the psychiatric admission
There is a geographical (prefectural) variation in the number and total medical cost of psychiatric admissions among recipients.
There is a positive correlation between recipients' psychiatric admission, the number of prefectural psychiatric beds per 100,000 population, and the prefectural proportion of the population receiving PA Nishioka D, et al. (46) 2020 Retrospective cohort study Adult recipients in two municipalities in Japan (>=20 years old) Municipal database 6,016 Frequent outpatient attendance Recipients living alone had an incidence of 1.58 (95% CI: 1.05-2.39)compared with those not living alone.Recipients visiting private institutions had an incidence of 1.74 (95% CI: 1.20-2.52)compared with those visiting medical corporations Isozaki A, et al. (47) 2021 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 as-

Figure 1 .
Figure 1.Flow diagram of the scoping review.

Table 1 .
Descriptive Information of the Studies Using Public Assistance as an Exposure Variable.
(18)ver, the association remained among the uninsured (aHR [95% CI]: 1.08 [0.78-1.51]and1.48[1.02-2.15],forPAand uninsured, respectively).PA, particularly if limited to casual workers and unemployed persons, may contribute to the improvement of survival rates (from the Kaplan-Meier curve results) Takenaka Y, et al.(18)2016 Retrospective cohort study Single center/newly diagnosed and histologically confirmed patients with head and neck squamous cell carcinoma (HNSCC), median age 76 years (range 28-92) Medical records Other insurance 407 (72/335) Mortality The clinical stage distribution was not significantly different between the PA groups and other insurances (OR: 1.36, 95% CI: 0.78-2.39,for stages III and IV).The 5-year overall survival, cumulative incidence of HNSCC death, and cumulative incidence of other death rates were 63.3% and 59.1%, 27.0% and 31.8%, and 10.3% and 9.7% for the PA and other insurance groups, respectively.
Children in households receiving PA had a higher risk of school refusal than those in households not receiving PA; children living in PA household were four times more likely to refuse to go to school than children living in LI households without PA (OR: 4.00, 95% CI: 0.85-18.84,p = 0.080)

Table 2 .
Descriptive Information on the Studies Using Public Assistance as an Entire Study Population.

Table 3 .
Descriptive Information on the Studies Using the Proportion of the Population Receiving PA as an Environmental Predictor in Ecological Studies Included in the Scoping Review.: 10.31662/jmaj.2024-0062JMA Journal: Volume 7, Issue 3 https://www.jmaj.jp/ DOI