Health-Related Quality of Life scores among low-income patients on Social Welfare Programs in Japan: A repeated cross-sectional study

doi:10.21203/rs.3.rs-1974473/v1

Background: Low-income is one of the well-established determinants of people’s health and health-related behavior including susceptibility to coronavirus disease 2019 (COVID-19) infection. To support financial access to medical care among low-income patients, there are two social welfare services in Japan: Public Assistance (PA) which provide both minimum income and medical costs, and Free/Low-Cost Medical Care (FLCMC) in which only medical costs were covered. The purpose of this study was to describe and compare the changes in Health-Related Quality of Life (HRQOL) scores before and after the COVID-19 pandemic among low-income patients on PA, FLCMC, and the general population, to examine if the social welfare services contributed to protect low-income people’s HRQOL during the pandemic.

Methods: We used repeated cross-sectional data obtained from adult patients on FLCMC or PA and those without social welfare services who regularly visit the Kamigyo clinic in Kyoto, Japan. We collected the data from 2018 and 2021 using a questionnaire about patients’ socioeconomic attributes and Medical Outcomes Study 12-Item Short Form Health Survey (SF-12).

Results: We analyzed data of 200 individuals in 2018 and 174 individuals in 2021. Low-income patients on social welfare services had lower physical health component summary (PCS) score, and the role-social component summary (RCS) score than general population in each year. The results of multiple linear regression analyses with robust standard estimator showed that the decline in Mental Component Summary (MCS) score was significantly larger among FLCMC recipients than patients without welfare services (coefficient: -4.71, 95% Confidence Interval: -8.92 to -0.51), while the decline in MCS scores among PA recipients were not significant when compared to the general population.

Conclusions: Low-income patients on social welfare services especially on FLCMC experienced the significant decline in MCS scores during COVID-19 pandemic. To maintain mental health of low-income patients on social welfare services in the pandemic, need to be provided with not only social care, but financial livelihood support may also be required.

Trial registration: N/A

Low-income

Poverty

Health Related Quality Of Life

Free/Low-Cost Medical Care program

Public Assistance

Low-income is one of the well-established determinants of people’s health and health behavior, which can affect quality of life (QOL) [1]. Low-income can be a barrier to maintaining healthy lives, for example, low-income populations have a higher risk of health-related problems [1], difficulties in health care access[2], unhealthy behaviors such as smoking and lower exercise [3], lower cancer screening rates [4], and vaccine hesitancy rates [5]. Further, low-income people suffer from a multidimensional difficulties of poverty-related issues including social isolation and time poverty [6–8]. Low-income people are considered to be susceptible to the spread of various infections including the present global spread of coronavirus disease 2019 (COVID-19) [9, 10]. COVID-19 has been reported to reduce physical activity, worsen mental function, and escalate states of social isolation especially among low-income people, which in turn has deteriorated their QOL further [11, 12].

As low-income is one of the strong determinants of health, governments in developed countries have several welfare programs that can provide financial support to improve livelihoods and healthcare access among the impoverished populations. In Japan, there are two well-known welfare services called Public Assistance (PA; ‘seikatsu-hogo’ in Japanese), and Free/Low-Cost Medical Care (FLCMC; ‘muryo-teigaku-shinryo’ in Japanese). PA is a governmental program for people who are living below the poverty line and without any assets. Approximately 1.7% of the Japanese population is enrolled in the PA program [13]. To evaluate the eligibility for PA, a rigorous test for means of each potential household is conducted by the local municipal welfare office (i.e., whether they are living below the poverty line, their ability to work, the financial support they receive from relatives, and their use of any other welfare services). The FLCMC program is a voluntary program governed by the Social Welfare Act, provided by designated healthcare institutions. The purpose of FLCMC involves providing free or low-cost medical care to people with financial difficulties so that they are not restricted in their access to necessary medical care for financial reasons [14]. FLCMC applicants are exempted from out-of-pocket medical payment at the designated institutions, which cover their medical care costs, if applicants meet the eligibility criteria, which are decided individually for each patient by the institution. Institutions can earn the benefits of tax exemptions depending on the proportion of patients who use their FLCMC program. Thus, we can regard PA recipients as impoverished people benefited by minimum income protection and livelihood including medical care costs, while FLCMC recipients as financially restricted people who are benefited only by medical care costs.

Previous global studies have shown that recipients of PA have more unfavorable health conditions when compared to general populations [15]. For example, PA recipients are more likely to have diabetes [16], depressive symptoms[17], and suicidal ideation/behavior[18]. Similarly, recipients of FLCMC in Japan are more likely to have lower health-related quality of life (HRQOL) [19–21]. These previous studies were reported using pre- COVID-19 pandemic data. Although the health impacts of the pandemic has been larger among low-income populations [9, 22], there are no studies investigating impact of welfare services on low-income people, who might receive protective health effects.

Therefore, the purpose of this study was to compare the changes in HRQOL during the COVID-19 pandemic among low-income patients on PA, FLCMC, and the general population, using the data of repeated cross-sectional surveys in Kyoto, Japan.

Data and design of the study

We used repeated cross-sectional data obtained from adult patients on FLCMC and PA programs who were registered at the Kamigyo clinic in Kyoto, Japan. For a comparison of the recipients of FLCMC and PA, we randomly sampled patients who were not receiving social welfare programs (general population). People not on social welfare services were randomly selected from the outpatients list of each year (1637 patients in 2018 and 1742 patients in 2021), by using the random function of Microsoft Excel for Mac (ver.16.54). We sampled the patients without social welfare services as much as recipients of FLCMC. We collected the repeated data at the two time points of 2018 (before COVID-19), and 2021 (during COVID-19). We performed the self-questionnaire survey about patients’ socioeconomic attributes and the HRQOL using the Japanese version of Medical Outcomes Study 12-Item Short Form Health Survey (SF-12) [23]. An anonymous questionnaire survey was conducted by mail. A reply envelope was enclosed and the postage was borne by the facility. We excluded participants who have missing data in the variables used in this study (Fig. 1).

Variables

Outcome variables. We used the HRQOL scores to determine the outcomes. The SF-12 comprises three subscales, the physical health component summary score (PCS), the mental health component summary score (MCS), and the role-social component summary score (RCS). In this study, these subscales were measured using the scoring method, based on a large-scale population study in Japan [23].

Explanatory variables. We used the variable of availing status of welfare services (FLCMC, PA, and no welfare services) and the year (2018/2021).

Covariates. We used sex (male/female), age (continuous), household composition (living alone or not), and working status (working or not).

Statistical analysis

First, we described the characteristics of the study participants in two-time survey across the availing statuses of social welfare services. Second, we performed univariable linear regression analysis, and multiple linear regression analysis adjusting for the covariates to calculate crude and multivariable-adjusted coefficients of the changes in HRQOL scores and the 95% confidence interval (CI) of explanatory variables. In addition, we included an interaction term of availing status of social welfare services and year variable in multiple regression analyses to investigate the heterogeneity of changes in HRQOL scores by welfare service recipients before and after the COVID-19 pandemic. We used robust standard error estimator in all regression analyses to control the influence of clustered data derived from the study participants in single-center. All analyses were performed using STATA MP Ver.17 (Stata Corp., College Station, TX, USA)

Ethical Considerations

All study participants provided informed consent. This study protocol was approved by the Ethics Committee of the Kyoto Min-iren Chuo Hospital (Approval No: 124).

From the 2018 data, 226 patients on FLCMC, 185 patients on PA, and 226 patients without welfare services were included in the study and, from 2021 data, 253 patients on FLCMC, 161 patients on PA, and 300 patients without welfare services were included. The response rates were 42.9% in the FLCMC group, 22.2% in the PA group and 38.1% in the no welfare services group in 2018, and 33.6% in the FLCMC group, 34.2% in the PA group and 31.3% in the no welfare services group in 2021.

Among the participants in 2018, a total of 200 patients’ data (excluding missing) was obtained. Among them, 86 (43.0%) patients were on FLCMC, and 31(15.5%) patients were on PA. Among the participants in 2021, a total of 174 patients’ data (excluding missing) was obtained. Among them, 83 (37.9%) patients were on FLCMC, 37 (21.3%) patients were on PA. The mean scores of PCS and RCS were lower among recipients of FLCMC and PA than those without welfare services in both 2018 and 2021 (Table 1). The mean scores of MCS were lower among recipients of FLCMC and PA than patients without welfare services in only 2021 (Table 1).

Table 1

Baseline characteristics of study participants availing welfare services by year
	2018 (n = 200)			2021(n = 174)
	FLCMC (n = 86)	PA (n = 31)	No welfare services (n = 83)	FLCMC (n = 66)	PA (n = 37)	No welfare services (n = 71)
HRQOL scores (Mean, SD)
PCS	36.5, 14.5	34.3, 15.6	42.4, 12.8	36.5, 17.5	36.4, 12.7	44.3, 13.6
MCS	51.8, 12.0	51.0, 12.4	52.0, 8.3	48.8, 8.3	46.6, 9.5	51.1, 8.6
RCS	43.1, 13.6	39.3, 13.2	46.3, 11.8	41.7, 13.9	37.7, 13.5	44.1, 10.9
Age (Mean, SD)	73.3, 12.9	69.2, 12.9	72.8, 11.9	74.5, 13.4	69.7, 11.2	70.0, 11.1
Sex
Male	44	16	36	32	22	32
Female	42	15	47	34	15	39
Household composition
Living alone	33	22	23	23	32	16
Not living alone	53	9	60	43	5	55
Working status
Working	24	4	33	19	3	29
Not working	62	27	50	47	34	42
SD: standard deviation, FLCMC: Free/ Low-Cost Medical Care Program, PA: Public Assistance, PCS: Physical Component Summary, MCS: Mental Component Summary, RCS: Role-social Component Summary.

The univariable linear regression analysis showed that use of social welfare services (both PA and FLCMC) were inversely associated with PCS, MCS and RCS scores (Table 2). In the year of 2021, MCS and RCS scores were lower when compared with the year of 2018 (Table 2). The results of multiple linear regression showed that adjusted coefficients scores of PCS, MCS, and RCS were lower in FLCMC recipients than patients not using welfare services (PCS − 5.27, 95% CI -9.34 to -1.20; MCS − 0.51, 95% CI -3.58 to 2.56; RCS − 3.12, 95% CI -6.81 to 0.57). Also, among the PA recipients, scores in PCS, MCS and RCS were lower than patients not using welfare services (PCS − 7.33, 95% CI -11.46 to -3.19; MCS − 2.88, 95% CI -6.24 to 0.47; RCS − 7.63, 95% CI -11.52 to -3.74) (Table 2).

Table 2

Results of univariable and multivariable regression analysis on HRQOL scores of study participants.
	PCS			MCS			RCS
	Coef.	95% CI		Coef.	95% CI		Coef.	95% CI
Univariable Regression
Explanatory Variable
Use of welfare services (Ref: not using)
FLCMC	-6.75	-10.03	-3.47	-2.00	-4.18	0.18	-2.80	-5.64	0.03
PA	-7.80	-11.74	-3.86	-2.99	-5.93	-0.04	-6.89	-10.53	-3.25
Year (Ref: 2018)
2021	1.05	-1.99	4.10	-3.22	-5.21	-1.23	-2.04	-4.67	0.59
Covariates
Male (Ref: female)	0.86	-2.15	3.88	-1.38	-3.40	0.65	-1.35	-3.98	1.27
Age (continuous)	-0.37	-0.48	-0.26	0.16	0.08	0.24	-0.17	-0.28	-0.05
Working (Ref: not working)	-6.97	-10.07	-3.88	1.08	-1.00	3.16	-5.78	-8.41	-3.15
Living alone (Ref: not living alone)	3.68	0.60	6.75	0.27	-1.81	2.35	0.44	-2.26	3.14
Multivariable Regressions
Explanatory Variable
Use of welfare services (Ref: not using)
FLCMC	-5.55	-8.79	-2.32	-2.61	-4.79	-0.44	-2.55	-5.34	0.23
PA	-7.33	-11.46	-3.19	-2.88	-6.24	0.47	-7.63	-11.52	-3.74
Year (Ref: 2018)
2021	0.97	-1.89	3.84	-3.09	-5.04	-1.14	-1.87	-4.42	0.68
Covariates
Male (Ref: female)	0.92	-1.86	3.69	-1.83	-3.81	0.15	-1.71	-4.31	0.88
Age (continuous)	-0.34	-0.46	-0.22	0.16	0.07	0.25	-0.13	-0.26	-0.01
Working (Ref: not working)	-1.78	-5.19	1.64	0.03	-2.37	2.43	-3.36	-6.37	-0.35
Living alone (Ref: not living alone)	1.16	-1.84	4.17	-0.49	-2.78	1.80	-2.63	-5.42	0.15
HRQOL: Health-Related Quality of Life, 95% CI: 95% Confidence Interval, FLCMC: Free/ Low-Cost Medical Care Program, PA: Public Assistance, PCS: Physical Component Summary, MCS: Mental Component Summary, RCS: Role-social Component Summary.

The multiple regression with an interaction model (use of welfare services and year) showed that the decline in MCS scores in 2021 was significantly larger among FLCMC recipients (-4.71, 95% CI -8.92 to -0.51) when compared with patients without welfare services. Similarly, the decline in MCS scores in 2021 among PA recipients was tended to be larger when compared with patients without welfare services (-4.27, 95% CI -10.05 to -1.51) (Table 3).

Table 3

Results of multivariable regression analysis on HRQOL scores of study participants: An interaction model.
	PCS			MCS			RCS
	Coef.	95% CI		Coef.	95% CI		Coef.	95% CI
Explanatory Variable
Use of welfare services (Ref: not using)
FLCMC	-5.27	-9.34	-1.20	-0.51	-3.58	2.56	-3.12	-6.81	0.57
PA	-8.24	-14.17	-2.31	-0.79	-5.56	3.99	-7.87	-13.07	-2.67
Year (Ref: 2018)
2021	0.90	-3.22	5.03	-0.40	-3.19	2.38	-2.47	-5.95	1.01
Use of welfare services (Ref: not using) × Year (Ref: 2018)
FLCMC × 2021	-0.64	-7.01	5.73	-4.71	-8.92	-0.51	1.27	-4.30	6.84
PA × 2021	1.80	-5.94	9.54	-4.27	-10.05	1.51	0.50	-6.72	7.71
Covariates
Male (Ref: female)	0.96	-1.82	3.74	-1.83	-3.80	0.15	-1.73	-4.33	0.87
Age (continuous)	-0.34	-0.46	-0.22	0.17	0.07	0.26	-0.14	-0.26	-0.01
Working (Ref: not working)	-1.80	-5.23	1.62	-0.05	-2.45	2.35	-3.34	-6.35	-0.32
Living alone (Ref: not living alone)	1.24	-1.78	4.26	-0.57	-2.86	1.72	-2.64	-5.45	0.17
HRQOL: Health-Related Quality of Life, 95% CI: 95% Confidence Interval, FLCMC Free/ Low-Cost Medical Care Program, PA Public Assistance, PCS Physical Component Summary, MCS Mental Component Summary, RCS Role-social Component Summary.

Our study found that low-income patients on FLCMC and PA had lower PCS and RCS scores than general population, both before and after the pandemic. Additionally, MCS scores in 2021 among FLCMC and PA recipients have declined from before pandemic when compared with general population. Especially, a significant decline was observed among FLCMC recipients. The strength of this study was that by using baseline data in 2018, we could evaluate the changes of health status before and after the COVID-19 pandemic among the low-income patients on social welfare services.

Findings in context

Our results indicating lower PCS scores among PA and FLCMC recipients were consistent with previous studies which were reported before COVID-19 pandemic [19–21]. Our study added the knowledge that existing evidence can also be applied to low-income social welfare recipients during COVID-19 pandemic. The findings that the RCS scores were lower among both PA and FLCMC recipients may be due to social isolation among these population. Previous literatures have shown that both PA and FLCMC recipients tend to live alone and to have fewer opportunities of interpersonal exchange[19, 20, 24]. The psychological strain by COVID-19 pandemic to socially vulnerable population may probably explains the decline in MCS scores among FLCMC and PA recipients [25, 26]. Particularly, significant decline in FLCMC recipients can be explained by lack of minimum income protection (FLCMC recipients are supported only medical costs) while PA recipients were protected by both minimum income and medical services by livelihood and medical assistance programs[27, 28].

Practice and policy implications

Our study provided novel evidence that the score of MCS declined among FLCMC and PA recipients. Organizations involved in the support for these population such as medical institutions and welfare offices should consider interventions that can maintain mental health among these low-income social welfare recipients. For example, it has been reported that community-based activities providing simultaneous medical and social care for socially vulnerable people can improve mental health and well-being among socially vulnerable populations [29, 30]. The findings of significant decline of MCS scores among FLCMC recipients suggested that social care including financial support for their livelihood might be important to maintain mental health for impoverished population [28].

Limitations

Our study had several limitations. First, the response rates among each population were low (42.5% in total) and we conducted complete case analyses, the findings in this study may be biased. The response rates and missing proportion were different across the study subpopulation, this may induce an additional bias. Second, because the study design was repeated cross-sectional study, the patients investigated in 2018 and 2021 were not always consistent. Third, the income level of general population was not considered. Finally, generalizing the data obtained from this study may be limited because this study used data from a single healthcare institution in Kyoto.

Low-income patients on social welfare services had lower PCS and RCS scores and experienced decline in MCS scores during COVID-19 pandemic when compared with general population. A significant decline of MCS score was observed among FLCMC recipients in whom only medical costs was protected while there were no significant reduction of MCS score among PA recipients whose minimum income and medical costs were protected. To maintain mental health of low-income welfare recipients in communicable diseases pandemic, providing both medical and social care including financial livelihood support may be required.

COVID-19: Coronavirus disease 2019; CI: confidence interval; FLCMC: Free or Low-Cost Medical Care; PA: Public Assistance; PCS: Physical Component Summary; MCS: Mental Component Summary; RCS: Role-social Component Summary; QOL: Quality of life; HRQOL: Health related quality of life.

Ethics approval and consent to participate

The study protocol was approved by the Ethics Committee of the Kyoto Min-iren Chuo Hospital (Approval No: 124).

Consent to Publish

Not Applicable.

Availability of data and materials

The data used in this study were collected from patients of Kamigyo Clinic which are not publicly available. The data are available from the authors upon reasonable request, with the permission of the Kamigyo Clinic.

Competing interests

Satoshi Wakata, Daisuke Nishioka, and Yukio Takagi declare no competing interests associated with this manuscript.

Funding

This study was supported by the Japan network of Health Promoting Hospitals & Services grants (1750-0015) and the Japan Society for the Promotion of Science KAKENHI grants (grant numbers: 21K21127).

Authors’ contributions

SW and DN conceptualized the study design. SW recruited participants and collected data. SW and DN analyzed the data and prepared the manuscript. YT reviewed the manuscript. DN finalized the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We would like to thank Editage [http://www.editage.com] for editing and reviewing this manuscript.

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No competing interests reported.

Health-Related Quality of Life scores among low-income patients on Social Welfare Programs in Japan: A repeated cross-sectional study

Status:

Version 1

Abstract

Figures

Background

Methods

Data and design of the study

Variables

Statistical analysis

Ethical Considerations

Results

Discussion

Findings in context

Practice and policy implications

Limitations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1