Health inequality is one of the major challenges in public health (1). Targeting specific populations with socioeconomic difficulties has been considered as one of the methods to address health inequality (2). The Public Assistance program works as a safety net to ensure the minimum standard of living as well as to promote independence for all citizens living in poverty. Given that the COVID-19 pandemic has led to an increase in the number of people living in poverty, the importance of this program has increased.
In Japan, eligibility for receiving public assistance is judged by municipal welfare offices, using information on personal assets, ability to work, relatives’ financial support, and use of other welfare services. In September 2020, 1.63% of Japanese residences had received public assistance (3). Although the evaluation of the income provided by the recipient varies depending on the household conditions (e.g., the living area, the number of people in the household, and other sources of income among other conditions), this program provides assistance covering most of the necessities, such as livelihood assistance, education assistance, housing assistance, medical assistance, long-term care assistance, maternity assistance, occupational assistance, and funeral assistance. Thus, one of the specific features of this program is that the recipients are financially protected in addition to receiving free access to healthcare, while non-recipients with the same income need to pay for these necessities. On the other hand, recipients of public assistance might be socially isolated and/or exposed to social stigma (4–6). Since these factors are strongly related to mental health(7), social participation might play an important role in influencing recipients’ mental health.
A review of 32 papers summarized that poverty can be associated with mental illness (8). Another systematic review reported that recipients of public assistance had worse mental health than non-recipients in high-income countries (9). On the other hand, an empirical study has reported that housing assistance was associated with improved health and psychological well-being (10).
The Japanese government reported that recipients of public assistance were more likely to have a risk of mental health problems than non-recipients (11). They found that the prevalence of mental health problems was 16.4% among public assistance recipients, while prevalence among non-recipients was 2.5% (11). In addition, a demographic survey showed that public assistance recipients had a higher risk of carrying out deliberate self-harm behaviors compared to non-recipients (12). These reports, however, did not consider influence of possible confounders (such as household income and comorbidity), and demographic factors which are well-known health risk factors (such as age, gender, marital status, and education). Therefore, it is not clear whether this difference in mental health is due to the participants’ income levels, or because of other socioeconomic and psychosocial factors associated with being a recipient of public assistance program (i.e., social isolation and social stigma).
Furthermore, a review study reports that few studies have focused on health of older public assistance recipients (13). In Japan, the majority of public assistance recipients are older people (55.5%) (3), and medical assistance occupies the largest portion of the public assistance budget (48.6%) (14). Furthermore, medical expenditure is significantly higher among the recipients of public assistance compared to the patients using universal public health insurance (15), and the recipients of public assistance have a higher risk of frequent outpatient attendance (16). These studies indicate that other negative factors might be contributing to public assistance recipient’s unhealthy behaviors or health conditions. Therefore, for sustainable public health programs, it would be unavoidable to consider role of additional factors in effecting health of older recipients of public assistance. In this study, we aimed to examine the relationship between receiving public assistance and depressive symptoms among older Japanese adults.