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Objectives: Exemption from paying dental care costs among recipients of public assistance contributes to universal health care coverage. Although this system might reduce the financial barriers to dental care among patients, there are still several other barriers for public assistance recipients. Therefore, this study examined whether receiving public assistance was associated with a higher prevalence of dental visits for any reason, treatment and prevention. Methods: Data were obtained from 16 366 respondents from the 2019 wave of a nationwide cohort study on older adults in Japan. Poisson regression analyses with robust error variance were used to examine the associations between receiving public assistance and dental visits, adjusting for number of teeth, dental pain, periodontal conditions, age, sex, number of family members, education, equivalent household income, working status, instrumental activities of daily living, medical conditions, depressive symptoms, instrumental support and geographical variations. Results: More than half of the non‐recipients of public assistance visited a dentist for some reason in the past 6 months. Meanwhile, only 37% of the recipients visited a dentist. In addition, almost half of the non‐recipients had treatment visits, while only 34% of the recipients visited. Furthermore, 46% of the non‐recipients had dental visits for prevention, while 32% of the recipients had preventive visits. In the fully adjusted models, compared to non‐recipients, public assistance recipients were 24% (Prevalence Ratio [PR]: 0.76, 95% Confidence Intervals [CI]: 0.64, 0.90), 23% (PR: 0.77, 95% CI: 0.65, 0.92) and 21% (PR: 0.79, 95% CI: 0.65, 0.95) less likely to have dental visits for any reason, treatment, and prevention, respectively. Conclusions: Although recipients were exempted from dental treatment fees, receiving public assistance was associated with a lower prevalence of dental visits for any reason, treatment and prevention. Future studies should identify the barriers to accessing dental care among public assistance recipients to improve dental visits. [ABSTRACT FROM AUTHOR]

Background: Public assistance programs aim to prevent financial poverty by guaranteeing a minimum income for basic needs, including medical care. However, time poverty also matters, especially in the medical care adherence of people with chronic diseases. This study aimed to examine the association between the dual burden of working and household responsibilities, with unscheduled asthma care visits among public assistance recipients in Japan. Methods: This retrospective cohort study included public assistance recipients from two municipalities. We obtained participants' sociodemographic data in January 2016 from the public assistance database and identified the incidence of asthma care visits. Participants' unscheduled asthma visits and the frequency of asthma visits were used as the outcome variables. Unscheduled visits were defined as visits by recipients who did not receive asthma care during the first three months of the observation period. Participants' age, sex, household composition, and work status were used as explanatory variables. Multiple Poisson regression analyses were performed to calculate the cumulative incidence ratio (IR) with a 95% confidence interval (CI) of unscheduled visits across the explanatory variables. The effect of modification on the work status by household composition was also examined. Results: We identified 2,386 recipients at risk of having unscheduled visits, among which 121 patients (5.1%) had unscheduled visits. The multivariable Poisson regression revealed that the working recipients had a higher incidence of unscheduled visits than the non-working recipients (IR 1.44, 95% CI 1.00–2.07). Among working recipients, the IRs of unscheduled visits were higher among recipients cohabiting with adults (IR 1.90 95% CI 1.00–3.59) and with children (IR 2.35, 95% CI 1.11–4.95) than for recipients living alone. Among non-working recipients, the IRs of unscheduled visits were lower for recipients living with family (IR 0.74, 95% CI 0.41–1.35) and those living with children (IR 0.50, 95% CI 0.20–1.23). A higher frequency in asthma visits was observed among working recipients living with family. Conclusions: Working adults cohabiting with children are at the greatest risk of unscheduled visits among adults receiving public assistance. To support healthy lifestyles of public assistance recipients, medical care providers and policymakers should pay special attention to the potentially underserved populations. [ABSTRACT FROM AUTHOR]

Whether national and local governments should assume larger financial responsibility for reducing disaster risk remains a controversial issue. Local governments lack resources to cover the full cost of managing mega-disasters and need assistance from higher level governments. However, national governments covering all costs may create moral hazards, discouraging local governments from investing in ex-ante measures. This study identifies national and local governments' fiscal responsibility determinants for disaster management. Despite the differences between the federal system in the US and the centralized system in Japan, the two countries' national governments share common practices. Both have continuously developed legislation to expand their financial responsibilities for relief and recovery efforts as disaster consequences have increased. We argue that despite major institutional differences in Japan's unitary and the US federal government systems, both have expanded the areas covered by national assistance along with the amount over time. These findings bring with them recommendations for governments in an era of increasing extreme weather events due to climate change. [ABSTRACT FROM AUTHOR]

Background: Low-income is one of the well-established determinants of people's health and health-related behavior, including susceptibility to the coronavirus disease 2019 (COVID-19) infection. Two social welfare services are available in Japan to support financial and medical care among low-income patients: Public Assistance (PA), which provide both minimum income and medical costs; and Free/Low-Cost Medical Care (FLCMC), wherein only medical costs were covered. In this study, changes in Health-Related Quality of Life (HRQOL) scores of low-income patients on PA and FLCMC, before and after COVID-19 pandemic, were described and compared against those that are not utilizing the said services (comparison group) to evaluate the contribution of social welfare services in protecting the HRQOL of the beneficiaries during the pandemic.Methods: We used repeated cross-sectional data of adult beneficiaries of FLCMC and PA, as well as 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 on patients' socioeconomic attributes and the Japanese version of Medical Outcomes Study 12-Item Short Form Health Survey (SF-12). The Japanese version of SF-12 can calculate the three components scores: physical health component summary (PCS), the mental health component summary (MCS), and the role-social component summary (RCS), which can be transformed to a 0-100 range scale with a mean of 50 and standard deviation of 10.Results: Data of 200 and 174 beneficiaries in 2018 and 2021, respectively, were analyzed. Low-income patients on social welfare services had lower PCS, and RCS than the comparison group in both years. Multiple linear regression analyses with cluster-adjusted standard error estimator showed that the decline in MCS was significantly higher among FLCMC beneficiaries than in those without welfare services (Beta: -4.71, 95% Confidence Interval [CI]: -5.79 to -3.63, p < 0.01), and a decline in MCS among PA recipients was also observed (Beta: -4.27, 95% CI: -6.67 to -1.87 p = 0.02).Conclusions: Low-income beneficiaries of social welfare may have experienced mental health deterioration during the COVID-19 pandemic. To maintain healthy lives during the pandemic, additional support on mental health for low-income recipients of social welfare services may be required. [ABSTRACT FROM AUTHOR]

Objective　Poverty is a significant health determinant. As public assistance recipients experience difficulties in health management, a healthcare management support program to provide health checks has been implemented by welfare offices in Japan since 2021. However, effective approaches to maximize health check rates are limited. This study aimed to identify the impact of telephone navigation on recipients' health check-receiving behaviors, using data from welfare offices in Toyonaka City.Methods　This study included recipients aged 40-60 years who received telephone navigation for health check programs in 2021 and 2022. In 2021, telephone navigation was provided to eligible recipients. In 2022, the recipients were divided into two groups based on their household identification numbers (even/odd). We examined the difference in the health check rate in 2021 depending on whether the navigation system was connected. Additionally, we examined the differences across groups and navigation periods in 2022.Results　In 2021, 32 (7.9%) recipients received health checks. Twenty-six (10.2%) of the 255 recipients and six (4.1%) of the 148 recipients in the navigated and non-navigated groups, respectively, underwent health checks. In the navigated group, health check rates were higher among recipients in their 50s (13.3% vs. 3.1%; P = 0.006), unemployed recipients (13.9% vs. 3.6%; P = 0.014), those who did not receive previous health checks (9.1% vs. 1.5%; P = 0.003), and those who did not receive regular medical consultations (8.3% vs. 0%; P = 0.012). In 2022, 247 and 225 patients were assigned to the odd- and even-numbered groups, respectively, with no differences in their characteristics. During the intervention period, four (1.6%) of the 247 recipients and 10 (4.6%) of the 219 recipients in the odd- and even-numbered groups, respectively, underwent health checks. During the non-intervention period, five (2.1%) and six (2.7%) recipients of the odd- and even-numbered groups, respectively, underwent health checks. Health check rates were higher toward the deadlines. The estimated conditional odds ratio for receiving the health checks by the navigation was 1.35 (95% confidence interval; 0.59-2.93, P = 0.503).Conclusion　Telephone navigation may be effective in some recipients. Meanwhile, targeting recipients with attributes, such as "in their 50s," "unemployed," "received no previous health checks," and "received no regular medical consultations" may increase the response rate. Therefore, policymakers should consider using reliable telephone navigation methods and navigating near deadlines.

Background: Mental health conditions among older recipients of public assistance should be considered because it has been reported that public assistance recipients tend to have higher risks of morbidity than non-recipients, and mental health is strongly related to frailty. We aimed to examine whether older recipients of public assistance were more likely to have depressive symptoms compared to non-recipients. Methods: Data were obtained from the Japan Gerontological Evaluation Study, a 2016 community-based study of older adults. Poisson regression analyses with a robust error variance using fixed effects were conducted to examine the relationship between receiving public assistance and depressive symptoms controlling for sociodemographic factors. Depressive symptoms were assessed by the Geriatric Depression Scale 15. Results: We found that the older recipients of public assistance were 1.57 times (95% confidence interval [CI]: 1.47, 1.67) more likely to have depressive symptoms compared to non-recipients. We also found that, when additionally adjusting for indicators of social participation, this relationship was slightly attenuated; however, the recipients still had worse mental health issues (Prevalence ratio: 1.33; 95% CI: 1.25, 1.42). Conclusions: Even after controlling for sociodemographic factors, older recipients of public assistance tended to be more depressed than non-recipients. However, our findings also indicated that social participation could slightly attenuate the negative relationship between receiving public assistance and depressive symptoms. Therefore, the public assistance program needs to consider the inclusion of mental healthcare support in addition to financial support. [ABSTRACT FROM AUTHOR]

Background: Maintaining oral health is one of the global public health challenges. Income and out-of-pocket payments for dental care services are predictors of dental care utilisation. Although public assistance programmes guarantee income security for impoverished people, access barriers other than financial costs may cause unmet dental care needs. We aimed to explore the potential sociodemographic factors determining dental care utilisation among recipients of public assistance in Japan using linkage data of public assistance database and medical assistance claim data administered by municipalities. Methods: This was a retrospective cohort study involving a sample of public assistance recipients. We extracted the recipients' sociodemographic data (age, sex, household number, employment status, nationality, disability certificates, and long-term care status) in January 2016 and observed them until December 2016 to identify incidences of dental care utilisation as outcomes. We performed a multivariable modified Poisson regression analysis with a robust standard error estimator to calculate the incidence ratio (IR) of dental care utilisation in each variable. Results: We identified a total of 4497 recipients at risk. Among them, 839 recipients used dental care services. Younger age was associated with a higher incidence of dental care utilisation. The female recipients had a higher incidence of dental care utilisation when compared to the male ones (adjusted IR, 1.22; 95% confidence interval [CI], 1.08–1.38). Immigrant recipients had a higher incidence of dental care utilisation than the Japanese ones (IR, 1.53; 95% CI, 1.16–2.01). Recipients with mental disabilities had higher incidences than those without disability certificates (IR, 1.30; 95% CI, 1.08–1.56). Conclusions: Non-financial sociodemographic inequities in dental care utilisation stemming from age, sex, nationality, and presence of mental disability were found despite minimum income protection and equitable financial dental service access amongst public assistance recipients in Japan. Providing targeted preventive care and treatments for dental care among underserved populations is required to tackle oral health inequities. [ABSTRACT FROM AUTHOR]

Aims/Introduction: Poverty is an important social determinant of diabetes. Poverty is a multidimensional concept including non‐financial difficulties, such as social isolation and exclusion from communities. Many countries provide financial social assistance programs for those in need. This study aimed to explore non‐financial social determinants of diabetes among public assistance recipients in Japan, by using linkage data of two municipal public assistance databases and medical assistance claim data. Materials and Methods: We carried out a retrospective cohort study. Public assistance is provided to households below the poverty line to ensure their income security. We extracted recipients' sociodemographic factors of January 2016 (household number and employment status as non‐financial social determinants of diabetes) and identified the incidence of diabetes diagnosis until December 2016 as the outcome. Results: We included the data of 2,698 younger individuals (aged <65 years) and 3,019 older individuals (aged >65 years). A multivariable Poisson regression, with a robust standard error estimator, showed that among 2,144 younger recipients at risk, unemployment and living alone were slightly associated with 1‐year cumulative incidence of diabetes diagnosis (adjusted incidence ratio 1.20, 95% confidence interval 0.93–1.54 and adjusted incidence ratio 1.15, 95% confidence interval 0.89–1.48, respectively). Among 2,181 older recipients at risk, there was no strong association between their sociodemographic factors and incidence of diabetes diagnosis. Conclusions: Unemployment and living alone might be additional risk factors for diabetes among younger public assistance recipients. Multidimensional supports assuring financial and non‐financial securities are required to prevent diabetes among people living in poverty. [ABSTRACT FROM AUTHOR]

Background: Children's healthy development is important. While governmental public assistance benefits financially troubled families, it cannot compensate for a lack of social support. Single-parenthood is a health risk factor for children owing to low-income-associated food insecurity and stress. No study has investigated the association between single-parenthood and health status in children from families receiving public assistance. This study aimed to examine the association between single-parent households and children's health among public assistance recipients in Japan by using linkage data of two municipal public assistance databases and administrative medical assistance data.Methods: We performed a retrospective cohort study. Public assistance for households below the poverty line ensures income security and medical care. The study population included all children aged 15 or younger availing public assistance in January 2016. We extracted recipients' sociodemographic factors from January 2016 and identified the incidence of childhood diseases' diagnosis until December 2016 as the outcome, including 1) acute upper respiratory infections; 2) influenza and pneumonia; 3) injuries, including fractures; 4) intestinal infectious diseases; 5) conjunctivitis; 6) asthma; 7) allergic rhinitis; 8) dermatitis and eczema, including atopic dermatitis; and 9) diseases of the oral cavities, salivary glands, and jaws, such as tooth decay or dental caries.Results: Among the 573 children, 383 (66.8%) lived in single-parent households. A multivariable Poisson regression, with a robust standard error estimator, showed that single-parenthood is associated with a higher prevalence of asthma (incidence ratio [IR] = 1.62; 95% confidence interval [CI], 1.16-2.26), allergic rhinitis (IR = 1.41; 95% CI, 1.07-1.86), dermatitis and eczema (IR = 1.81; 95% CI, 1.21-2.70), and dental diseases (IR = 1.79; 95% CI, 1.33-2.42) compared to non-single parent households, whereas little association was found between single-parenthood and children's acute health conditions.Conclusions: Among public assistance recipients, living in single-parent households may be a risk factor for children's chronic diseases. The Japanese public assistance system should provide additional social care for single-parent households. Further investigations are necessary using more detailed longitudinal data, including environmental factors, the severity of children's health conditions, contents of medical treatments, and broader socioeconomic factors. [ABSTRACT FROM AUTHOR]

Public assistance is one option for providing a safety net to protect the health of children, but assistance may also generate feelings of shame that impact self-esteem. This study aims to elucidate the impact of public assistance on child mental health. We used cross-sectional data on 6920 first graders from the Adachi Child Health Impact of Living Difficulty (A-CHILD) study. We found children living in relative poverty had more behavioral problems, low resilience, and were likely to refuse to go to school. After propensity-score matching among low-income households, the likelihood of children refusing to go to school was larger in the families receiving assistance as compared to non-recipients (OR 4.00, 95% CI 0.85-18.84) although there were no significant differences between recipients and non-recipients in low-income households. Our study produced insufficient evidence to indicate that social assistance is associated with child mental health, resilience, or school refusal. [ABSTRACT FROM AUTHOR]

For this paper we apply the framework of resilience as an adaptive process to examine alternative practices that assist socially vulnerable populations into the urban fabrik. The recent direction of Osaka’s inner city rental housing market for public assistance recipients is used as case study. We look on systemic aspects such as changing tenant revenues and welfare policies, and analyze the innovative housing reuse practices of local landlords and real estate agents. Our results show that the resilience-producing systemic properties are co-produced by public assitance policies, the particular condition of Osaka’s inner city and individual stakeholders' actions. While these stakeholders have benefited immensely from the housing market’s resilient response, it is structured by uneven dependencies, which ultimately affects the housing opportunities and care services for current and future tenants. [ABSTRACT FROM AUTHOR]

Abstract: Forecasting welfare caseloads has grown in importance in Japan because of their recent rapid increase. Given that the forecasting literature on welfare caseloads only focuses on US cases and utilizes limited classes of forecasting models, this study employs multiple alternative methods in order to forecast Japanese welfare caseloads and compare forecasting performances. In pseudo real-time forecasting, VAR and forecast combinations tend to outperform the other methods investigated. In real-time forecasting, however, a simple version of forecast combinations seems to perform better than the remaining models, predicting that welfare caseloads in Japan will surpass 1.7 million by the beginning of 2016, an approximately 20% increase in five years from the beginning of 2011. [Copyright &y& Elsevier]

In recent years, Japan has pursued two paths to deal with the growing number of welfare recipients: ‘second safety net programs’ that pre-empt reliance on the public assistance system and ‘self-reliance programs’ for current public assistance recipients. This paper examines the effectiveness of these programs. Its findings suggest that the relationship between social work practice and the success of poverty measures should be explored further. It is necessary to develop a methodology to evaluate the efficacy of social work practices in reducing poverty and social exclusion. [ABSTRACT FROM AUTHOR]

In countries where local governments are heavily involved in financing health care for the indigent, regional disparities in local revenues may adversely affect the access of the poor to medical care. It is thus important to examine how central governments provide funds for such local medical needs. In Japan, local governments finance all medical costs for the poor through their Public Assistance (PA) programs. Using the unique mechanism of the Japanese system of central grants, I construct a measure of 'transfer deficit' which shows the portion of the PA expenditures that fails to be secured by the central grants. The distribution of such a measure provides important information to assess the regional equity in financing local programs. The results suggest a compromise on the regional equity in financing medical care for the indigent. Then, I explore the determinants of the deficit measure by performing a quantile regression analysis. Since no effects of potential determinants imply that the central grants well accommodate changes in local needs, finding such effects helps evaluate the performance of the transfer system. The results shows that, among others, the number of PA households and the factors related to mental illness of PA recipients have positive impacts that attenuate toward the top of the conditional quantile of the transfer deficit. I elaborate on plausible causes of such attenuating responses. [ABSTRACT FROM AUTHOR]

• We examined factors governing commencement and termination of public assistance. • Higher perception of mutual help is a predictor of initiation of public assistance. • Higher attachment to community is a predictor of termination of public assistance. • Social role in community is a predictor of termination of public assistance. • Psychosocial factors are key to accessing and terminating public assistance. Public assistance programs guarantee a minimum living standard, promoting independence for impoverished citizens. Although public assistance eligibility is mainly based on economic factors like poverty, psychosocial factors may be important in initiating and terminating participation. We explored factors governing commencement and termination of public assistance by the older Japanese population between 2013 and 2016. We used panel data from the Japan Gerontological Evaluation Study (JAGES), conducted in 2013 and 2016. Fixed-effects regression was used to examine variables in 2013 that were related to receiving public assistance in 2016. The Tokyo Metropolitan Institute of Gerontology -competence index (TMIG-CI) was used to assess higher-level activities of daily living (ADL, i.e., instrumental ADL, intellectual activity, and social role). The role of individual perceptions of community social cohesion (community trust, mutual help, and attachment), and sociodemographic factors were considered. While 215 people (0.5%) started receiving public assistance between 2013 and 2016, almost 50% stopped participating. People with higher perceived mutual community help were 1.21 times (95% confidence interval [CI]: 1.02–1.46) more likely to commence public assistance three years later. Public assistance recipients who felt community attachment to their resident community, and had social roles were 1.16 (95% CI: 1.06–1.28) and 1.15 (95% CI: 1.01–1.30) times more likely to give up public assistance three years later, respectively, independent of socioeconomic statuses. Psychosocial factors, including maintaining good relationships with community residents, could be important in accessing and terminating public assistance services. [ABSTRACT FROM AUTHOR]

As part of research into the perceptions of poverty in Japan, the current paper examines perceptions on the part of poor single mothers and suggests issues for future research. The survey revealed that even single mothers receiving welfare benefits tended not to perceive poverty as an immediate issue, but rather to see it as a more marginal issue, i.e., as ‘someone's’ problem ‘somewhere.’ Major factors behind the hesitation in directly calling for broader attention to their own problems included the following: (1) not having the time in their daily lives, (2) bias in the information they get, (3) the lack of direct connection between policy and their lives, and (4) not knowing who to call out to. In addition to feeling a sense of resignation and the sense that they have no choice but to treat their problem as a matter of personal responsibility, it was also found that the women had unconsciously developed coping strategies and attitudes designed to avoid criticism from those around them, such as purposefully acting with reserve or thinking it better not to vocally address the issue of poverty. For their small voices to reach the larger society, it is necessary for each and every one of us to turn our attention in a conscious effort to all aspects of the lives of people living in poverty. With regard to perceptions of poverty on the part of social workers, who are in a position to speak on behalf of the poor, it is necessary to focus on the gap in their respective value systems between those giving assistance and those receiving it. [ABSTRACT FROM AUTHOR]

This article examines inequality and poverty among older people in Japan. It compares Japan with that of a sample of other OECD coun- tries. Provisions within the social insurance system that enable old-age pensioners to work and draw incomes from labor explain some of the inequality and poverty that is seen in Japan. So, too, do the low rate of take up of social assistance, the low level of benefits available from the first tier pension, the uneven coverage of second-tier pensions, the lack of progressiveness of the income tax system and the fact older people live in multi-generational households whilst others live alone. [ABSTRACT FROM AUTHOR]

The public assistance system in Japan provides detailed and comprehensive livelihood support for low-income families with various needs. As one example, and the beneficiaries of the public welfare program in Japan can receive the same medical treatments as those insured of the universal public health insurance without any financial burdens. This system has greatly contributed to maintaining and improving the health of public assistance beneficiaries but may cause excessive healthcare utilization: moral hazard. This study uses a large sample taken from two nationally representative claim data for public assistance and public health insurance patients to estimate the magnitude of moral hazard effect in basic outpatient utilization. The results of the fixed-effect regression analysis utilizing the concept of pseudo panel data analysis and those of propensity score matching show that the average treatment effect of public assistance assignment on healthcare utilization is significantly positive. Specifically, public assistance assignment increases monthly healthcare expenditure by 17.5 to 22.9 percent and the monthly number of doctor visits by 23.1 to 27.8 percent, respectively. In addition, the average treatment effects on the treated are also significantly positive, suggesting that monthly healthcare expenditure significantly decreases by 22.7 to 25.0 percent and the number of visits by 27.6 to 29.7 percent, respectively, when imposing a copayment on public assistance beneficiaries. However, the estimated price elasticity based on these results is very small, approximately -0.02, indicating that the level of copayment rate has little effect on the intensive margin of outpatient healthcare utilization., Competing Interests: The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Yuda.)

Objectives: Although several individual risk factors of frequent outpatient attendance (FOA) have previously been reported, identifying a specific risk profile is needed to provide effective intervention for impoverished citizens with complex biopsychosocial needs. We aimed to identify potential risk profiles of FOA among public assistance recipients in Japan by using classification and regression trees (CART) and discussed the possibilities of applying the CART to policypractice as compared with the results of conventional regression analyses., Design: We conducted a retrospective cohort study., Setting: We used secondary data from the public assistance databases of six municipalities in Japan., Participants: The study population included all adults on public assistance in April 2016, observed until March 2017. We obtained the data of 15 739 people on public assistance. During the observational period, 435 recipients (2.7%) experienced FOA., Outcome Measure: We dichotomised a cumulative incidence of FOA during the study period into a binary variable of exhibiting FOA or not. We adopted the definition of FOA by the Ministry of Health, Labour, and Welfare: visiting the same medical institution more than 15 days a month., Results: The results of the CART showed that an employed subpopulation with mental disabilities exhibited the highest risk of FOA (incidence proportion: 16.7%). Meanwhile, multiple Poisson regression showed that the adjusted incidence ratio of being unemployed (vs employed) was 1.71 (95% CI 1.13 to 2.59)., Conclusions: Using the CART model, we could identify specific risk profiles that could have been overlooked when considering only the risk factors obtained from regression analysis. Public health activities can be provided effectively by focusing on risk factors and the risk profiles., Competing Interests: Competing interests: Daisuke Nishioka, Shiho Kino, and Keiko Ueno declare no competing interests associated with this manuscript. Naoki Kondo conducted collaborative research with Kitanihon Computer Service Co. (KITACOM), from where the data used in the present paper were obtained. Naoki Kondo received a research fund and a scholarship donation from KITACOM. The research funding bodies had no discretion and involvement in our study protocol, analysis, interpretation of the results, or the submission of this manuscript., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Public assistance recipients in Japan are financially empowered by social welfare but are also exposed to social stigma. Therefore, when their status of receiving public assistance changes, the conditions of their social life likely change. We examined whether the social relationships of older adults receiving public welfare are influenced by either starting or terminating their use of public assistance. This study used the Japan Gerontological Evaluation Study panel data from 2013 to 2016. To measure social relationships, we used four indicators: the frequency of meeting with friends, the number of friends whom the participants had met with in the past month, their frequency of participating in sports clubs, and their frequency of participating in hobby clubs. In the analyses, changes in social relationships between 2013 and 2016 were used as the study outcomes. Linear regression analyses were conducted to examine if their social relationships changed before and after starting or terminating public assistance while adjusting for confounders. We found that people who stopped receiving public assistance experienced an increase in their frequency of meeting with friends (coefficient: 0.56; 95% CI: 0.06, 1.07), the number of friends (coefficient: 0.60; 95% CI: 0.20, 0.99), participation in sports clubs (coefficient: 0.91; 95% CI: 0.46, 1.39), and participation in hobby clubs (coefficient: 0.70; 95% CI: 0.26, 1.13) compared to those who continued to receive public assistance. Contrarily, the measured social relationships did not change after the participants started receiving public assistance. Our main findings were that terminating one's reception of public assistance increases informal socializing and social participation while starting public assistance does not interrupt pre-existing relationships. These findings contribute to the literature by adding that social relationships are not negatively influenced by either terminating or starting public assistance. Targeted promotions of social connections would effectively maintain the health statuses of low-income older adults. • People who stop receiving public assistance more frequently meet with friends. • When people stop receiving public assistance, their number of friends increases. • People participate more frequently in social clubs once they stop receiving welfare. • Starting to receive public welfare does not impact one's pre-existing. [ABSTRACT FROM AUTHOR]

Background: Recognising the importance of the social determinants of health, the Japanese government introduced a health management support programme targeted at type 2 diabetes (T2D) for public assistance recipients (PAR) in 2018. However, evidence of the T2D prevalence among PAR is lacking. We aimed to estimate T2D prevalence by age and sex among PAR, compared with the prevalence among health insurance enrollees (HIE). Additionally, regional differences in T2D prevalence among PAR were examined., Methods: This was a cross-sectional study using 1-month health insurance claims of both PAR and HIE. The Fact-finding Survey data on Medical Assistance and the National Database of Health Insurance Claims data were used. T2D prevalence among PAR and HIE were assessed by age and sex, respectively. Moreover, to examine regional differences in T2D prevalence of inpatients and outpatients among PAR, T2D crude prevalence and age-standardised prevalence were calculated by prefecture. Multilevel logistic regression analysis was also conducted at the city level., Results: T2D crude prevalence was 7.7% in PAR (inpatients and outpatients). Among outpatients, the prevalence was 7.5% in PAR and 4.1% in HIE, respectively. The mean crude prevalence and age-standardised prevalence of T2D (inpatients and outpatients) among 47 prefectures were 7.8% and 3.9%, respectively. In the city-level analysis, the OR for the prevalence of T2D by region ranged from 0.31 to 1.51., Conclusion: The prevalence of T2D among PAR was higher than HIE and there were regional differences in the prevalence of PAR. Measures to prevent the progression of diabetes among PAR by region are needed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Polypharmacy and multi-drug prescription are major public health problems in Japan, but only a few studies have investigated the regional differences. By revealing regional differences in the multi-drug prescriptions, we can infer regions with high rates of multimorbidity or inappropriate prescribing. This study revealed regional differences in multi-drug prescriptions (the number of simultaneous prescriptions of seven or more internal medicines) and investigated the factors affecting the difference using the National Database of Health Insurance Claims and Specific Health Checkups of Japan data., Results: The standardized claim ratio (SCR) of the number of multi-drug prescriptions, which corrected the difference in sex and age distribution of prefectures, varied depending on prefectures. A panel data analysis investigating the association between the SCR and explanatory variables (Medical institutions, socioeconomic factors, and physical characteristics of people in prefectures) revealed that the number of public assistance recipients per 1,000 persons was positively and significantly associated with the SCR (Standardized partial regression coefficient = 0.244, p-value = 0.038). In conclusion, regional differences in the number of the multi-drug prescriptions were revealed in Japan, suggesting that public assistance recipients tend to experience multi-drug prescriptions., (© 2021. The Author(s).)

Background: To reduce health disparities, prevention of non-communicable diseases (NCD) by performing desirable health behavior in older adults living alone with low socioeconomic status is an essential strategy in public health. Self-perception of personal power and practical skills for daily health are key elements of desirable health behavior. However, methods for measuring these concepts have not been established. This study aimed to develop a health behavior scale for older adults living alone receiving public assistance (HBSO)., Methods: The self-administered mail survey covered 2818 older adults living alone receiving public assistance (OAP) randomly selected from the list of people receiving public assistance (Seikatsu-hogo in Japanese) at all 1250 local social welfare offices across Japan. Construct validity was confirmed using confirmatory factor analysis. Internal consistency was calculated using Cronbach's alpha. The self-efficacy for health promotion scale and Health check-up status were administered to assess the criteria-related validity of the HBSO., Results: In total, 1280 participants (response rate: 45.4%) responded, of which 1069 (37.9%) provided valid responses. Confirmatory factor analysis identified 10 items from two factors (self-perception of personal power and practical skills for daily health) with a goodness of fit index of 0.973, adjusted goodness of fit index of 0.953, comparative fit index of 0.954, and root mean square error of approximation of 0.049. Cronbach's alpha was 0.75. The total HBSO score was significantly positively correlated with the self-efficacy for health promotion scale (r = 0.672, p < 0.001) and the group with health check-up had significantly higher HBSO scores than the group without it (p < 0.001)., Conclusions: The HBSO is an easy-to-self-administer instrument that is reliable and valid for OAP. The HBSO could facilitate appropriate assessment of OAP who need to improve their health behavior to prevent NCD, and could be used to determine effective support., (© 2021. The Author(s).)

Importance: Socioeconomic factors in the disparities in COVID-19 outcomes have been reported in studies from the US and other Western countries. However, no studies have documented national- or subnational-level outcome disparities in Asian countries., Objective: To assess the association between regional COVID-19 outcome disparities and socioeconomic characteristics in Japan., Design, Setting, and Participants: This cross-sectional study collected and analyzed confirmed COVID-19 cases and deaths (through February 13, 2021) as well as population and socioeconomic data in all 47 prefectures in Japan. The data sources were government surveys for which prefecture-level data were available., Exposures: Prefectural socioeconomic characteristics included mean annual household income, Gini coefficient, proportion of the population receiving public assistance, educational attainment, unemployment rate, employment in industries with frequent close contacts with the public, household crowding, smoking rate, and obesity rate., Main Outcomes and Measures: Rate ratios (RRs) of COVID-19 incidence and mortality by prefecture-level socioeconomic characteristics., Results: All 47 prefectures in Japan (with a total population of 126.2 million) were included in this analysis. A total of 412 126 confirmed COVID-19 cases (326.7 per 100 000 people) and 6910 deaths (5.5 per 100 000 people) were reported as of February 13, 2021. Elevated adjusted incidence and mortality RRs of COVID-19 were observed in prefectures with the lowest household income (incidence RR: 1.45 [95% CI, 1.43-1.48] and mortality RR: 1.81 [95% CI, 1.59-2.07]); highest proportion of the population receiving public assistance (1.55 [95% CI, 1.52-1.58] and 1.51 [95% CI, 1.35-1.69]); highest unemployment rate (1.56 [95% CI, 1.53-1.59] and 1.85 [95% CI, 1.65-2.09]); highest percentage of workers in retail industry (1.36 [95% CI, 1.34-1.38] and 1.45 [95% CI, 1.31-1.61]), transportation and postal industries (1.61 [95% CI, 1.57-1.64] and 2.55 [95% CI, 2.21-2.94]), and restaurant industry (2.61 [95% CI, 2.54-2.68] and 4.17 [95% CI, 3.48-5.03]); most household crowding (1.35 [95% CI, 1.31-1.38] and 1.04 [95% CI, 0.87-1.24]); highest smoking rate (1.63 [95% CI, 1.60-1.66] and 1.54 [95% CI, 1.33-1.78]); and highest obesity rate (0.93 [95% CI, 0.91-0.95] and 1.17 [95% CI, 1.01-1.34]) compared with prefectures with the most social advantages. Among potential mediating variables, higher smoking rate (RR, 1.54; 95% CI, 1.33-1.78) and obesity rate (RR, 1.17; 95% CI, 1.01-1.34) were associated with higher mortality RRs, even after adjusting for prefecture-level covariates and other socioeconomic variables., Conclusions and Relevance: This cross-sectional study found a pattern of socioeconomic disparities in COVID-19 outcomes in Japan that was similar to that observed in the US and Europe. National policy in Japan could consider prioritizing populations in socially disadvantaged regions in the COVID-19 response, such as vaccination planning, to address this pattern.

Background: An increase in the rate of relative poverty and the number of welfare recipients is a serious social problem in Japan. A recent overseas survey demonstrated that lack of health insurance was associated with increased in-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study is to investigate the clinical features of STEMI patients who receive welfare public assistance in Japan., Methods: We enrolled 525 STEMI patients who were hospitalized in our hospital from 2010 to 2019. We divided patients into groups of patients receiving welfare public assistance (WPA group, N = 67) and groups of patients not receiving welfare public assistance (non-WPA group, N = 458). Patient characteristics, clinical outcome, and cardiac function on transthoracic echocardiography were compared., Results: WPA group were younger than non-WPA group (61.2 ± 10.9 years VS 64.5 ± 13.3 years, p = 0.03). The prevalence of smoking was higher in WPA group compared to non-WPA group (91.0% VS 81.1% p = 0.04) and high-density lipoprotein cholesterol value of WPA group was lower than in non-WPA group (43.2 ± 9.9 mg/dl vs 47.1 ± 12.8 mg/dl, p = 0.005). Ventricular arrhythmia on admission was significantly more frequent in WPA group (11.9% VS 4.8%, p = 0.02). In acute and chronic phase, left ventricular ejection fraction in WPA group was lower than non-WPA group (in acute phase 46.6 ± 10.7% vs 53.3 ± 8.6% p = 0.001, in chronic phase 48.7 ± 10.1% vs 55.3 ± 9.4%, p = 0.008)., Conclusion: STEMI patients receiving welfare public assistance had poorer control of coronary risk, increased risk of fatal arrhythmia, and reduced systolic function than those not receiving welfare public assistance. It is necessary to have a system that can strengthen lifestyle management, such as diet and smoking cessation for the purpose of improving the prognosis of welfare recipients after AMI., (Copyright © 2020 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

The aim of this study was to clarify the risk factors for chlamydial infection and determine whether infection during pregnancy is associated with preterm birth in Japanese women. The subjects were women who underwent Chlamydia trachomatis polymerase chain reaction testing during a singleton pregnancy and delivered after the 22nd week of gestation at a tertiary care center between January 1, 2000 and December 31, 2016. We compared Chlamydia-positive (n = 259) and Chlamydianegative (n = 1,974) groups and evaluated the pregnancy outcomes. The Chlamydia-positive group had a higher rate of public assistance coverage, smoking during pregnancy, nulliparity, lack of a partner, presence of other sexually transmitted infections, high-risk social status, and younger age (P < 0.01). The incidence of preterm births was not different between the groups, with an odds ratio of 0.95 (95% confidence interval: 0.62-1.46). The incidences of low birth weight deliveries, premature rupture of membranes, and preterm premature rupture of membranes prior to the 37th week were also comparable between the groups. Chlamydial infection during pregnancy had no effect on preterm birth, even after adjustment for confounding factors.

Background: Understanding the area-specific resource use of inpatient psychiatric care is essential for the efficient use of the public assistance system. This study aimed to assess the geographical variation in psychiatric admissions and to identify the prefecture-level determinants of psychiatric admissions among recipients of public assistance in Japan., Methods: We identified all recipients of public assistance who were hospitalized in a psychiatric ward in May 2014, 2015, or 2016 using the Fact-finding Survey on Medical Assistance. The age- and sex-standardized number of psychiatric admissions was calculated for each of the 47 prefectures, using direct and indirect standardization methods., Results: A total of 46,559 psychiatric inpatients were identified in May 2016. The number of psychiatric admissions per 100,000 population was 36.6. We found a 7.1-fold difference between the prefectures with the highest (Nagasaki) and lowest (Nagano) numbers of admissions. The method of decomposing explained variance in the multiple regression model showed that the number of psychiatric beds per 100,000 population and the number of recipients of public assistance per 1,000 population were the most important determinants of the number of psychiatric admissions (R 2 = 28% and R 2 = 23%, respectively). The sensitivity analyses, using medical cost as the outcome and data from different survey years and subgroups, showed similar findings., Conclusions: We identified a large geographical variation in the number and total medical cost of psychiatric admissions among recipients of public assistance. Our findings should encourage policy makers to assess the rationale for this variation and consider strategies for reducing it.

Objectives　The aim of this study is to report on the health status of residents in supportive housing in urban areas of Japan, and to explore the differences in health conditions across different age groups within this population.Methods　The participants were 341 residents who had newly been admitted to supportive housing managed by a nonprofit organization. We examined their admission records and documented their health conditions. Differences in health conditions across age groups were also explored.Results　More than 90 percent of the participants were single men, aged 40 or older, and living on welfare. The main reasons for their utilization of supportive housing were the lack of accommodation after leaving a hospital or facility, decrease in physical function, and progression of dementia. A high proportion of participants under 40 years had an addiction problem, schizophrenia, intellectual disorders, or developmental disorders. Participants aged 40-59 years had high rates of lifestyle-related diseases in addition to mental illnesses. Furthermore, for those aged 60 years and older, the prevalence of geriatric syndromes such as dementia, hearing impairment, and visual impairment was high. Additionally, there was a high proportion of elderly participants whose health status was unknown when they were admitted to supportive housing.Conclusion　Most residents who had been admitted to supportive housing in the urban areas of Japan had physical or mental illnesses, and their life and support needs varied by age group. These findings suggest that it may be necessary for residents living in urban supportive housing in Japan to receive not only increased medical and psychological care but also age group-specific care.

Background: More research on sustainment of interventions is needed, especially return on investment (ROI) studies to determine cost-benefit trade-offs for effort required to sustain and how much is gained when effective programs are sustained. The ROSE sustainment (ROSES) study uses a sequential multiple assignment randomized (SMART) design to evaluate the effectiveness and cost-effectiveness of a stepwise approach to sustainment of the ROSE postpartum depression prevention program in 90 outpatient clinics providing prenatal care to pregnant women on public assistance. Postpartum depression (PPD) is common and can have lasting consequences. Outpatient clinics offering prenatal care are an opportune place to provide PPD prevention because most women visit while pregnant. The ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns) program is a group educational intervention to prevent PPD, delivered during pregnancy. ROSE has been found to reduce cases of PPD in community prenatal settings serving low-income pregnant women., Methods: All 90 prenatal clinics will receive enhanced implementation as usual (EIAU; initial training + tools for sustainment). At the first time at which a clinic is determined to be at risk for failure to sustain (i.e., at 3, 6, 9, 12, and 15 months), that clinic will be randomized to receive either (1) no additional implementation support (i.e., EIAU only), or (2) low-intensity coaching and feedback (LICF). If clinics receiving LICF are still at risk at subsequent assessments, they will be randomized to either (1) EIAU + LICF only, or (2) high-intensity coaching and feedback (HICF). Additional follow-up interviews will occur at 18, 24, and 30 months, but no implementation intervention will occur after 18 months. Outcomes include (1) percent sustainment of core program elements at each time point, (2) health impact (PPD rates over time at each clinic) and reach, and (3) ROI (costs and cost-effectiveness) of each sustainment step. Hypothesized mechanisms include sustainment of capacity to deliver core elements and engagement/ownership., Discussion: This study is the first randomized trial evaluating the ROI of a stepped approach to sustainment, a critical unanswered question in implementation science. It will also advance knowledge of implementation mechanisms and clinical care for an at-risk population., Trial Registration: Clinicaltrials.gov, NCT03267563 . Registered June 14, 2018.

Objectives: To measure the effect of employment and health insurance status on the survival of working age tuberculosis (TB) patients in Japan., Methods: Retrospective cohort analysis of new smear-positive pulmonary TB patients aged 15-59 years registered in the Japanese national TB surveillance system between 2007 and 2010. We performed univariate and multivariate Cox proportional hazard model analysis. The survival curves for employment and health insurance status were calculated using Kaplan-Meier analysis., Results: Of 9097 patients studied, 267 (2.9%) died of TB within 12 months. After adjustment with a multivariate model, employment and health insurance status were independently associated with increased risk of TB death: unemployment (HR 2.80, 95%CI 2.11-3.72), absence of insurance (HR 1.48, 95%CI 1.02-2.15). The analysis of survival curves indicated that those with public assistance had almost the same survival rate as insured patients in the unemployed group. Permanent workers (employed >30 days) had the highest survival rates, followed by casual workers (employed <30 days) and the unemployed in the insured group., Conclusion: Patients with permanent jobs had better survival rates than unemployed patients and casual workers. Despite being unemployed, receiving public assistance could improve survival. Health measures are required for the unemployed and casual workers.

Aims: To identify profiles associated with treatment retention in Japanese patients with methamphetamine use disorder., Methods: The study used a retrospective design based on clinical records. The subjects were 101 patients at the Kanagawa Psychiatric Center, Serigaya Hospital, who were diagnosed as having methamphetamine use disorder. They were divided in two groups, namely those who remained in treatment 3 months after the initial assessment, and those who did not. The primary analysis compared patient profiles between the two groups to detect discriminating variables, which were then submitted for secondary analysis using logistic regression to determine the most relevant predictor of retention., Results: Primary analysis indicated that older age, having psychotic symptoms, receiving public assistance, and history of incarceration were associated with treatment retention after 3 months. Secondary analysis showed that positive history of incarceration was the most significant predictor of the outcome., Conclusions: History of incarceration had the most significant treatment-retention effect on Japanese patients with methamphetamine use disorder. The development and introduction of integrated programs that link methamphetamine-dependent offenders to drug treatment is recommended in outpatient treatment for Japanese patients with methamphetamine user disorder.

Background: In Asia there are few reports considering time intervals in the examination of clinical features of primary biliary cirrhosis (PBC). Therefore, we tried to compare the characteristics of patients with PBC in two different years., Methods: In two fiscal years (1999 and 2004), 9,761 and 13,142 patients with symptomatic PBC were registered to receive public financial aid from the Ministry of Health, Labour and Welfare of Japan, respectively. For the present study, clinical data from 2,127 patients in 1999 and 6,423 ones in 2004 were available. We compared the data in the two different years, including sex, age, major symptoms, and laboratory data., Results: Male/female ratios were the same figure (0.13 for 1999 and 2004). The median age was significantly older in 2004 than in 1999 (59 years for 1999, 63 years for 2004, respectively, p<0.01). Jaundice and esophageal varices were found significantly less frequent in 2004 than in 1999 (p<0.01 for each item). Levels of total bilirubin,gamma-glutamyl transpeptidase (gamma-GTP), total cholesterol, and immunoglobulin M were significantly lower in 2004 than in 1999 (p< 0.02 for total bilirubin, and p<0.01 for other each item). The positive rate of antimitochondrial antibodies was significantly higher in 1999 than in 2004 (87.0% for 1999, 83.5% for 2004, respectively, p<0.01)). Complicated autoimmune diseases such as Sjögren's syndrome, rheumatoid arthritis, and chronic thyroiditis were found significantly more frequent in 2004 than in 1999 (p<0.01 for each item)., Conclusions: Among the patients with PBC in 2004, an increase in median age, and lower levels of laboratory data such as gamma-GTP have been found compared to 1999. These results may show an accumulation of patients with better prognosis and the recent medical progress in controlling patients with PBC.J Epidemiol 2007; 17: 210-214.

Objective: The purpose of this study is to evaluate effects of community DOTS on treatment outcome by cohort data derived from TB surveillance system and to find further problems., Subjects: New sputum smear positive pulmonary TB patients registered in 2003 and 1998 under standard course regimens., Methods: In Japan, DOTS as a method of directly observed treatment by Short Course Chemotherapy is divided into hospital DOTS and community DOTS. Hospital DOTS is to observe hospitalized patients' drug taking directly by hospital staff such as nurses, pharmacists or other hospital staff. Community DOTS is to observe or confirm discharged patients' drug taking by several methods such as direct observation at facility or patient's home, confirmation through checking treatment notes and examining empty blister packages and so on. TB patients were categorized to following 3 groups by available methods of community DOTS. Treatment outcome of patients registered in 2003 was compared with outcome of patients registered in 1998 as the control group before the introduction of community DOTS. Group 1: TB patients under PHC where at least daily observation DOTS (daily observation of drug taking at clinic or PHC to TB patients with risk factors of defaulting such as homeless, alcohol abuse, past history of default and so on) is available. Group 2: TB patients under PHC where home-visit DOTS (home-visit for observation of drug taking to the elderly TB patients who have risk to forget to take TB medicines regularly) only is available or, PHC where home-visit DOTS and confirmation DOTS (periodical confirmation of drug taking to TB patients without risk of defaulting) is available. Group 3: TB patients under PHC where only confirmation DOTS is available. Group 4: TB patients under PHC where community DOTS is not available. In addition, high death rate of patients under public assistance is analyzed., Results: In group 1 with daily observation DOTS, TB patients under social or national health insurance showed higher treatment success rate and lower defaulter rate. TB patients with insurance for aged showed lower defaulter rate but high death rate due to old age did not improve. Patients under public assistance showed relatively lower defaulter rate. In group 2 with home-visit DOTS, TB patients with national health insurance and insurance for aged showed rather lower defaulter rate. Cohort evaluation of TB patients under group 3 with confirmation DOTS and group 4 without community DOTS is difficult as high rate of unknown treatment result. TB patients receiving public assistance showed lower death rate than patients requiring but not receiving public assistance. Patients detected at clinic and hospitals showed higher death rate than other patients detected by screening for high risk groups and so on., Conclusion: Daily observation DOTS and home-visit DOTS were effective to improve success rate and defaulter rate but effect of confirmation DOTS was not proved due to lack of information. High death rate of patients with insurance for aged in all groups and lack of treatment results in group 3 and 4 were problems to be solved in the future. In order to avoid TB death among TB patients under public assistance, screening for homeless people as high risk groups, earlier detection and referral system of TB symptomatics and improvement of coverage in public assistance might be effective and be tried.

Objective: This study was performed to assess changes over a 5-year period in the number of patients with intractable diseases living in Kyoto city who received public financial aid for treatment. Variation in the quality of their lives was also investigated., Methods: Questionnaires were mailed to all patients with intractable diseases who lived in Kyoto city and who applied for financial aid for treatment in 1996 and in 2001., Results: 1. The total number of patients increased 1.4-fold over the 5 years (from 4,097 to 5,891). 2. The number of patients who required medical treatments increased. Especially a considerable number of patients required treatments for secondary conditions ascribable to a long-term bed-confined state or prolonged treatment for primary diseases. 3. The number of patients who required care to support daily life or hospital visits increased 2-fold. 4. It was demonstrated that 52.8% of patients felt their lives had improved after the introduction of long-term care insurance system., Conclusions: The number of patients with intractable diseases appears to be increasing and their clinical courses are becoming chronic and more severe. This situation can be expected to persist in the near future, so that further consideration of measures to provide medical care and welfare is necessary.

Objective: To investigate the "secondary medical regions" where mentally disordered people receive out-patient and in-patient medical care in Fukuoka prefecture, and examine factors related receiving care in medical facilities outside of their secondary medical region of residence., Methods: 16,129 out-patients on June 30, 2001 using "the public assistance system of outpatients' medical expenses" in line with the Law on Mental Health and Welfare for People with Mental Disorders were analyzed. 7513 in-patients with mental disorders in hospitals were also analyzed utilizing data from the "Patient Survey" by the Ministry of Health and Welfare in 1999. Whether they received out-patient care and in-patient medical care in their own region of residence or not was clarified for all of 13 secondary medical regions. Univariate and multivariate analyses with the multiple logistic regression model were employed to evaluate the relationship between the medical care outside their residential region and characteristics, such as the secondary medical region, gender, age, diagnosis, medical care insurance and so on., Results: With out-patient care, patients in secondary medical regions with a small population size tended to receive care outside of their residential region. Other characteristics associated with a significantly an increased proportion receiving care outside of their region included; young age, receiving care in clinics, and medical care insurance as "public corporation staff mutual aid association" and "employees' insurance or government's managed health insurance". For in-patients care, patients in secondary medical regions with a small number of psychiatric beds per population showed a marked tendency to receive care outside of their residential region. A slight correlation was observed between population ant the proportion receiving care outside of their region. Young and diagnoses such as of "mental and behavioural disorders due to use of alcohol," "other mental or behavioural disorders" "neurotic, stress-related and somatoform disorders" or "mood [affective] disorders", were other characteristics associated with an increased proportion receiving care outside of their region., Conclusions: With the societal prejudice against mental disorders and regional differences in psychiatric medical facilities, it is of interest that this study indicated that mental disordered people receive medical care in a wide and relatively close area beyond their secondary medical region of residence.

We conducted an epidemiological study of systemic sclerosis in Japan using the records of patients who had been registered to receive public financial aid. A total of 10,956 patients were registered as having systemic sclerosis in 1999. We statistically analyzed the data on the patients, including sex, age, major symptoms, and laboratory findings. We also made contingency tables in order to evaluate the correlations of the data. Our study estimated that the male/female ratio was 1:7.3. The mean ages of male and female patients were 58.8 and 58.5 years old, respectively. The major symptoms were as follows: Raynaud's phenomenon 92.4%, skin sclerosis 94.7%, dyspnea 29.9%, and dysphagia 32.2%. With respect to specific antibodies, antinuclear antibody was present in 92.2%, antitopoisomerase I antibody in 27.5%, anticentromere antibody in 37.7%, and antiribonucleoprotein antibody in 19.9%. Making contingency tables, we could elucidate the association of antitopoisomerase I with lung fibrosis.

The Research Committee of Epidemiology of Intractable Disease (Ministry of Health and Welfare, Japan) conducted a Nationwide survey of 34 intractable diseases with each of the 47 prefectural governments reporting information on all patients having any of 34 intractable diseases, and who received financial aid for the disease from April 1992 to March 1993. Information collected about each patient was the identification number, which included the disease code, sex, age, the code of the municipality where the patient lived, the medical institution which treated the patient, and the department where the patient was treated. The results can be summarized as follows: 1) The total number of patients who received financial aid for disease was 247,726 (Male 93,251 Female 154,274) for a sex ratio of 0.60, and 61.7% of patients were between 40 and 69 years of age. Of 109,387 patients whose status could be confirmed regarding either outpatient or inpatient, 13.5 percent were inpatients. Of the patients, 47,222 (53.0%) were treated in departments of internal medicine. 2) Of all 34 intractable diseases, the greatest number receiving aid were patients with systemic lupus erythematosus with 35,690 receiving aid between April 1992 and March 1993. Of new patients commencing financial aid between April 1992 and March 1993, the largest group was patients with ulcerative colitis with 5,361. 3) The numbers of patients and those who started receiving the aid in the observed one year was larger than those in 1984 and 1988. The increase in numbers between 25 and 34 years of age was remarkable. By age group, the largest number of patients became older within the 8 years from 1984 to 1992.