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Conditional cash transfer and mortality among interpersonal violence victims: A cohort study [1]

['Camila Bonfim', 'Centre Of Data', 'Knowledge Integration For Health', 'Cidacs', 'Salvador', 'Bahia', 'Flávia Alves', 'Department Of Global Health', 'Social Medicine', 'Harvard Medical School']

Date: 2026-05 

Abstract Background Interpersonal violence is a significant public health issue, increasing mortality risks for those affected. While Cash Transfer Programs offer health benefits, their role in addressing the needs of interpersonal violence victims remains unclear. This study aims to examine the association between Brazil’s Bolsa Família Program (BFP) participation and reduced mortality rates among interpersonal violence victims. Methods and findings This cohort study was conducted using data from 100 Million Brazilian Cohort, which were linked with interpersonal violence registries (2011−2015). All individuals with a record of interpersonal violence following their registration in Brazil’s primary social assistance system during the study period were included. The primary outcome was overall mortality, while secondary outcomes comprised deaths due to natural and unnatural causes, as recorded in the Mortality Information System (SIM) and classified according to the International Classification of Diseases, 10th Revision (ICD-10). We used Cox proportional hazards models with propensity score-based method to analyze overall mortality and competing risk models to assess specific causes of death, estimating the association between BFP participation and mortality rates. A total of 29,075 individuals who were victims of interpersonal violence were followed throughout the five-year period. A total of 990 individuals died from overall causes. BFP participation was associated with an 18% reduction in overall mortality rate (hazard ratio, HR 0.82, 95% CI [0.70,0.95]; p = 0.011) and a 66% reduction in mortality rate from natural causes (HR 0.34 [95% CI 0.28, 0.41]; p < 0.001). This sample includes only individuals who seek healthcare services, which may overrepresent more severe cases of interpersonal violence. Conclusions The association between BFP participation and lower mortality rates, especially from natural causes, among interpersonal violence victims highlights that such programs may be associated with reductions in poverty, improvements in health outcomes, and increased survival in vulnerable populations.

Author summary Why was this study done? Interpersonal violence is a major public health problem associated with increased risk of morbidity and mortality.

Although cash transfer programs are known to improve health outcomes and reduce social inequalities, their role in addressing the specific needs of victims of interpersonal violence remains unclear. What did the researchers do and find? This cohort study followed nearly 30,000 victims of interpersonal violence from the 100 Million Brazilian Cohort over a 5-year period.

There was an association between the Bolsa Família Program (BFP) and a reduction in all-cause mortality (18%)

This was primarily driven by a significant decrease in deaths from natural causes (66%). What do these findings mean? Our findings underscore the potential of cash transfers in reducing mortality rate among people victimized by interpersonal violence even when these programs were not specifically designed for them.

Cash transfer programs could be used as a tool for prevention, reducing the mortality burden among victims of interpersonal violence.

Hence, it is imperative for health administrators to advocate for the allocation of funds to support victims of interpersonal violence while concurrently addressing their health needs.

The main limitation of this study is that it was restricted to individuals who sought healthcare services, which likely represent the most severe cases of interpersonal violence and may have led to misclassification bias.

Citation: Bonfim C, Alves F, Barreto ML, Patel V, Machado DB (2026) Conditional cash transfer and mortality among interpersonal violence victims: A cohort study. PLoS Med 23(5): e1004673. https://doi.org/10.1371/journal.pmed.1004673 Academic Editor: Mark Tomlinson, Stellenbosch University, SOUTH AFRICA Received: May 23, 2025; Accepted: April 16, 2026; Published: May 6, 2026 Copyright: © 2026 Bonfim et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The information examined in this research is stored and managed by the Center for Data and Knowledge Integration for Health (CIDACS). Complete access to this data is limited due to its confidential nature and the specific licensing agreement that restricts its use to this study. Brazilian ethical guidelines, as determined by the Ethics Committee, prevent this data from being publicly shared. However, upon request if all ethical and legal criteria are satisfied, the data curation team at the institution may grant access to the data. For additional details, inquiries can be sent to cidacs.curadoria@fiocruz.br. The code used in the analysis is available from Github [https://github.com/profacamilabonfim/Do-file-of-the-paper-Conditional-cash-transfer-and-mortality-among-interpersonal-violence-victims.git] and archived in Zenodo [https://doi.org/10.5281/zenodo.18852494]”. Funding: The research presented in this manuscript was funded by the National Institute of Mental Health, part of the National Institutes of Health (URL: https://grants.nih.gov/), through Award Number R01MH128911 awarded to DBM. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Abbreviations: AIC, Akaike Information Criteria; BFP, Bolsa Família Program; BIC, Bayesian Information Criteria; CIDACS, Center for Data Integration and Knowledge in Health; CTPs, Cash Transfer Programs; HR, hazard ratio; ICD-10, International Classification of Diseases, 10th Revision; IPTW, Inverse Probability of Treatment Weighting; LMICs, Low- and Middle-Income Countries; PS, propensity score; SIH, Hospitalization Information System; SIM, Mortality Information System; SINAN, National Disease Notification System; STROBE, Strengthening the Reporting of Observational Studies in Epidemiology

Introduction Interpersonal violence is a multifactorial public health problem encompassing a wide range of relational contexts and manifestations. It may involve family members, intimate partners, friends, acquaintances, or strangers, and includes various forms such as child maltreatment, youth violence, violence against women, and elder abuse [1]. Its consequences extend across multiple domains, including physical, psychological, financial, sexual, neglect-related, and other dimensions [2,3]. It affects millions of people worldwide, ranking as the third leading cause of disability-adjusted life years and the second leading cause of years of life lost due to premature mortality in 2019 [4]. In addition to experiencing violence, these individuals also face reduced life expectancy [4]. However, what is associated with lower mortality among individuals exposed to violence is still not well-established [5]. This is a global issue, with a higher impact in countries such as Brazil, where the mortality rate due to violence is among the highest worldwide, reaching 22.4 per 100,000 inhabitants [5]. Although previous studies have estimated the global prevalence of interpersonal violence [4,6,7], assessing its health burden remains challenging due to its complexity and frequent underreporting, as many victims do not seek healthcare after violent episodes [2]. Interpersonal violence has been associated with social inequalities related to poverty, such as limited employment opportunities, restricted access to education, and gender, racial, and income disparities [2,5], highlighting heterogeneity according to the vulnerability of the at-risk population. These inequalities further increase vulnerability to the negative health outcomes observed in victims of interpersonal violence [8]. They are at higher risk of non-communicable diseases such as cardiovascular disease, cancer, respiratory problems, and diabetes as well as psychiatric disorders [2,9]. Exposure to violence can also lead to damage to the nervous, endocrine, and immune systems in addition to genetic changes associated with the environment [9]. Furthermore, the victims commonly have worse health habits such as alcohol abuse, tobacco use, and physical inactivity [2]. These factors contribute to increased mortality risk [4,6,10]. Considering interpersonal violence an important risk factor for poor health across the life course, preventing this public health problem has been a goal of various initiatives [2,6]. Programs that reduce social inequalities such as Cash Transfer Programs (CTPs) have had an association with decreased violence risk [2,5]. CTPs are social protection programs designed to reduce poverty and vulnerability through cash-based benefits [11]. They can be unconditional or conditional, the latter can include attendance at health appointments, access to social services, school attendance when the family have children or adolescents, prenatal appointments for pregnant and mandatory vaccinations for children [11]. CTPs such as Bolsa Família Program (BFP) have been associated with improved health outcomes among beneficiaries [12]. This is one of the largest conditional cash transfer initiatives globally [12]. Since its implementation in 2004, it has played a significant role in reducing poverty and extreme poverty among Brazilian families [13]. Although originally designed as a social equity policy, evidence indicates that the BFP is also associated with improvements in health outcomes and lower mortality [12]. These associations may reflect not only the income transfer itself but also from the program’s conditionalities [12]. By providing financial support to families, the program contributes to improved living conditions and fosters engagement with healthcare services and school attendance [12]. It is already known that these programs, especially conditional CTPs, may be associated with lower mortality among people hospitalized with psychiatric disorders [14], homicide [15], and suicide [16] rates in the general population. However, whether conditional CTPs would reduce mortality rates among people victimized by interpersonal violence, remains unanswered. The role of BFP in health and mortality has been studied, and its main mechanisms have been explored [12,17,18]. Regarding specific populations, such as individuals exposed to interpersonal violence, we believe that the role of BFP operates through secondary prevention, by facilitating referral to health services, as well as through the well-documented improvement of living conditions reported in other studies [12,19]. We hypothesized that the reduction in mortality may occur by improving access to health services and mitigating physiological stress responses to violence as well as facilitating connection to other social protection programs, promoting social inclusion, better living conditions, and improved physical and mental health [2,5]. These individuals face dual vulnerability, as they live in poverty [20] and have been victims of violence [4,5] both strong risk factors for mortality. The literature has significant limitations, as none of the available studies have evaluated competing risks of death in this specific population. Assessing this is crucial, as mortality risks vary depending on the context [21]. Therefore, this study aimed to test the association between receiving benefits from the Brazilian conditional CTP, the Bolsa Familia Program (BFP), and decreased mortality rates among victims of interpersonal violence. We hypothesized that BFP would be associated with a reduction in mortality rates, controlling for competing death risks, among these individuals.

Discussion This is the first study to estimate the role of a conditional CTP on mortality among individuals with a documented history of interpersonal violence. Using longitudinal data from over 29,000 low-income individuals followed for up to five years, we observed an 18% reduction in overall mortality and a 66% reduction in mortality from natural causes as well as 10% from unnatural causes (non-significant) among program participants. These findings support the hypothesis that CTPs, primarily designed to alleviate poverty, can also improve the living conditions of individuals who have experienced violence, thereby preventing health deterioration and reducing mortality. While there is some divergence in the literature regarding the role of conditional CTPs on violence [5], the role of such programs on mortality in the general population is well-established [5,41,42]. A multinational study that used data from 7 million people living in 37 Latin American countries showed that CTPs reduced overall mortality [43]. While preventing violence remains a global challenge, identifying measures that mitigate adverse outcomes among victims is crucial. To our knowledge, no previous studies have specifically evaluated the contribution of CTPs on mortality in populations who have been victims of interpersonal violence. Our study addresses a critical evidence gap by providing the first empirical support that participation in the BFP is associated with a substantial reduction in mortality among individuals exposed to interpersonal violence populations that not only endure the immediate harm of violence but also face long-term risks to their life expectancy. These findings highlight the potential of social protection policies to mitigate the lethal consequences of violence. These findings are particularly striking, given that individuals affected by violence exhibit significantly higher mortality rates compared to the general population, primarily due to violent causes [44]. The BFP might affect mortality in people who have been victims of interpersonal violence through different processes. First, through the conditionalities, these programs are associated with improved access to health services, which in turn may be linked to fewer deleterious changes in the nervous, endocrine, and immune systems related to the stress of violence2, thereby reducing the risk of mortality. Additionality due to the conditionalities, these individuals may have greater access to other social Brazilian programs which promote inclusion and social protection for people in vulnerability and social risk [45]. Second, the role of the Family Health Strategy in monitoring families who receive benefits through home visits and follow-ups, can be highly relevant in reporting violence, facilitating subsequent treatment, and monitoring other health conditions [46]. Third, the benefit can also promote a greater sense of social inclusion and citizenship by providing access to social, educational, and health services, reducing the vulnerability associated with poverty and violence [5,47]. Fourth, financial support can improve living conditions and nutrition, increase resources, and reduce stress, which can contribute to improving physical and mental health [5,41]. Surprisingly, the BFP was not associated with non-natural causes of death. This finding might have happened because victims of interpersonal violence have an increased risk of dying from violent causes, given that recipients often reside in areas characterized by high rates of urban violence [6], and that a set of systematic public actions, together with the cash transfer, may be required for this already vulnerable population [2]. The findings further indicate that beneficiaries may experience improvements in overall health through the conditionalities of the BFP; however, the program may be insufficient to prevent deaths from violent causes [2]. BFP was also associated with reduced mortality especially among females, possibly by mitigating household-level financial stress [15]. Furthermore, previous research has highlighted the beneficial contribution of CTPs on women’s health, particularly in programs such as the BFP, which target pregnant and breastfeeding women [24,48]. Evidence from Low- and Middle-Income Countries (LMICs) indicates that cash transfers improve women’s health and increase their use of health services, particularly for maternal and childcare [48]. Another factor that may influence women’s health outcomes is the continued presence of the perpetrator within the household. Evidence from previous studies indicates that CTPs can enhance women’s autonomy and bargaining power [41], primarily because, in general, women are prioritized in the receipt of the social benefit [23]. Income transfer may alter household power or control dynamics, leading to separation processes when women are exposed to domestic violence [49]. However, it is also possible that perpetrators may appropriate the financial resources provided, thereby sustaining the cycle of domestic violence [41]. This dynamic is reflected in evidence indicating that CTPs have not led to a reduction in femicide rates [49], underscoring the need for complementary public policies specifically aimed at addressing perpetrator behavior and preventing severe forms of violence. This study has strengths and limitations. To our knowledge, it is the first to examine the association between BFP and overall mortality in victims of interpersonal violence, using nationwide linked datasets. Additionally, since the 100 Million Brazilian Cohort includes data from Brazil’s poorest population, this study uniquely highlights the potential contribution of a nationwide social program like BFP in reducing mortality rates among those in socioeconomic vulnerability. In addition, we used a robust analytical approach with a PS-based method, as well as various methodological strategies to check the robustness of our data. Moreover, this study took advantage of estimating survival using a competing risks model. Classical survival analysis models tend to overestimate survival probabilities and underestimate the risks of death, as the presence of competing risks is not considered in the analyses. This highlights the relevance of the competing risks model used in this study. Finally, using administrative data linked with a robust and accurate method reduced recall bias commonly associated with primary data collection. With regards to limitations, the datasets used in this study were composed of administrative data. Although these data are widely used for many studies [14–18,32,33], they were not designed for research purposes, and some missing data was observed in the covariates. However, the main data used in this study related to outcomes and exposure were fully complete. Second, considering registration on interpersonal violence from SINAN was not mandatory before 2011, we could only include individuals victimized from 2011 onward, which only enabled us to investigate the short-term contributions of BFP. A longer follow-up may be necessary to fully assess the impact of receiving BFP on mortality long-term, especially among individuals with repeated exposure to violent events. Furthermore, our study only included individuals that seek healthcare services, which likely represent the most severe types of interpersonal violence, potentially resulting in misclassification bias. Additionally, less visible forms of violence, such as psychological violence, may be underreported due to stigma and the difficulty healthcare professionals face in identifying them [50]. Third, we were unable to isolate the contribution of other smaller interventions that might also target low-income families registered at CadÚnico. Similarly, it is difficult to disentangle the role of receiving the benefit itself from the conditionalities attached to it. Therefore, it remains unclear whether the observed associations are attributable to the financial component per se or to behavioral changes required to maintain eligibility for the program. Fourth, although we controlled for sociodemographic covariates, we must consider the influence of unmeasured confounders, especially those related to behavioral factors, such as alcohol abuse. In addition, the covariates were available only at the baseline of the study, which may limit their contribution to the outcome, especially age [39]. Finally, this study may have biases due to the computational complexity involved in the linkage process and the absence of a unique number that identifies individuals across the health and social systems. However, the data used in this study presented high sensitivity and specificity in validation processes which allowed us to find that these errors are probably nondifferential [25]. Considering that we used data from the 100 million Brazilian cohort, which includes individuals with socioeconomic difficulties who applied for social benefits, our findings cannot be generalized for all Brazilian people. The cohort has a specific profile being predominantly composed by women and younger individuals [23]. It is also noteworthy that the profile of the population in this study differed from other studies that used SINAN [51], which is related to the focus of this study on individuals registered in CadÚnico after the violent event. Our findings revealed the potential contribution that a conditional CTP may have as a public policy for preventing negative health consequences related to interpersonal violence, in a specific population with greater vulnerability due to living in poverty and being victimized by violence. Our study showed that a considerable number of mortalities could be avoided by participation in the BFP. Therefore, governments should integrate cash transfers into efforts to prevent deaths among those vulnerabilized by interpersonal violence, especially conditional programs that improve access to health and social services. Furthermore, based on these findings, it is argued that governments should implement conditional CTPs worldwide, given the significant contribution interpersonal violence has on public health. Conditional CTPs should be advisable for governments to implement than non-conditional programs, as they have the potential to constructive behaviors, mitigating adverse health outcomes associated with interpersonal violence.

Supporting information S1 Appendix. Method A – Description of the main datasets used in the study. Method B – Description of the linkage. Table A – Logistic regression to estimate propensity scores for receiving Bolsa Familia Program according to covariates. Table B – Association of Bolsa Família Program participation with overall mortality by sex (2011–2015). Table C – Association of Bolsa Família Program participation with the outcomes using Poisson model. Table D – Association of Bolsa Família Program participation with the outcomes considering overall population who were victim of interpersonal violence (2011–2015). Table E – Association of Bolsa Família Program participation with overall mortality considering missing as a category (2011–2015). Table F – Crude association of Bolsa Família Program participation with overall mortality (2011–2015). Table G – Association of Bolsa Família Program participation with overall mortality using time-varying BFP status (2011–2015). Table H – Information Criteria–Based Model Comparison Evaluating the Inclusion of an Interaction Term. Table I – Association of Bolsa Família Program participation with overall mortality considering other age categorization in the propensity score estimation (2011–2015). Fig A – Distribution of the propensity score in the sample, 2011–2015. https://doi.org/10.1371/journal.pmed.1004673.s001 (DOCX) S1 STROBE Checklist. The STROBE checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org. https://doi.org/10.1371/journal.pmed.1004673.s002 (DOC)

Acknowledgments We extend our gratitude to the data production team and all collaborators at CIDACS/FIOCRUZ for their efforts in developing the 100 million Brazilian Cohort.

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