Journal of Health Economics: Ana C. Dammert, Jose C. Galdo, Virgilio Galdo

Journal of Health Economics 35 (2014) 147161
Contents lists available at ScienceDirect
Journal of Health Economics

journal homepage: www.elsevier.com/locate/econbase
Preventing dengue through mobile phones: Evidence from a eld

experiment in Peru
Ana C. Dammert a,b, , Jose C. Galdo a,b , Virgilio Galdo c
a
Carleton University, Canada

IZA, Germany
c
World Bank, United States
b
a r t i c l e
i n f o
Article history:
Received 24 August 2012
Received in revised form 7 February 2014
Accepted 7 February 2014
Available online 5 March 2014
JEL classication:
I10
O12
Keywords:
Dengue
e-Health
Peru
Framing
Experimental design
a b s t r a c t
Dengue is the most rapidly spreading mosquito-borne viral disease in the world (WHO, 2009). During
the last two decades, the dramatic rise in the number of dengue infections has been particularly evident in Latin American and the Caribbean countries. This paper examines the experimental evidence
of the effectiveness of mobile phone technology in improving households health preventive behavior in
dengue-endemic areas. The main results suggest that repeated exposure to health information encourages
households uptake of preventive measures against dengue. As a result, the Breteau Index in treatment
households, an objective measure of dengue risk transmission, is 0.10 standard deviations below the
mean of the control group, which shows a reduction in the number of containers per household that test
positive for dengue larvae.
The estimates also show marginally signicant effects of the intervention on self-reported dengue
symptoms. Moreover, we use a multiple treatment framework that randomly assigns households to one
of the four treatment groups in order to analyze the impacts of framing on health behavior. Different
variants emphasized information on monetary and non-monetary benets and costs. The main results
show no statistical differences among treatment groups.
2014 Elsevier B.V. All rights reserved.
1. Introduction
Dengue is one of the most serious mosquito-borne viral diseases
affecting humans and is a leading cause of illness in the tropics
and subtropics. It is transmitted by the bite of Aedes mosquitoes
infected with any of four dengue serotypes. According to the World
This research has beneted from comments and suggestions received by the editor, three anonymous referees as well as seminar participants at the 2012 LACEA,
2013 Canadian Economics Association Meeting, and 2013 RECODE meeting. We
thank SASE Asociacion Civil, Centro IDEAS, and the Ministry of Health-DIRESA Sullana for their logistic and institutional support. Special thanks to Cecilia Bustamante,
Teodoro Saez, Dr. Walter Vegas, and Mary Villavicencio for their dedication and
care in the project implementation, eld work, and data collection. Minoru Higa
and Rene Castro provided excellent research assistance. This work was supported
by a research grant from the Inter-American Development Bank (Proyecto Red de
Centros de Investigacion - ATN/SF-11298-RG). The standard disclaimer applies.
Corresponding author at: Department of Economics and Norman Paterson
School of International Affairs, 1125 Colonel by Drive, Ottawa, ON K1S5B6, Canada.
Tel.: +1 613 5202600.
E-mail addresses: ana dammert@carleton.ca (A.C. Dammert),
jose galdo@carleton.ca (J.C. Galdo), vgaldo@worldbank.org (V. Galdo).
http://dx.doi.org/10.1016/j.jhealeco.2014.02.002
0167-6296/ 2014 Elsevier B.V. All rights reserved.
Health Organization, dengue represents an enormous global health

burden, with 2.5 billion people worldwide at risk of contracting the
disease (WHO, 2009). Most alarming is the fact that, in the two last
decades, humanity has experienced a global emergence of dengue
as a major public health problem due to large demographic shifts,
lack of effective mosquito control, inadequate water and sewer
management systems, and weak public health infrastructure.
This paper presents evidence from the rst large-scale, clustered, randomized control trial that evaluates the effectiveness of
mobile phone technologies in enhancing households health preventive behavior in dengue-endemic areas. In recent years, mobile
phone service has become the most rapidly adopted technology in
developing countries, as the costs of installing mobile phone towers
are low relative to those of landlines (Jensen, 2010). Mobile phone
service could facilitate the diffusion of knowledge and best practices, reduce transaction costs, and improve the delivery of public
services (Aker and Mbiti, 2010; Chong, 2011).
Indeed, a small number of non-experimental microeconomic
studies have investigated the role of mobile phone technologies
in fostering economic development, particularly in rural agricultural markets. Studies of shermen in India (Jensen, 2007) and of
148
A.C. Dammert et al. / Journal of Health Economics 35 (2014) 147161
farmers in Niger (Aker, 2010) and Uganda (Mutu and Yamano,

2009) have shown that access to mobile phone service is associated
with signicant increases in arbitrage, declines in price dispersion,
and increases in the number of markets over which farmers trade,
all of which have led to improvements in farmers welfare. Despite
these promising results, mobile phone service has not yet been
used extensively to advance preventive health care in developing
countries (Blaya et al., 2010). Given that households in developing
countries invest little in preventive health care, and considering
that the treatment of one single case of dengue ranges from US$10
to US$25 (WHO, 2009), the provision of preventive information
through text messages has the potential to be a cost-effective
health care intervention.
We also contribute to the literature regarding mosquito-borne
diseases, which has focused on malaria due to the signicant
number of lives worldwide that have been claimed by this disease. Not much has been written on dengue in the economics
literature. Dengue can cause recurring and debilitating infections
and without adequate treatment, it increases vulnerability to
other diseases, affects educational performance of children, and
reduces labor market productivity of adults (Beatty et al., 2011;
Anderson et al., 2007). There is no specic antiviral medicine or
vaccine against dengue; thus policy makers have turned their
attention to prevention policies which can be classied into
those that kill adult mosquitoes (indoor residual sprays), those
that inhibit mosquito breeding (larval habitat management), and
those that reduce dengue infection in humans (mosquito-treated
nets).1
Previous research in the medical literature has shown that there
are large private returns from the prevention of dengue, although
the adoption of preventive measures is low (Anders and Hay, 2012).
In the standard model of investments in human capital, individuals invest in health products if the expected benets from the
preventive product outweigh its costs. Low adoption of preventive products could be due to a lack of knowledge or peoples
underestimation of the importance of controlling the mosquito
vector, since dengue may present as a mild illness episode (Elder
and Lloyd, 2006). Given that the Aedes mosquito thrives in urban
environments with limited water supply and ensuing shortage, it
has been shown that one of the most effective ways to control
dengue is to provide households with preventive information so
that they can eliminate the breeding places of the mosquito through
house maintenance and disposal of tires and plastics (EspinozaGomez et al., 2002). Thus, the goal of our intervention was to
provide repetitive access to information in order to improve knowledge of preventive practices, which may lead to reductions in
dengue infestation risk. In contrast to recent experimental studies on health information, where households received a one-time
randomly assigned message, we sent 30 messages over a period
of 3 months before the peak of the dengue season. Reminders can
mitigate attentional failure and thus change intertemporal allocations, and improve consumer welfare by providing associations
between future opportunities and todays choices (Karlan et al.,
2010).
We conducted the eld experiment in 100 urban localities in the
province of Talara in the department of Piura in northern Peru. Our
area of study is considered an endemic dengue area because of its
weather conditions, proximity to the Equatorial tropical area, and
low development of water supply and sanitation facilities. In fact,
the Peruvian Ministry of Health has declared the area as endemic
since a dengue outbreak in 2001 infected 11,703 people with this
1
We do not focus on indoor residual spray, since the costs of this intervention are
borne by the government, which is in charge of conducting the spraying campaigns.
virus in Piura. Since then, more than 20,000 people have been clinically diagnosed with the virus (Ramrez, 2011).
Following the World Health Organization guidelines on dengue
prevention, we sent information regarding the mosquitos life cycle
(e.g., eggs laid on the wet walls of containers of water), the conditions that allow dengue to spread, and several strategies for
controlling the spread of the disease. To be effective, messages were
locally relevant by customizing them based on local uses of language and local illness classications. We measure the impact of
this informational exposure on health-preventive behavior (covering of water reservoirs, the use of mosquito nets and window
screenings, among others), self-reported dengue symptoms, cases
of diarrhea, and the presence of dengue larvae in water containers three months later. Importantly, the presence of externalities
is addressed by using GIS coordinates for all households in the
sample.
Based on several prior experiments on health prevention that
were done mainly in developed countries, we are also interested
in analyzing whether the perspective in which the information is
presented affects preventive behavior. It has been shown that the
framing of messages could shape attitudes toward risk and thereby
inuence behavior and choices (Kahneman and Tversky, 1979). In
order to analyze the impacts of message framing on health behavior, we randomly assigned localities within the treatment group
to one of four treatment groups. Each framing group highlighted
a piece of general information; some messages provided general
information by highlighting the positive (and negative) consequences of adopting a preventive behavior while other messages
emphasized the monetary cost.
Several results emerged. First, exposure to repeated health
preventive information affects households health behavior. The
Breteau Index, an objective measure of dengue risk transmission,
shows that households exposed to preventive information experienced a decrease in the number of water containers per household
testing positive for dengue with respect to the control group.
This is explained by changes in household behavior since there
are statistically signicant increases in the probability of covering water reservoirs, cleaning of water reservoirs, consumption of
safe water, and the use of screens in windows and/or mosquito
bed nets. These ndings contribute to the literature on preventive behavior, the area in which most of the experimental studies
that nd small effects provided information during a one-time
visit (Dupas, 2009). Studies that nd positive effects were conducted over many months by providing repetitive information
(Cairncross et al., 2005; Luby et al., 2004; Pop-Eleches et al., 2011;
Lester et al., 2010).
Second, we evaluated the impact of exposure to repetitive
information on different dengue indicators. The follow-up data
included self-reported information on dengue incidence and illness
of household members during the treatment period. The results
show that behavioral changes associated with the intervention
translated into a reduction in dengue symptoms (fever, headache,
and eyes pain) but did not affect the number of clinical diagnosed
dengue cases. Mild episodes of dengue may not lead to signicant
costs to households, but they affect peoples perception toward the
severity of the disease. We also analyzed whether the behavioral
changes are big enough to have an effect on preventable waterrelated diseases. The results show a decline in the incidence of
diarrhea in treatment households, although the null of no difference between the treatment and control areas cannot be rejected
at standard levels. These indicators, however, were self-reported
and thus are likely to be affected by recall error and misdiagnosis.
Third, the point estimates suggest that households exposed
to non-monetary loss messages experienced a slightly higher
increase in almost all preventive outcomes relative to other types

of messages. However, the null of equality of coefcients between
treatment groups is not rejected at standard levels in most cases.
This result is similar to other experimental studies that nd no
framing effects on health behavior (e.g., Dupas, 2009). Moreover,
there is some evidence of the heterogeneous effects as the increase
in preventive measures against dengue was concentrated among
the poorest households. We do not nd, however, differences
according to the gender of the cell-phone owner or by previous
exposure to dengue in the house. Finally, we do not nd evidence
of geographical spillovers except in one outcome, the Container
Index. This nding shows that, as we increase the number of
treated households in the neighborhood, households in the treatment group experienced a decrease in the number of containers
testing positive for dengue.
The remainder of the paper is organized as follows. Section 2
reviews the literature. Section 3 describes the study area, intervention, and dataset. Section 4 presents our estimates. Section 5
concludes and outlines the envisaged main policy implications.
2. Related literature
In recent years, the use of text messages to deliver health services has been studied mostly in developed countries with the
aimed at encouraging people to change their health behavior. For
instance, reminders for outpatient appointments were associated
with a reduction in the likelihood of patients missing their appointments (Koshy et al., 2008), promotion of weight-loss behavior
among overweight people (Patrick et al., 2009; Joo and Kim, 2007),
smoking cessation (Rodgers et al., 2005) and adherence to diabetes treatment among children and adolescents (Franklin et al.,
2006). Nonetheless, after a careful meta-evaluation of more than 33
studies from the medical literature in developed countries, Fjelsoe
et al. (2009) reported that only fourteen studies satised quality standards, four studies targeted preventive health behaviors,
and ten studies targeted clinical care. The authors conclude that
SMS-delivered interventions have positive short-term behavioral
outcomes, but further research is required to evaluate preventive
health behaviors.
Text messaging has not been used to spread awareness and
information about infectious diseases in endemic regions despite
recent evidence suggesting that households are responsive to information on the health risks they face (Dupas, 2011a; Cairncross et al.,
2005; Rhee et al., 2005). Madajewicz et al. (2007), for example,
show that informing households about the arsenic concentration
in their well water increased the probability that they would switch
to a safer well. Similarly, Jalan and Somanathan (2008) report
that households that receive information about the concentration
of fecal bacteria in drinking water improved water-purication
behavior. Prevention is a key component of dengue control and can
be achieved through vector control and personal protection measures (WHO, 2009). Not all information, however, can be effective.
Dupas (2011b) review of the literature shows that the provision
of information can inuence peoples behavior when they are not
fully informed about the health situation they face, when the source
of information is credible, and when they are able to process the
new information.
It is also important to analyze how informational campaigns
affect the adoption of preventive measures against the disease.
Prior work in psychology has shown that message framing has
an effect on motivating people to change their behavior (for
a review of framing on health outcomes, see Rothman and
Salovey, 1997; Salovey and Williams-Piehota, 2004; Rothman
et al., 2006). In particular, framing might have differential effects
149
on health prevention, detection, and treatment, depending on

whether the outcome is perceived to involve some risk or uncertainty. For example, preventive behavior could be viewed as
relatively safe (i.e., it provides a relatively certain outcome), while
detection could be viewed as the act of taking a risk of nding the presence of a health problem (Rothman and Salovey,
1997). Therefore, the main implication of the prospect theory
on health behavior is that gain-framed messages are more persuasive than loss-framed messages in encouraging preventive
behavior, while loss-framed messages are more persuasive than
gain-framed messages in encouraging detection behavior. Alternatively, independent of the perceived risk of the outcome, loss
framing might have greater effects due to negativity bias in processing the information wherein people are inuenced more by
negative information than with comparable positive information
(Meyerowitz and Chaiken, 1987). Thus, people are more motivated
to avoid a loss than to attain a gain of equal magnitude or loss
aversion.
We have scant empirical evidence on how framing shapes economic behavior in developing countries. Bertrand et al. (2010)
show that demand for credit can be manipulated through letters
sent to potential borrowers containing randomly assigned psychological features motivated by specic types of frames and cues
such as prole pictures in South Africa. Chong et al. (2013), on the
contrary, show that informational messages emphasizing environmental, social, or authority content were not effective in increasing
recycling behavior in Peru.
In a more related paper, Dupas (2009) analyzed an experimental
design in Western Kenya, where households receiving vouchers for
insecticide-treated bed nets were exposed to a one-time-only randomly assigned message (yer). Participants in the health-framing
group received a marketing message in which morbidity and mortality were emphasized, while participants in the nancial group
received a marketing message where nancial gains from preventing malaria were emphasized. The main results suggest that
neither of the two framing options affected the uptake of bed nets.
One possible explanation is that liquidity constraints are the main
barriers to investments in malaria prevention.
Our paper follows this line of inquiry, although it differs in
important ways. First, we sent multiple messages over a period of
three months, since repetition of information affects the processing
of the information into the memory system (encoding), which in
turn affects comprehension and long-term retention (PAHO, 2004).
From a theoretical economic standpoint, this might be explained
by models of attentional failure (Karlan et al., 2010) or rational
inattention (Reis, 2006). Reminders might change intertemporal
allocations, and improve consumer welfare, by providing associations between future opportunities and todays choices that
mitigate the attention failure (Karlan et al., 2010). Second, we are
interested in the effects of the provision of preventive information through text messages. A number of recent empirical studies
in developing countries have shown that text reminders increase
adherence to HIV antiretroviral treatment (Pop-Eleches et al., 2011;
Lester et al., 2010) and health workers adherence to malaria
treatment (Zurovac et al., 2011). Third, our experimental design
considers that households might be willing to change their behavior but may not be able to do so if the income constraint is binding
or if they are unable to borrow to purchase mosquito nets or
screens. For that reason, we also provided preventive information
that does not involve any direct cost, such as cleaning and covering
water reservoirs or discarding water-holding solid waste where
mosquitoes breed outside the house (e.g., tires, bottles, or other
small water reservoirs). Finally, we focus on a Latin American country where experimental interventions addressing health practices
are scant.
150
Fig. 1. Study areas. Note: Study areas included 100 localities in Parinas, Piura. Red dots represent localities in the treatment group, while blue dots represent those in the
control group. (For interpretation of the references to color in this gure legend, the reader is referred to the web version of the article.)
3. Experimental design
We implemented a randomized intervention in the district of
Department of Piura, located in the northern region of Peru

Parinas,
(Fig. 1). Most households in Parinas

have access to piped water
through house connections; however, safe water is only provided
a few days a week due to problems with the distribution pipe and
inadequate energy sources. Households report receiving water on
average 3.4 times a week, with an average of 7 h per day. Thus,
households use different reservoirs to store water: plastic storage
tanks or cisterns, drums, discarded buckets, or ground-level cement
water storage tanks, among others.
into
The Ministry of Health has divided the district of Parinas
19 health zones containing 100 localities based on the availability of safe water, dengue propagation, and roads, among others
(see Appendix A). A household eligible to participate in the experimental design is one where the head of household or spouse is a
cell phone user and is literate enough to read a simple message.
According to the 2007 Peruvian Census, 55.8% of households in
had a cell phone in 2007. From that year to the year of

Parinas
the intervention, the percentage of households with mobile phones
has increased signicantly (INEI, 2012). Appendix B shows that the
average cell phone sample household looks similar to the average
according to the 2007

household that owns a cell phone in Parinas,
Peruvian Census data. It is important to note that our results are
informative for those households who had cell phones and therefore are somewhat richer and more educated than households with
no cell phone are. In this regard, one should assess with caution the
external validity of the results.
Two independent sets of randomizations at the locality level
were conducted based on the administrative information from
the Ministry of Health, complemented with a customized baseline survey data. In the rst step, a stratied random assignment
between treatment and control localities was implemented following a ratio of 2:1. The stratication was based on two key
characteristics: poverty index and dengue index. The former was
constructed from the principal component analysis of 13 household assets and 6 dwelling characteristics, including access to safe
water and toilet facilities. The latter was constructed using health
administrative data regarding the incidence of dengue at the locality level. The dengue index is based on various indicators measuring
the percentage of houses where dengue larvae was found, the
percentage of containers where the larvae was found, and the
percentage of infected containers per 100 inspected houses. We
complemented this analysis with baseline information on the availability of mosquito nets, window screenings, and indoor residual
spraying at the locality level. Random stratication proceeded after
we split the data into four categories according to the distribution of
the poverty and dengue indices: high/high, high/low, low/high, and
low/low. Thresholds were determined according to the median of
the distribution for each index. Within each category, we conducted
random assignment between treatment and control localities following a ratio of 2:1. As a result, we randomly assigned 64 localities
to the treatment group and 36 localities to the control group.
In the second step, within treatment localities, we randomly
assigned localities to two orthogonal information sets: gain/loss
messages and monetary/non-monetary messages. This framework
allows us to make causal comparisons within each domain (i.e.,
gain versus loss groups and monetary versus nonmonetary groups)
as well as across four different combinations (i.e., monetary/gain,
monetary/loss, nonmonetary/gain, and nonmonetary/loss treatment groups).
Approximately 1 out of 5 households that own a mobile phone
was included in the nal sample. This represents 2021
in Parinas
households, of which 1350 belong to the treatment localities and
671 to control localities.2 Of the initial 2021 households with complete baseline information, 1784 (88%) were re-interviewed in early
March 2010, three months after the intervention started and during the month at which temperatures in the region are at their
peak. The main reasons for attrition were migration (3.9%), the
inability to nd eligible respondents despite repeated visits (5.7%),
2
Within the treatment localities, 309 households were assigned to the monetary/gain framing, 383 to monetary/loss framing, 362 to nonmonetary/gain framing,
and 296 to nonmonetary/loss framing.
and refusal (2.4%). Appendix C shows similar statistical signicant

attrition rates across all experimental groups.
3.1. Treatment and SMS framing
Based on PAHOs (2004) framework, we created 21 messages
targeting two different goals: (i) preventing production of adult
mosquitoes; i.e., water storage, refuse disposal, water-holding solid
waste in the yard, among others, and (ii) preventing exposure to the
bites of Aedes mosquitoes; i.e., screening of windows and doors,
use of bed nets, and use of repellents. We also created nine neutral
patient-care text messages or disease recognition messages, but
we did not frame them. In total, households received over 30 SMS
regarding dengue prevention, detection, and control over a period
of 3 months.3 Every effort was made to ensure that participants
knew how to send and receive text messages. It is important to note
that incoming SMS messages are free of charge, so households did
not incur any cost when they received a text message.
Households in the randomly assigned treatment group were
exposed to different framed messages according to their assigned
framing group. In the monetary framing group, households
received messages about the nancial gains or losses they would
realize (e.g., working days lost to illness, cost of medical care). In
the gain/loss groups, some households received messages about
the benets of taking preventive measures, while others received
messages about the losses from not taking such measures. Following Levin et al. (1998), the negative frames were written using a
simple negation (i.e., not adopting the behavior), to avoid incorporating biases due to differences in linguistic connotation by using
alternative terminology. Table 1 provides some examples.
3.2. Baseline household survey
The baseline survey was completed in JulySeptember 2009.
The head of household provided information on demographic
characteristics of each household member (i.e., age, educational
attainment, gender, siblings) and dengue episodes of any household member over the two years prior to the survey.4 In addition,
3
Given that text messages must contain up to 143 characters, it was quite important to tailor the messages to the uses and representations of the local people. For
this reason, we conducted a focus group in the area of intervention during July
2009. The use of focus groups was particularly important to gather information
on language uses in terms of dengues knowledge and preventive practices. Representatives from the Asociacin de Mujeres de Negritos, an NGO actively working
on health interventions, participated in this rst focus group. Their feedback was
complemented with detailed interviews with personnel from the public health system, who provided useful information about current policies implemented by the
Ministry of Health aimed at facilitating communication with the population in the
area of intervention. Once the content of text messages was dened, a second focus
group was carried out in Piura with the participation of communication specialists
in epidemiological health care. The aim was to check the relevance of the information, identify the messages that needed to be adjusted (e.g., better wording),
identify additional information that should be included, and validate the health
content based on local illness classications. Finally, we received feedback from the
local enumerators after testing their comprehension of the messages.
4
The NGO IDEAS in collaboration with FORO Salud-Piura administered the preintervention baseline survey. All local enumerators, supervisors, and monitors
participated in an intensive weekend training program, including discussion of
interview methods, questionnaire content, survey protocol, data quality checks,
and mock interviews. Survey manuals developed specically for the baseline survey
were provided to all enumerators, supervisors, and monitors. Numerators assisted
in reviewing the survey instruments for inconsistencies and problems before implementing the survey. In addition, we provided each enumerator with an information
pamphlet with local phone numbers in case the members of the household had questions about the veracity of the survey. In the baseline survey, the surveyor gathered
verbal consent to participate in this study and provided information regarding the
possibility of receiving text messages.
151
the dataset provided detailed information on dwelling characteristics including toilet facilities, house infrastructure, and household
density, which proxy for households long-run economic status
(Filmer and Pritchett, 2001).
Table 2 shows the p-values for the mean differences in relevant baseline covariates across treatment and control localities. The
results do not reject the null hypothesis of equality of means for
most covariates, as the differences are not statistically signicantly
different from zero.5 Likewise, Table 2 shows no statistically significant differences across all treatment groups except for household
size, the rate of computer ownership, and the proportion of households reporting that vaccinations prevent dengue. The differences
are very small for the last two variables though, and they are only
statistically signicant due to the size of the standard deviations.
Nonetheless, we control for these differences in the econometric
estimations. Overall, the result shows that the stratied randomization was effective in balancing the covariate mean values
between treatment and control households.
From Table 2, the average head of household is a 50-year-old
male, with 9 years of completed schooling, living with 4.9 family
members in the household. About 96% of cell phone users have a
pre-paid phone, which is used mostly to communicate with family members (85% among heads of households and 96% among
spouses). The average amount spent on pre-paid phone cards was
18 soles (about US$6.50) during the month before the survey. About
5% of the sample did not send and/or receive text messages, the
majority of them report not knowing how to do so.
Most respondents in the sample had heard about dengue; 89% of
the sample knew that it is transmitted by mosquito bite. However,
23% reported that dengue could be prevented by using the chemical treatment temephos (distributed under the name Abate) to kill
the larvae in the container. Abate is distributed free of charge by
the Ministry of Health and is one of the cores of the current public
educational campaign. In addition, 3% incorrectly report that vaccinations can prevent dengue. Concerning dengue incidence, about
25% of the sample self-reported being diagnosed with dengue during the previous two years: 64% were diagnosed by a doctor or
nurse, 13% were diagnosed by a family member or self-diagnosed,
and 7% were diagnosed by a pharmacist. On average, the illness
lasted for over a week. It is important to note that the head of the
household or the spouse provided this information for all members
of the household; therefore, recall error might have affected these
self-reported data.
4. Results
4.1. Overall effects of text messaging
This section examines whether providing any type of information about preventive health affected household behavior. The
relevant parameter of interest is the intent-to-treat (ITT) that measures the average impact of being exposed to preventive information
via text messages. For household i, the estimated regression for
each preventive outcome Yi (buying nets or screens, treating storage water, cleaning reservoirs, among others), is given by:
Yi = + 1 Ti + X + i ,
(1)
where Ti is an indicator that equals 1 if the household was randomly

exposed to the preventive information and X is a vector of baseline characteristics, including head of household characteristics,
5
Unreported results show that there are no differences in means and signicance
of the tests of equality if the means are computed over the sample of households
present at follow-up only. Results are available upon request.
152
Table 1
Message treatment (examples).
Frame
Monetary
Non-monetary
Messages
Water
Window screens
Water-holding solid
waste
Symptoms (same for

all)
Gain
You will not spend

money eradicating
dengue in your house if
you cover the water
used for personal
consumption
Use window screens to

prevent dengue in your
house. You will not
spend money in
treatment!
Loss
You will spend money

eradicating dengue in
your house if you dont
cover the water used
for personal
consumption
If you dont use

window screens,
dengue will spread in
your house and you
will spend money in
treatment!
You will not spend

money in dengue
treatment if you
discard old tires,
broken water
reservoirs, and bottles
from your yard
You will spend money
in dengue treatment if
you dont discard old
tires, broken water
from your yard
Go to the nearest
health center if you or
a family member has
fever, headache, pain
below the eyes, or a
rash. It could be
dengue!
Go to the nearest
a family member has
rash. It could be
dengue!
Gain
You will not get

you cover the water
used for personal
consumption
Use window screens to

prevent dengue in your
house!
You will not get

you discard old tires,
broken water
from your yard
Loss
You will get dengue in

cover the water used
for personal
consumption

use window screens!

discard old tires,
broken water
from your yard
Go to the nearest
a family member has
rash. It could be
dengue!
Go to the nearest
a family member has
rash. It could be
dengue!
poverty index, and dengue index. Standard errors are clustered at

the locality level to account for random assignment across localities. We also report the p-value from a test of equality of the
treatment indicator for the different groups.
Since we have multiple measures of dengue preventive behavior
in the survey, following Kling et al. (2007), we created a summary
measure (Y*) dened as the unweighted average of the different
indicators as follows:
1 YK K
K
k
K
Y =
k=1
where each indicator k is standardized by the mean and variance

of the control group at baseline. Thus, the magnitude of the estimated index shows where the mean of the treatment group is in
the distribution of the control group in terms of standard deviation
units. This allows us to test whether the treatment had an overall
positive or negative ITT effect.
Panel A of Table 3 shows that households receiving a text message reported a change in their health preventive behavior. Looking
at the overall index, the average impact is a statistically significant 0.12 standard deviation of the control group. Households
reported an increase in the probability of covering water reservoirs
by 3.4 percentage points (column 2), a change that represents a 4.6%
improvement relative to the control group. Moreover, households
receiving a text message reported an increase in the frequency in
which they clean the water reservoirs by 8.4 percentage points (column 3) and in the consumption of safe water (either boiling it or
adding chlorine) by 3.3 percentage points. These numbers represent a 9.6% and 3.8% improvement relative to the control group,
respectively.
Households exposed to the preventive information reported an
increase in the usage of screening in the windows and/or mosquito
bednets of about 4.5 percentage points, or a 4.5% improvement

relative to the control group and a reduction of 2.6 percentage
points in solid waste (tires or bottles) left outside the house.
Furthermore, there is no effect of exposure to preventive information on the usage of chemical larvicida (Abate) to kill the larvae
in the container. The information sent by text message did not
emphasize the usage of Abate given that the Ministry of Health
provides Abate free of cost to all households in the area of intervention.
Our ndings are related to Cairncross et al. (2005) and Luby et al.
(2004), who nd a positive effect of information campaigns conducted over many months on hygiene. In addition, our results are
related to recent studies that focus on preventive e-health interventions in developing countries. Pop-Eleches et al. (2011) show that
participants exposed to weekly text message reminders increase
their adherence to HIV antiretroviral treatment (of at least 90%)
by 1316% relative to the control group. Similarly, Lester et al.
(2010) show an increase in HIV antiretroviral treatment in patients
exposed to weekly text messages inquiring about their health status and reminders about the availability of phone-based support in
Kenya.
With regard to framing effects, we do not nd statistically signicant differences between groups, except for one outcome. As
Panel B of Table 3 shows, the monetary frame is equally effective as the non-monetary frame. We nd statistically signicant
effects of the non-monetary message compared to the control
group when the change in behavior does not involve a direct cost
incurred by the household. For example, households exposed to
non-monetary messages report an increase in the frequency in
which they clean the water reservoirs by 9.6 percentage points,
consumption of safe water by 4.1 percentage points, and having less
water-holding solid waste outside the household by 3.6 percentage points, compared to the control group. Panel C of Table 3 shows
153
Table 2
Descriptive statistics 2009 baseline health survey.
Treatment groups
Cement wall
Electricity
Radio
TV
Refrigerator
Computer
Piped water
Piped sewage
Wealth index
Dengue index
Head: age
Head: male
Head has health
insurance
Head: years of
completed
schooling
Head: level of education
No schooling
Primary
Secondary
Post-secondary
Household size
Dengue is
transmitted by a
mosquito bite
Dengue could be avoided by:
Getting
vaccinated
Using abate in water
reservoirs
A member of the
household was
diagnosed with
dengue during the
past two years
By a doctor/nurse
By family member/self
diagnosed
Pharmacist
Number of days ill
Monthly money
spend on pre-paid
cell phone cards
(soles): head
Spouse
Dont know how to
send/read a text
message: head
Spouse
Control
group
Difference
(T C)
p-Value
p-Value of joint
F-test
[T1 = T2 = T3 = T4]
Any
Monetary
gain (T1)
Monetary
loss (T2)
Nonmonetary
gain (T3)
Nonmonetary
loss (T4)
0.825
0.988
0.963
0.975
0.593
0.196
0.914
0.943
0.677
0.372
50.334
0.736
0.584
0.847
0.994
0.963
0.977
0.530
0.150
0.910
0.962
0.675
0.346
49.534
0.761
0.602
0.809
0.969
0.974
0.977
0.589
0.247
0.915
0.948
0.695
0.347
50.987
0.738
0.581
0.869
0.998
0.967
0.970
0.659
0.249
0.947
0.969
0.712
0.405
51.522
0.732
0.608
0.776
0.990
0.950
0.976
0.594
0.139
0.885
0.894
0.627
0.389
48.875
0.713
0.541
0.796
0.979
0.968
0.980
0.602
0.214
0.908
0.914
0.685
0.356
49.307
0.773
0.539
0.029
0.009
0.004
0.005
0.010
0.018
0.006
0.029
0.008
0.016
1.027
0.037
0.045
0.544
0.331
0.687
0.573
0.837
0.565
0.827
0.346
0.828
0.710
0.366
0.235
0.247
0.481
0.499
0.630
0.965
0.452
0.019
0.419
0.648
0.426
0.791
0.589
0.837
0.634
9.486
9.828
9.291
9.398
9.488
9.787
0.301
0.394
0.832
0.025
0.296
0.444
0.235
4.973
0.888
0.032
0.249
0.476
0.243
4.770
0.913
0.029
0.291
0.476
0.204
5.228
0.885
0.025
0.326
0.403
0.246
4.867
0.854
0.014
0.314
0.422
0.250
4.986
0.909
0.019
0.267
0.477
0.237
4.867
0.903
0.006
0.029
0.032
0.002
0.106
0.015
0.444
0.360
0.274
0.955
0.347
0.424
0.437
0.498
0.126
0.849
0.014
0.240
0.032
0.213
0.010
0.184
0.039
0.259
0.047
0.221
0.027
0.176
0.021
0.232
0.011
0.019
0.212
0.738
0.026
0.683
0.239
0.208
0.238
0.249
0.258
0.251
0.012
0.687
0.483
0.641
0.139
0.652
0.184
0.688
0.112
0.583
0.140
0.640
0.137
0.632
0.198
0.009
0.057
0.858
0.317
0.316
0.731
0.067
6.924
20.843
0.046
7.045
22.972
0.047
7.013
21.113
0.088
6.724
19.047
0.085
6.949
20.740
0.044
6.837
20.994
0.023
0.088
0.151
0.359
0.754
0.923
0.578
0.558
0.143
16.850
0.053
18.463
0.045
16.438
0.047
15.914
0.058
16.455
0.061
17.483
0.067
0.634
0.014
0.499
0.476
0.399
0.913
0.043
0.045
0.039
0.039
0.051
0.063
0.020
0.163
0.933
Note: Data from 2021 households included in the pre-intervention baseline survey. For each variable, the p-values report the values for a test of the null hypothesis that the
means are identical in treatment and control groups and the values for a test of the null hypothesis that the means are identical across the experimental groups.
that the gain frame is equally effective as the loss frame except
for cleaning water reservoirs daily or weekly. Households receiving loss messages experienced a statistically signicant increase in
the probability of cleaning the water reservoirs by 14 percentage
points. From a health policy standpoint, these results suggest that
SMS framing for health preventive behavior is not as important as
providing the information itself. This lack of statistical signicance
for framing effects is consistent with the evidence found in Dupas
(2009).
We are also interested in learning whether there are heterogeneous effects, since households investment decisions on
preventive health care depend on factors such as access to nancial
markets and ex ante information on the burden associated with
the specic disease. We then consider variation in the effects of
text messaging as a function of observable characteristics through
the interaction of the treatment indicator with baseline indicators.
First, households are classied in three categories: high if their
baseline wealth index belongs to the highest quartile of the index
154
Table 3
Effects of text messaging.
Panel A
Any message
Panel B
Monetary
Non-monetary
p-Value of
[M = NM]
Panel C
Gain
Loss
p-Value of
[G = L]
Mean control
group
(5)
Use mosquito
nets for
sleeping and/or
screens in
windows
(6)
Have
water-holding
solid waste
(tires, bottles,
or others)
(7)
0.033**
(0.015)
0.017
(0.020)
0.046**
(0.022)
0.026*
(0.014)
0.072
(0.040)
0.096**
(0.042)
0.576
0.025
(0.018)
0.040**
(0.017)
0.358
0.030
(0.024)
0.003
(0.022)
0.228
0.047*
(0.025)
0.044*
(0.026)
0.917
0.015
(0.014)
0.037**
(0.020)
0.216
0.025
(0.021)
0.042**
(0.018)
0.260
0.027
(0.048)
0.140**
(0.053)
0.008
0.034*
(0.026)
0.031*
(0.018)
0.852
0.001
(0.028)
0.034
(0.025)
0.119
0.065**
(0.030)
0.026
(0.032)
0.129
0.030**
(0.015)
0.022
(0.027)
0.654
0.927
0.639
0.895
0.685
0.734
0.065
Overall
standardized
index
Cover water
reservoirs
Clean water
reservoirs daily
or weekly
Drink boiled
water or treat
water with
chlorine
Change abate
every 3 months
(1)
(2)
(3)
(4)
0.120***
(0.034)
0.034**
(0.014)
0.084**
(0.036)
0.115**
(0.040)
0.124**
(0.038)
0.829
0.030*
(0.017)
0.038**
(0.016)
0.597
0.102**
(0.041)
0.137***
(0.037)
0.380
Note: N = 1754 households. Controls in all regressions include head of household characteristics at baseline (age, gender, schooling, employment, and health insurance),
assets index and dengue index. Observations are clustered at the locality level. Robust standard errors in parenthesis.
*
10%.
**
5%.
***
1%.
distribution (richest), medium if their index belongs to the 2nd and

3rd quartiles, and low if their index belongs to the lowest quartile
(poorest) (Panel A of Table 4). Panel A shows that a higher fraction of low assets index households (poorest) exposed to the text
messages report treating their water for consumption, having less
solid waste outside the household, and using mosquito nets and/or
screens in windows compared to medium- and high-wealth index
households. On the contrary, the results show no differential effects
of messages on the probability of covering water reservoirs.
Moreover, we analyzed whether the gender of the cell phone
owner had a differential effect on the outcomes of interest, since
women are usually the ones responsible for the activities related to
dengue prevention inside the house and they tend to invest more
in goods improving childs well-being and health (Thomas, 1990).
At baseline, the proportion of male cell ownership is similar across
groups, 44% in the treatment group and 46% in the control group,
and the difference is not statistically signicant different from zero
(p-value = 0.468).6 As Panel B of Table 4 shows, we do not nd evidence of gender differential effects at follow-up. Note, however,
that we did not randomly select the head of household or spouse
for participation in the program to examine whether the adoption
of preventive action varied by gender.
Finally, one might wonder if households are more responsive to
SMS preventive health information if a family member had been
diagnosed with dengue in the past. For instance, Dupas (2011b)
meta-analysis shows that provision of information is less effective in inuencing peoples preventive behavior when they are well
informed about the health situation they face. As Panel C of Table 4
shows, there are no statistical differences in the intent-to-treat
6
We inputted the gender of the head of household in cases where both the head
of household and the spouse owned a cell phone, (95 cases, or 5% of the sample).
estimates between households who had experienced dengue

before and those who did not.
4.2. Impacts on dengue indicators
In order to compare the objective measures of dengue risk
transmission with self-reported measures that might suffer from
non-random measurement error, a week after the follow-up, survey health personnel from the Ministry of Health collected larvae
samples by inspecting water containers and other water-holding
solid waste (e.g., tires, bottles or other small water reservoirs) in
each household of our sample.7 Households were not aware of this
visit.
Following WHO (2009), containers were examined for the presence of Aedes larvae and pupae. Based on this information, we
created three commonly used indices of the abundance of Aedes
mosquitoes: (i) the House Index, dened as the percentage of
houses testing positive for Aedes larvae; (ii) the Container Index,
dened as the percentage of water-holding containers testing positive for Aedes larvae; and (iii) the Breteau Index, dened as the
number of positive water-holding containers per household. Each
index was standardized by the mean and variance of the control
group.
As Table 5 shows, our objective measures of dengue infestation
show signicant point estimates of exposure to preventive information on the Container Index and the Breteau Index (Panel A).
The Container Index shows that households in the treatment group
7
In addition, our previous self-reported estimates could be affected by the
Hawthorne effect, as study participants having received messages stressing prevention measures might be more likely to report having taken those measures, even if
not true. We thank one of the referees for pointing this out.
155
Table 4
Heterogeneous effects of text messaging.
Overall
standardized
index
Cover water
reservoirs
Clean water
reservoirs daily or
weekly
Drink boiled water

or treat water with
chlorine
Use mosquito nets

for sleeping and/or
screens in windows
(1)
(2)
(3)
(4)
(5)
Have
water-holding
solid waste (tires,
bottles, or others)
(6)
0.076
(0.069)
0.087*
(0.051)
0.153**
(0.066)
0.091
(0.066)
0.039
(0.067)
0.0280
0.037*
(0.020)
0.027
(0.022)
0.027
(0.037)
0.005
(0.027)
0.048
(0.031)
0.1326
0.015
(0.061)
0.042
(0.053)
0.129*
(0.070)
0.118*
(0.067)
0.043
(0.075)
0.2539
0.006
(0.033)
0.025
(0.019)
0.069**
(0.029)
0.010
(0.027)
0.006
(0.033)
0.0633
0.071
(0.045)
0.015
(0.035)
0.084**
(0.039)
0.000
(0.047)
0.023
(0.046)
0.0677
0.026
(0.018)
0.016
(0.029)
0.052**
(0.024)
0.014
(0.029)
0.035
(0.026)
0.0777
Panel B: gender of the cellphone owner

0.120**
T
(0.039)
TMale
0.003
(0.042)
0.037*
(0.020)
0.008
(0.023)
0.070*
(0.039)
0.031
(0.051)
0.020
(0.018)
0.028
(0.026)
0.078**
(0.027)
0.073
(0.046)
0.004
(0.016)
0.046
(0.028)
Panel C: household experienced previous dengue

0.124**
T
(0.042)
0.009
TYes
(0.045)
0.040*
(0.024)
0.013
(0.025)
0.078
(0.048)
0.012
(0.050)
0.025
(0.024)
0.014
(0.030)
0.052
(0.032)
0.012
(0.043)
0.025
(0.018)
0.001
(0.022)
Panel A: wealth index

THigh
TMedium
TLow
Medium
Low
p-Value
TLow = TMed = THigh
Note: ***1%. Controls in all regressions include head of household characteristics at baseline (age, gender, schooling, employment, and health insurance), assets index and
dengue index. Observations are clustered at the locality level. Robust standard errors in parenthesis.
*
10%.
**
5%.
Table 5
Dengue risk transmission indices.
Panel A
Any message
Panel B
Monetary
Non-monetary
Panel C
Gain
Loss
Panel D
Monetary gain
Monetary loss
Non-monetary gain
Non-monetary loss
Standardized
Container
Index
(1)
Standardized
House
Index
(2)
Standardized
Breteau
Index
(3)
0.108**
(0.046)
0.045
(0.064)
0.098**
(0.047)
0.106**
(0.051)
0.109**
(0.049)
0.047
(0.079)
0.044
(0.069)
0.089
(0.054)
0.107**
(0.048)
0.081*
(0.052)
0.133**
(0.049)
0.006
(0.076)
0.093
(0.073)
0.073
(0.052)
0.121**
(0.050)
0.047
(0.062)
0.152**
(0.053)
0.112**
(0.056)
0.106*
(0.054)
0.050
(0.104)
0.122
(0.093)
0.036
(0.089)
0.054
(0.080)
0.041
(0.068)
0.127**
(0.057)
0.102*
(0.053)
0.113**
(0.052)
Notes: ***1%. N = 1496 households. Controls in all regressions include head of household characteristics at baseline (age, gender, schooling, employment, and health
insurance), assets index and dengue index. Observations are clustered at the locality
level. Robust standard errors in parenthesis.
*
10%.
**
5%.
experienced a decrease of 0.108 standard deviations in the percentage of water-holding containers testing positive for dengue, while
the Breteau Index shows that households in treatment localities
experienced a decrease in the number of positive containers per
household by 0.098 standard deviations of the mean of the control
group. We do not nd, however, statistically signicant effects on
the Standardized House Index. These results imply that households
in the treatment group experienced a decreased in the percentage of water-holding containers testing positive for dengue larvae
(1.44% vs. 2.47% in the treatment and control groups) as well as the
number of positive water-holding containers per household (10.66
vs. 18.91 in the treatment and control groups). These effects were
not big enough, however, to change the percentage of houses with
at least one positive water-holding container.
It is important to note that, even though there is a correlation between the critical levels of the mosquito breeding and
the intensity of virus transmission, the interpretation of the various indices in relation to human infection and disease can be
difcult to assess (Focks, 2004). For example, larvae might be clustered in a small number of containers so that the Container Index
will be low, although the number of infectious bites per person
may be high. The relationship between dengue risk measures and
dengue infestation gets more complicated when one realizes that
the latter is affected by mosquito longevity, the immunological
status of the human population, and temperature (Silver, 2008).
International evidence, for instance, suggests that the majority of
dengue outbreaks occurred in localities with low Aedes indices, and
more importantly, even when there is some statistical relationship
between the indices, these were inconsistent across years within
the same localities (Shah et al., 2012). Indeed, it is widely argued
the need for better methods to quantify the relationship between
dengue risk and dengue endemicity to ensure better future
156
vaccination and control strategies (Anders and Hay, 2012).

Nonetheless, the Pan American Health Organization denes three
levels of risk for dengue transmission as low (HI < 0.1%), medium
(HI 0.15%), and high (HI > 5%) (MINSA 2001). Our data estimate
that the House Index was 8.15% in the treatment group and 9.26%
in the control group at follow-up. In both areas, the level of risk
transmission was high.8
The follow-up survey also collected information on dengue incidence and illness of household members during the treatment
period. In our sample, less than 1% of households self-reported
having a member clinically diagnosed with dengue at the time of
the follow-up survey.9 This low number may have been accrued
because the follow-up occurred too soon after the intervention
to capture a signicant number of dengue episodes or because
self-reported measures may be affected by the underreporting
of dengue. In fact, reporting an objective measure of incidence
of dengue is not simple. First, only health ofcials can provide
information of dengue incidence after performing laboratory tests
on individuals. Routine checkups or self-observation of symptoms is not enough for dengue diagnosis. Moreover, even if this
information would be available from public health centers, it will
be severely affected by undercoverage, as it is a common practice among many individuals affected by this virus to be treated
by means of domestic health practices at home (Beatty et al.,
2011).10
Given that undercoverage and misreported error may bias
self-reported measures of dengue incidence, as an alternative measure, we also recorded whether a household member had dengue
symptoms (fever, headaches, eye pain, and diarrhea) during the
treatment period. At follow-up, 3.4% of households in the treatment group reported having a household member with dengue
symptoms, while 6.6% in the control group did so. Column 1 of
Table 6 shows that the difference of 3 percentage points is statistically signicant at the 10 percent level. Yet it is worth mentioning
that most of the dengue symptoms can be easily confused with
other common health problems, which makes difcult to connect
symptoms or dengue risk measures to morbidity and dengue infestation.
We also analyzed whether any member of the household experienced diarrhea during the month prior to the follow-up. Since
households report cleaning their water reservoirs and treating
water for consumption, one might wonder, whether these changes
in behavior are big enough to have an effect on preventable waterrelated diseases. Column 2 of Table 6 shows that households
exposed to text messages self-report a decline in the incidence
of diarrhea by 2 percentage points, which translates into a 13%
improvement relative to the control group (albeit not statistically
signicant). Looking into the different groups, as Panel B of Table 6
shows, the reduction in the incidence of diarrhea is higher and statistically signicant for households receiving monetary messages
(5.3 percentage points).
8
Malaria endemicity is commonly measured by the proportion of a population
with detectable malaria parasite in their blood. As Anders and Hay (2012) showed,
however, no comparable measure exists to quantify the endemic level of dengue
where most epidemiological data rely on clinical reports.
9
Reports from the Ministry of Health also show low levels of clinical dengue cases
in the area during the same months in 2010.
10
An alternative explanation of the low dengue infection prevalence in our sample
population could be due to the suppression of the mosquito vector population in the
area under study. This might not be the case, however, given that Talara reported
about 52% of the total number of clinical cases in the region during the summer
months of 2013.
Table 6
Effects of text messages on dengue symptoms and diarrhea.
Panel A
Any message
Panel B
Monetary
Non-monetary
p-Value of
[M = NM]
Panel C
Gain
Loss
p-Value of [G = L]
Mean control
group
N
Had a member of the

household show
dengue symptoms
(fever, headache, eye
pain) since November
of 2009?
(1)
Had a member of the

household had
diarrhea during the
previous month?
(2)
0.031*
(0.018)
0.021
(0.019)
0.032*
(0.019)
0.031
(0.020)
0.9360
0.053**
(0.023)
0.013
(0.024)
0.0167
0.029
(0.021)
0.033*
(0.019)
0.8670
0.066
0.021
(0.023)
0.020
(0.025)
0.9831
0.159
1730
1754
Note: ***1%. Controls in all regressions include head of household characteristics at

baseline (age, gender, schooling, employment, and health insurance), assets index
and dengue index. Observations are clustered at the locality level. Robust standard
errors in parenthesis.
*
10%.
**
5%.
4.3. Spillover effects

Several health studies have shown signicant spillover effects.
Depending on the characteristics of the preventive product, these
effects can either increase adoption of preventive measures (e.g.,
bednets as discussed in Dupas, 2013) or decrease it (e.g., deworming drugs as discussed in Miguel and Kremer, 2004). In our setting,
there are possible channels through which externalities may occur:
people may share the information they got from the text message
or people who change their preventive behavior may discuss the
benets with friends and family. A standard approach to assess
individual externalities would be to rely on the information on
the number and type of social links for both participant and nonparticipant households, as in Tontarawongsa et al. (2011) when
studying bednet adoption in India.
In terms of mosquito density, residential proximity is also
important since increasing uptake of preventive measures among
those exposed to the repetitive information may change the
mosquito vector population in the area under study. We follow this
line of inquiry by providing evidence on spatial spillovers using GPS
location to examine the extent to which outcomes are inuenced
by treatment density (Dupas, 2013; Tarozzi et al., 2013).11
We conducted a complete mapping of the study area and
recorded longitude and latitude coordinates for 1754 households
(households with complete address information and that are
present at both baseline and follow-up). Based on the GIS coordinates, we constructed measures of treatment density within a
given radius of our sample household. On average, households have
11
It is important to note that, in our paper, as in Tarozzi et al. (2013), there is no
treatment variation within localities. This is different from Dupas (2013), where the
author is able to exploit the exogenous variation given by the randomization of the
fraction of beneciary households within each locality.
157
Table 7
Testing for spillover effects.
Standardized
Container
Index
Standardized
House Index
Standardized
Breteau
Index
(5)
(6)
(7)
(8)
0.006
0.003
0.004
0.002
0.008
0.000
0.010
(0.006)
0.007
(0.004)
0.001
(0.006)
0.008
(0.003)
0.003
(0.011)
0.028
(0.014)
0.017
(0.010)
0.008
(0.013)
0.006
(0.008)
0.003
(0.012)
0.007
(0.006)
0.002
(0.024)
0.043*
(0.030)
0.018
(0.022)
0.003
(0.013)
(0.008)
(0.013)
(0.006)
(0.025)
(0.031)
(0.023)
0.005
0.003
0.002
0.003**
0.004
0.001
0.005
(0.003)
0.011**
(0.002)
0.006*
(0.003)
0.004
(0.001)
0.003
(0.005)
0.016*
(0.007)
0.015
(0.005)
0.004
(0.005)
0.003
(0.003)
0.004
(0.004)
0.005
(0.002)
0.001
(0.009)
0.023**
(0.011)
0.017*
(0.008)
0.010
(0.005)
(0.003)
(0.004)
(0.002)
(0.008)
(0.011)
(0.008)
0.001
0.003**
0.001
0.003**
0.002
0.002
0.003
(0.002)
0.004
(0.001)
0.003
(0.002)
0.002
(0.001)
0.004**
(0.004)
0.008
(0.005)
0.011
(0.003)
0.002
(0.003)
0.002
(0.002)
0.000
(0.003)
0.003
(0.002)
0.001
(0.006)
0.012**
(0.007)
0.007
(0.005)
0.006
(0.003)
(0.002)
(0.003)
(0.001)
(0.005)
(0.007)
(0.005
1754
1754
1754
1754
1487
1487
1487
Clean water
reservoirs
daily or
weekly
Drink boiled
water or
treat water
with chlorine
(1)
(2)
Within 50 m of household
0.000
Number of
households
(0.003)
Number of
0.006
treated
households
(0.006)
Treatment# of
0.004
treated
households
(0.006)
0.002
Number of
households
(0.001)
Number of
0.003
treated
households
(0.002)
0.001
Treatment# of
treated
households
(0.002)
0.002**
Number of
households
(0.001)
Number of
0.004**
treated
households
(0.002)
Treatment# of
0.001
treated
households
(0.001)
N
Have waterholding solid

waste (tires,
bottles, or
others)
(3)
Use mosquito
nets for
sleeping
and/or
screens in
windows
(4)
Cover water
reservoirs
1754
Note: ***1%. The estimation includes locality xed effects and controls for head of household characteristics at baseline (age, gender, schooling, employment, and health
insurance) Robust standard errors in parenthesis.
*
10%.
**
5%.
3.8 neighbors within a 50-meter radius (10.3 neighbors within

50100 m radius, and 12.5 within 100150 m radius) who were
exposed to text messages. We also constructed a measure of total
sample population density within a given radius. Table 7 presents
the coefcient estimates controlling for locality xed effects. We
focus on a radius of less than 150 meters, since epidemiological
studies of dengue have shown that the Aedes mosquito has a dispersal of approximately 100 m (Anders and Hay, 2012).12
As Table 7 shows, the coefcient estimates on the interaction
terms between the treatment group and treatment intensity are not
statistically signicantly different from zero for all self-reported
outcomes (columns 15). These results suggest that households in
12
We have assessed the presence of externalities by testing whether the number
of control households living within a 150 m radius of treatment localities experienced changes in behavior and health outcomes. The point estimates, however, are
imprecisely estimated. We thank one of the referees for pointing this out.
treatment and control localities experienced similar effects from

proximity to treated households. Columns 68 show the objective
measures of dengue risk transmission; however, the results suggest
some positive spillover effects. If we increase the number of treated
households within 50 m, 100 m, or 150 m, households in the treatment group experienced a decrease in the standardized Container
Index (column 6). As expected, this effect declines as distance from
the index household increases.
Why are no spatial spillovers observed in the self-reported data?
It might be possible that the follow-up occurred too soon after the
intervention and there was not enough time for the information to
travel in the neighborhood. An alternative explanation is that information on preventive behavior may have been spread out, but its
benets are not immediate; thus, people in endemic dengue areas
are waiting for the peak of the dengue season to change their behavior and/or for the Ministry of Health to spray the area once a certain
number of clinical episodes are observed. A study conducted over
a longer time horizon and identifying social networks may be able
158
to identify some of these effects more accurately. Moreover, variation in treatment density may be correlated with unobservable
characteristics of observed location characteristics.
Table A1
Ministry of Health Division.
Urban Parinas
Sector
Localities
J.CHAVEZ,M.SULLON, A.H.ALGARROBOS, AH.VENECEDORES,LAS

GARDENIAS Y PILAR NORES, MARIO AGUIRRE
QUINONES,9OCTUBRE,SANSEBASTIAN,STA.ROSA,B.AIRES,S.CERRO,
5. Conclusions
2
The dengue burden is high for developing countries that face

tight health budget constraints. Several countries in Latin American
and the Caribbean, including Peru, have implemented strategies to
eradicate the disease, including indoor residual spraying and the
distribution of temephos (distributed as Abate) to kill the larvae in
water containers. Dengue infections, however, continue to rise over
the last years (PAHO, 2007). A key stylized fact on health behavior in developing countries is that households invest little in the
preventive health course. A plausible explanation for this behavior
is the lack of information on illness prevention. Our intervention
provides evidence on the link between information campaigns and
preventive behavior.
We randomly assigned over 2000 households in northern Peru
to information treatment and control groups to evaluate the effectiveness of providing repetitive information via mobile phone
technologies on enhancing households health behavior. Households in the treatment group received more than 30 tailored text
messages during a three-month period designed to increase the
adoption of preventive measures against dengue. The main results
suggest that exposure to repeated health preventive information
affected household behavior. Overall, the Breteau Index, an objective measure of dengue infestation, shows that households that
are repeatedly exposed to preventive information experienced a
decrease of 0.10 standard deviations of the mean of the control
group, which is explained by positive changes in household behavior and is translated into a reduction of self-reported incidence of
dengue symptoms. Given that mobile phone service offers a large
pool of individual instant and inexpensive access to information,
and since it costs US$10 to US$25 to treat one case of dengue (WHO,
2009), this health preventive care intervention can be considered
cost-effective.
Further evidence shows positive externalities for the objective
measures of risk transmission, as the number of water-holding containers testing positive for dengue decreases in treatment areas as
the number of treated households increase. This result suggests
that changes in household behavior may affect the density of the
mosquito vector, however further research is needed to analyze
further the spillover effects in the prevention of mosquito borne
diseases. Moreover, we do not nd statistically signicant framing
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
J.BASADRE
7JUNIO,A.GARCIA,L.A.SANCHEZ,M.CHAVEZ,A.FUJIMORI,LOS
GERANIOS,AH.LOS ROBLES,AH.MIRAFLORES,BELLO
HORIZONTE,H.CARLIN,2FEBRERO,LOS FICUS,JOSE.C.MARIATEGUI
TALARA ALTA,LAS PALMERAS,URB.LOS ROBLES,CRISTO REY CRUZ
DE MAYO,02 MAYO,URB.MARIA AUXILIADORA
AV. F PAR, URB. LOS VENCEDORES, JAMES STORE, SUDAMERICA,
ENAPU, V.TALARA, L.ALVA CASTRO, M.CABREDO, LUCIANO
CASTILLO.
APROVISER,FONAVI,LAS MERCEDES
URB. LOS PINOS. URBA, VILLA FAP CORPAC
PARQUES DEL 4357, AV. H PAR; AV. E, F IMPAR Y G.
PARQUE DEL 3542 y 5862; AV. H IMPAR AV. D E y G.
PARQUES DEL 6372, LA PARADA, AV. E, AV. A; URB LOS JAZMINES,
CENTRO CIVICO Y MERCADO CENTRAL.
PARQUE DEL 8 22, AV A y B, URB. A.TABOADA
PARQUES 17 y 2227 AV. A, B y C; PARQUE 78; UNIDAD VECINAL;
CALLE 4
PARQUE 2834 AV. B Y BARRIO PARTICULAR, BLOCK MILITAR,
BLOCK PROFESORES Y URB. STA.ROSA
URB. MUNICIPAL, L.VILLANUEVA, SAN JUDAS TADEO, J.OLAYA, B.EL
PESCADOR, SAN MARTIN, LAS MERCEDES, CEMENTERIO, TALLERES
UNIDOS, MUELLE, B.ESPECIALISTAS
SAN PEDRO, JESUS MARIA, STA. RITA, B. ESTIBADORES, LAS
PENITAS.
PT. ARENAS
SACOBSA
NEGREIROS
ENACE
results. From a policy standpoint, this result suggests that the framing of SMS health messages is not as important as the provision of
the information itself. Finally, this study showed that the largest
impacts on preventive behavior against dengue were concentrated
among the poorest households, a pattern that could be related to
the fact that these households in general are the least informed
about the health situation they face.
These ndings provide valuable evidence for other developing
countries interested in incorporating digital technologies on health
programs. Although text messages considered in this evaluation
were related to dengue prevention, this cost-effective approach
has the potential for use in the prevention of other types of
Table A2
Census 2007.
Cement wall
Electricity
Piped water
Piped sewage
Refrigerator
Computer
Head: male
Head: level of completed schooling
No schooling
Primary
Secondary
Post-secondary
Number of households
Baseline survey (2009)
Urban Parinas:
Census 2007
All
Cell-phone household
Non-cell phone household
0.817
0.986
0.917
0.933
0.598
0.211
0.749
0.751
0.873
0.765
0.767
0.422
0.142
0.740
0.811
0.921
0.821
0.820
0.537
0.220
0.762
0.696
0.827
0.705
0.715
0.277
0.045
0.712
2.53
29.29
45.68
22.50
2021
2.66
27.80
37.59
31.95
20772
1.83
21.40
37.13
39.64
11570
3.71
35.84
38.18
22.27
9202
Source: 2007 Census (www.inei.gob.pe).

Note: Ownership of radio and TV are not comparable with those in our data. The Census questionnaire asks for color TV only while our questionnaire asks for ownership of
any TV (color or black and white TV). Likewise, our questionnaire asks for a radio while the Census asks for radio separately from ownership of any music equipment.
0.082 (0.071)
0.009 (0.020)
0.033 (0.038)
0.033 (0.040)
0.060 (0.072)
0.008 (0.015)
0.054 (0.066)
0.021 (0.035)
0.056 (0.064)
0.022 (0.035)
0.043 (0.065)
0.034 (0.048)
0.041 (0.059)
0.040 (0.055)
0.020 (0.033)
0.048 (0.056)
0.135 (0.087)
0.105 (0.060)
0.086 (0.073)
0.124 (0.113)
0.037 (0.052)
(2)
(1)
Table A3 presents the attrition that occurred between the baseline and follow-up surveys by treatment status. Attrition was 12%
for the entire sample, 11.2% in the treatment group and 13.7% in
the control group. As column 8 shows, the difference is not statistically signicant from zero. Likewise, after disaggregating the
rate of attrition across three different sources (respondent not
present, migration, and refusal) we observe statistical similarity
between the treatment and control groups. The test statistic does
not reject the null hypotheses of equality of means across all three
categories.
Table A3
Attrition rates.
Appendix C. Attrition
0.044 (0.056)
Treatment
All
Monetary gain
(T1)
(3)
Monetary loss
(T2)
(4)
Non-monetary
gain (T3)
(5)
The 2007 Peruvian Census provides online information for different economic and demographic variables at the district level.
Table A2 presents the descriptive statistics of all localities in the
district of Parinas,
disaggregated by whether the households had
a mobile phone or not. The rst column corresponds to the baseline information presented in Table A2. First, we investigate how
our sample is similar to cell phone households in the same district.
had at least one
As the table shows, 56% of households in Parinas
mobile phone in 2007. By comparing the rst and third columns,
the results show that our sample looks similar to the average cell
phone household in Parinas.

Second, we analyze how different are cell-phone households
from non-cell phone households in Parinas.

Comparing demographic and household characteristics across columns, we can see
that cell phone households are more educated and have better
household infrastructure than non-cell phone households have.
This is not surprising given that the cost of handsets and services
are not affordable to all households. Thus, we cannot generalize the ndings to all households in urban areas. Nevertheless,
the empirical ndings suggest the potential relevance of ICTs and
different messages on household behavior for cell phone users,
who are an important fraction of Peruvian households. Moreover,
there are potential positive spillovers accrued from the reduction
of the Aedes mosquito in cell phone households as Table 7 suggest.
0.112 (0.087)
Appendix B. Census data
0.121 (0.089)
See Table A1.
Attrition Rate
(n = 100
localities)
Respondent
not present
Migration
Refusal
Non-monetary
loss (T4)
(6)
Appendix A.
Note: Test of equality is based on regression of attrition on treatment group with clustered standard errors at the locality level. N = 2021 including 1350 households in treatment group localities and 671 in control group
localities. Standard deviations in parenthesis.
0.0866
0.0330
0.004 [0.759]
0.003 [0.666]
0.058 (0.062)
0.024 (0.037)
0.2560
0.018 [0.134]
0.055 (0.063)
0.3873
0.025 [0.174]
0.137 (0.092)
(7)
p-Value of F-test
[T1 = T2 = T3 = T4]
(9)
Difference T C
[p-value]
(8)
Control
diseases or risky behaviors. In addition, the ndings highlight the

importance of considering the dynamic nature of the information
to alter health behavior where the repeated dissemination of information is important. Reminders might mitigate attentional failure,
change intertemporal allocations, and improve consumer welfare
by providing associations between future opportunities and todays
choices (Karlan et al., 2010).
Indeed, booming mobile phone connectivity in developing
countries is shifting policy attention focus and increasing the number of initiatives aimed at empowering vulnerable groups with
access to tailored content-value information delivered to them
through a new technological platform. We believe that, in contexts
of poverty, weak institutional structures, and imperfect markets
where information is often costly or incomplete, mobile phone
applications that provide repetitive information to people about
risky behaviors could have non-negligible effects that need to be
unveiled.
159
160
Looking into across the various treatment groups, columns 36

show that there are no statistically signicant differences across
the different treatment and control groups except for the percentage of refused interviews. The gain group has a 1-percentage point
difference in the percentage of refused interviews compared to the
control group, while the loss group has a 1.5 percentage point difference with the control group. The overall difference, however, is
small and not statistically signicant due to the size of the standard
deviations.
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Journal of Health Economics: Ana C. Dammert, Jose C. Galdo, Virgilio Galdo

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Journal of Health Economics 35 (2014) 147161

Contents lists available at ScienceDirect

Journal of Health Economics

Preventing dengue through mobile phones: Evidence from a eld

Carleton University, Canada

Health Organization, dengue represents an enormous global health

A.C. Dammert et al. / Journal of Health Economics 35 (2014) 147161

farmers in Niger (Aker, 2010) and Uganda (Mutu and Yamano,

A.C. Dammert et al. / Journal of Health Economics 35 (2014) 147161

increase in almost all preventive outcomes relative to other types

on health prevention, detection, and treatment, depending on

A.C. Dammert et al. / Journal of Health Economics 35 (2014) 147161

Department of Piura, located in the northern region of Peru

(Fig. 1). Most households in Parinas

had a cell phone in 2007. From that year to the year of

according to the 2007

A.C. Dammert et al. / Journal of Health Economics 35 (2014) 147161

and refusal (2.4%). Appendix C shows similar statistical signicant

where Ti is an indicator that equals 1 if the household was randomly

A.C. Dammert et al. / Journal of Health Economics 35 (2014) 147161

Symptoms (same for

You will not spend

Use window screens to

You will spend money

If you dont use

You will not spend

You will not get

Use window screens to

You will not get

You will get dengue in

You will get dengue in

You will get dengue in

poverty index, and dengue index. Standard errors are clustered at

where each indicator k is standardized by the mean and variance

bednets of about 4.5 percentage points, or a 4.5% improvement

A.C. Dammert et al. / Journal of Health Economics 35 (2014) 147161

A.C. Dammert et al. / Journal of Health Economics 35 (2014) 147161

distribution (richest), medium if their index belongs to the 2nd and

estimates between households who had experienced dengue

A.C. Dammert et al. / Journal of Health Economics 35 (2014) 147161

Drink boiled water

Use mosquito nets

Panel B: gender of the cellphone owner

Panel C: household experienced previous dengue

Panel A: wealth index

A.C. Dammert et al. / Journal of Health Economics 35 (2014) 147161

vaccination and control strategies (Anders and Hay, 2012).

Had a member of the

Had a member of the

Note: ***1%. Controls in all regressions include head of household characteristics at

4.3. Spillover effects

A.C. Dammert et al. / Journal of Health Economics 35 (2014) 147161

Have waterholding solid

3.8 neighbors within a 50-meter radius (10.3 neighbors within

treatment and control localities experienced similar effects from

A.C. Dammert et al. / Journal of Health Economics 35 (2014) 147161

J.CHAVEZ,M.SULLON, A.H.ALGARROBOS, AH.VENECEDORES,LAS

The dengue burden is high for developing countries that face

Baseline survey (2009)

Non-cell phone household

Source: 2007 Census (www.inei.gob.pe).

A.C. Dammert et al. / Journal of Health Economics 35 (2014) 147161

phone household in Parinas.