Epistemic_Statements  

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Id Subject Object Predicate Lexical cue
T1 0-111 Epistemic_statement denotes Health shocks and their long-lasting impact on health behaviors: Evidence from the 2009 H1N1 pandemic in Mexico
T2 122-246 Epistemic_statement denotes Worldwide, the leading causes of death could be avoided with health behaviors that are low-cost but also difficult to adopt.
T3 247-385 Epistemic_statement denotes We show that exogenous health shocks could facilitate the adoption of these behaviors and provide long-lasting effects on health outcomes.
T4 883-909 Epistemic_statement denotes Published by Elsevier B.V.
T5 911-1005 Epistemic_statement denotes Worldwide, the adoption of low-cost technologies could improve health outcomes and save lives.
T6 1283-1397 Epistemic_statement denotes However, despite their effectiveness, the take up rates of these products or behaviors is very low (Dupas, 2011) .
T7 1398-1671 Epistemic_statement denotes For instance, while the role of hand washing as an effective way to reduce gastrointestinal diseases has been known for more than a century (Koplik, 1902) , 2 in developing countries, only 30% of household members wash their hands before preparing food or after defecation.
T8 2169-2260 Epistemic_statement denotes Mothers, he added, "should carefully cleanse their hands before feeding the baby" (p. 321).
T9 2905-3058 Epistemic_statement denotes See Hammer and Spears (2016) for a discussion on whether the sites where village sanitation projects take place might be likely to exhibit large effects.
T10 3540-3755 Epistemic_statement denotes 5 In particular, an emerging conclusion suggests that the mere provision of information might not matter (e.g., smokers do know that smoking is harmful and may even overestimate the risk of smoking, Viscusi, 1990) .
T11 3756-3869 Epistemic_statement denotes Rather, the emphasis seems to be on when information alters the decision-making process (Luoto and Carman 2014) .
T12 3870-4170 Epistemic_statement denotes Our paper contributes to this literature by showing that health shocks such as disease outbreaks can operate as "natural nudges" that facilitate changes in health behaviors that lead to improvements in health outcomes, and that these types of shock-induced improvements can have long-lasting effects.
T13 4171-4556 Epistemic_statement denotes In particular, we illustrate how in Mexico, a middle-income country with near universal access to water and sanitation but where intestinal infections are the second main cause of child death and 11 percent of children under five suffer from acute diarrhea, the onset of the 2009 H1N1 influenza (swine flu) led to a large, robust and long-lasting decline in diarrhea cases of children.
T14 4860-5090 Epistemic_statement denotes Relying on administrative data −where trained medical professionals register their diagnoses-and several robustness checks, we rule out the possibility that our findings are driven by misdiagnosis of either H1N1 or diarrhea cases.
T15 5091-5166 Epistemic_statement denotes Additional placebo tests and robustness checks further support our results.
T16 5167-5341 Epistemic_statement denotes For example, we find no association between diarrhea-related cases before the H1N1 outbreak (2006) (2007) (2008) and the number of confirmed swine flu cases observed in 2009.
T17 5800-5940 Epistemic_statement denotes Thus, people experienced an environment where the new virus was affecting a large number of individuals, and could, in some cases, be fatal.
T18 6842-6979 Epistemic_statement denotes 5 Other strategies include, but are not limited to, taxation, cash incentives and restrictions on use or purchase of preventive products.
T19 6980-7125 Epistemic_statement denotes See Cawley and Ruhm (2011) for an extensive discussion of policy options and theoretical models related to risky behaviors in advanced economies.
T20 7126-7253 Epistemic_statement denotes For developing countries, a growing literature explores the role of subsidies on the adoption of health products and behaviors.
T21 7301-7401 Epistemic_statement denotes increase in the incidence of the H1N1 is associated with more searches for this preventive behavior.
T22 7402-7523 Epistemic_statement denotes Other mechanisms, such as the role of government expenditure and health infrastructure, do not seem to play a major role.
T23 7524-7666 Epistemic_statement denotes Further incidence of the H1N1 after 2009 allows us to test whether such "reminders" continue to have an impact on health outcomes beyond 2009.
T24 7790-7970 Epistemic_statement denotes However, when testing for the persistence of the 2009 shock, we find that this effect dominates the contemporaneous impact suggesting long-lasting consequences of the larger shock.
T25 7971-8145 Epistemic_statement denotes This is an important result because, as we will show later, the evidence on whether information campaigns have long-lasting effects is scant (e.g., Cairncross et al., 2005) .
T26 8352-8598 Epistemic_statement denotes In that regard, our findings are consistent with previous studies that have shown, in the case of the United States, that smokers are more likely to quit when they experience more severe health shocks (Sloan et al., 2003; Margolis et al., 2014) .
T27 8599-8862 Epistemic_statement denotes It is also consistent with the findings from Philipson and Posner (1994) , who document a rapid reduction in gonorrhea for the male homosexual community in San Francisco as a result of a change towards safer sex practices soon after the onset of the HIV pandemic.
T28 9151-9256 Epistemic_statement denotes Section five describes the possible mechanisms while section six examines the persistence of the effects.
T29 9744-9865 Epistemic_statement denotes This influenza virus can survive on environmental surfaces such as kitchen counters and door knobs for up to eight hours.
T30 9941-10124 Epistemic_statement denotes However, while it is rare to have gastrointestinal symptoms from the seasonal flu, some cases of the swine flu, around 13 percent, exhibited nausea, vomiting or diarrhea (SSA, 2011) .
T31 10431-10596 Epistemic_statement denotes Most of the confirmed H1N1 cases in Mexico involved a relatively younger cohort, aged 10-39, compared to the population typically affected by the seasonal influenza.
T32 10993-11221 Epistemic_statement denotes The announcement of the first case of H1N1 on April 23, 2009, was followed by a series of other actions coordinated by the Mexican government, including the Ministry of Health, and other national and international organizations.
T33 11595-11817 Epistemic_statement denotes The goal of the campaign was to educate the public about frequent and proper hand washing techniques, covering sneezes or coughs, using face masks and hand sanitizers, seeking care if ill, and discouraging self-medication.
T34 11818-12110 Epistemic_statement denotes The Ministry of Health and the Office of the President coordinated with media outlets to provide daily updates on the number of confirmed cases, which was reflected on substantial coverage on the number of confirmed cases in each state as well as key messaging on how to prevent transmission.
T35 12576-12897 Epistemic_statement denotes Throughout the development of the outbreak, the World Health Organization actively updated their assessment from "event of international concern" on April 24 to pandemic phase 4 (sustained community transmission) on April 27, to phase 5 (imminent pandemic underway) on April 29, and then to phase 6 (pandemic) on June 11.
T36 12898-12987 Epistemic_statement denotes Although the pandemic was still underway, activities began to return to normal in Mexico.
T37 13380-13527 Epistemic_statement denotes It is unclear how long the screeners were in place, but there are reports that screeners in schools were only present for a few days (SSA, 2009a) .
T38 13528-13764 Epistemic_statement denotes Additional collaboration at the state, local, and international level also occurred to disseminate information in the workplace, public transportation, and local communities, although the details are too varied for us to summarize here.
T39 14068-14231 Epistemic_statement denotes Thus, while the swine flu remains in Mexico today, none of the following years had the same level of intensity, awareness and possible "panic" as observed in 2009.
T40 14232-14456 Epistemic_statement denotes In the next section we describe our data and how we exploit the variation across time and space to identify the causal impact of an exogenous shock that induced changes in behavior and ultimately reduction in child diarrhea.
T41 17917-18006 Epistemic_statement denotes These limitations prevent us from using the month-recording dataset in our main analysis.
T42 18119-18219 Epistemic_statement denotes However, the report does not indicate whether the reported 91.6 million users included repeat users.
T43 18794-18926 Epistemic_statement denotes .if there is more than one (condition), the one that is considered to be responsible for the most use of resources must be selected.
T44 20988-21110 Epistemic_statement denotes This heavily limits the possibility of misclassification with other diseases that could share symptoms with the swine flu.
T45 21934-22194 Epistemic_statement denotes For example, these data have been used to predict economic indicators in the United States and Germany (Choi and Varian, 2012; Askitas and Zimmermann, 2009; D'Amuri and Marcucci, 2010) as well as discrimination and voting behavior (Stephens-Davidowitz, 2014) .
T46 22494-22586 Epistemic_statement denotes In that way, our data provide the 14 Multiple symptoms can be associated with the swine flu.
T47 22587-22793 Epistemic_statement denotes The top two symptoms associated with potential cases of the swine flu were cough (90 percent) and fever (86 percent), with diarrhea, nausea or votiming being present in 13 percent of the cases (SSA, 2011) .
T48 22794-22909 Epistemic_statement denotes 15 An alternative to laboratory-confirmed cases could be the use of the actual number of people infected with H1N1.
T49 22910-23121 Epistemic_statement denotes However, this number is unknown, as infections do not always create influenza-like symptoms and different approaches are used to compute estimates for the aggregate number of infections (Shrestha et al., 2011) .
T50 23322-23413 Epistemic_statement denotes However, there is no spatial variation in this variable and cannot be used in the analysis.
T51 24770-24943 Epistemic_statement denotes Except for these two variables, the test of difference in means suggests there is no difference between the pre-2009 and post-2009 periods as captured by most key variables.
T52 24944-25230 Epistemic_statement denotes We exploit the temporal (the onset of the swine flu in 2009) and cross-sectional variation (by state) of the swine flu to examine its effect on diarrhea cases, that is, diseases that may be prevented with improved hygiene behavior that followed the onset of the H1N1 pandemic in Mexico.
T53 25828-26046 Epistemic_statement denotes We use H1N1 counts rather than rates because we believe that part of the mechanism through which individuals' perceptions changed was rooted in the perceived magnitude of the problem as reported on news media channels.
T54 26877-27201 Epistemic_statement denotes In our main specification, we compare the changes in diarrhea cases between 2008 and 2009 as we expect several state characteristics, including health infrastructure (e.g., stocks of hospitals and clinics), to remain constant over such a short period, thereby reducing the possibility of a bias in the parameter of interest.
T55 27202-27400 Epistemic_statement denotes Thus, if the H1N1 pandemic induced changes in hygiene behavior, we would expect to observe a larger decline in the incidence of diarrheal dis- eases in states where the swine flu was more prevalent.
T56 27401-27480 Epistemic_statement denotes In other words, we would expect ␤ to be negative and statistically significant.
T57 28527-28760 Epistemic_statement denotes That is, 3404 cases of H1N1 (or 4.9 percent of all confirmed cases) would have the same effect in the reduction of diarrhea (32 percent) as the estimated average effect from the costly interventions reviewed by Ejemot-Nwadiaro et al.
T58 28938-29069 Epistemic_statement denotes We find that 1000 cases of the H1N1 are linked to a 3.5 percent reduction in diarrhea cases among young children (p-value = 0.051).
T59 29070-29257 Epistemic_statement denotes This impact is smaller than the 9.4 percent found in the inpatient setting, suggesting that the effect is more pronounced among severe cases, that is, those that required hospitalization.
T60 29258-29460 Epistemic_statement denotes In this section we examine the possibility that the documented reductions in diarrhea cases were purely "mechanical" and driven by a misclassification of diagnoses created by the onset of the swine flu.
T61 29461-29641 Epistemic_statement denotes For example, with the arrival of the H1N1, cases that should have been identified as diarrhea (belonging to ICD codes A00-A09X) could have been incorrectly classified as swine flu.
T62 29764-29848 Epistemic_statement denotes We argue that this misclassification is an unlikely event for the following reasons.
T63 30218-30410 Epistemic_statement denotes So if parents suspect their children have H1N1, when the actually have diarrhea, what is recorded is the actual assessment of the physician and not what the patient (or his parents) suspected.
T64 30411-30763 Epistemic_statement denotes 21 Third, we expect medical professionals to be less likely to misdiagnose a diarrhea case not only because of their medical training but because Mexico has identified intestinal infections as a public health issue based on the magnitude and prevalence of the disease (with at least 11% of children under five being affected by this problem each year).
T65 30764-30866 Epistemic_statement denotes These professionals are also more likely to be aware of the population at risk for different diseases.
T66 31091-31160 Epistemic_statement denotes This difference further reduces the possibility of misclassification.
T67 31161-31403 Epistemic_statement denotes Fourth, even if one assumes that doctors might not be fully aware of these epidemiological differences but rather have a flat prior with respect to the risk by age groups, then we should expect the misclassification to take place at all ages.
T68 31404-31613 Epistemic_statement denotes However, when we run our main specification for other age groups and not just for children under five, we do not find evidence suggesting there is a mechanical misclassification of diarrhea to H1N1 (Table 3 ).
T69 31716-31928 Epistemic_statement denotes However, it is positive, small and not statistically different from zero for all other age groups (columns 1, 3-5), including older patients who are the second most at-risk age group of diarrhea (as shown in Fig.
T70 32148-32235 Epistemic_statement denotes Moreover, we explore other outcomes that could be affected by better hygiene practices.
T71 32236-32463 Epistemic_statement denotes In Table 4 we include cases of conjunc-21 It is worth noticing that the official guidelines sent by the Mexican government to parents and schools rarely include diarrhea as one the key symptoms to identify a possible H1N1 case.
T72 32648-32717 Epistemic_statement denotes We find a negative association between H1N1 and conjunctivitis cases.
T73 32718-32810 Epistemic_statement denotes However, conjunctivitis affects only a fraction of children under five compared to diarrhea.
T74 32927-33001 Epistemic_statement denotes This could explain the lack of statistical significance for this estimate.
T75 33002-33259 Epistemic_statement denotes When we add hepatitis A (ICD-10 code B15, also from the Anuarios de Morbilidad) and conjunctivitis together as a new outcome we continue to observe a negative association with H1N1, alas unable to reject the null hypothesis (results available upon request).
T76 33260-33395 Epistemic_statement denotes Again, this could be explained by the few cases of hepatitis A among this age group (only 4348 in 2008) relative to the diarrhea cases.
T77 33396-33622 Epistemic_statement denotes We think this evidence, although not as strong as desired, adds to the support that the negative, robust and statistically significant effect of H1N1 on diarrhea is less likely to come from a mechanical classification problem.
T78 33623-33820 Epistemic_statement denotes Finally, we take advantage of the fact that diarrhea cases are classified in different ICD codes depending on the cause or disease etiology, where for most cases the cause of diarrhea is not known.
T79 33821-34157 Epistemic_statement denotes If during the H1N1 outbreak doctors misclassified diarrhea cases, these cases are more likely to come from those where the cause is unknown (ICD-10 code A09X) and much less so, if at all, from those where the cause is known (ICD-10 codes A00-A08) (see Appendix Table 2 in Supplementary material for details about specific ICD-10 codes).
T80 34158-34296 Epistemic_statement denotes In Table 4 we test for this hypothesis by using the ratio between known cases of diarrhea and the unknown sources as our outcome variable.
T81 34297-34464 Epistemic_statement denotes Misclassification implies that more cases of H1N1 will be positively associated with this ratio: the denominator (the unknown sources) decreases but not the numerator.
T82 34533-34608 Epistemic_statement denotes We find no association between the ratio and the H1N1 (Table 4 , column 1).
T83 34984-35106 Epistemic_statement denotes b Known causes include International Classification of Diseases (ICD-10) A00-A08; Unknown causes include ICD-10 code A09X.
T84 35889-35992 Epistemic_statement denotes all these results indicate that our findings are not driven by some misclassification of the diagnosis.
T85 36090-36331 Epistemic_statement denotes In such a short period, the inclusion of state fixed effects serves as a more credible assumption because unobservables, such as culture or geography and maybe even institutions, are less likely to vary compared to the use of longer periods.
T86 36332-36583 Epistemic_statement denotes Nonetheless, it could be the case (however unlikely) that some of the unobserved characteristics specific to the 2008 cross-sectional distribution of the diarrhea cases could "predict" the spread of the 2009 swine flu and therefore bias our estimates.
T87 36584-36682 Epistemic_statement denotes With that in mind, we explore whether redefining or expanding the base period alters our findings.
T88 36929-37235 Epistemic_statement denotes The second specification discards the pairwise comparison and expands the sample 24 We also explored the possibility that, before 2009, the new strain of the H1N1 virus might have been a latent disease and those cases were incorrectly labeled as diarrhea, because the new virus has not been identified yet.
T89 37236-37554 Epistemic_statement denotes Based on the number of H1N1 cases in 2009 for children under five (7238) and that 13% of cases, that at most, could include a diarrhea-like symptom, we estimated that the highest number of cases incorrectly labeled as diarrhea for 2008 cannot exceed 2.3 percent of the hospitalizations and 0.06% of the morbidity data.
T90 37777-37895 Epistemic_statement denotes The inclusion of more years permits us to add state-specific trends that were not possible in the pairwise comparison.
T91 37896-37998 Epistemic_statement denotes The results of these new specifications indicate that our findings are not sensitive to these changes.
T92 38097-38268 Epistemic_statement denotes We continue to find a negative association (but with lower precision) and these parameters are not statistically different from the estimates using the original base year.
T93 38711-38932 Epistemic_statement denotes Thus, it is unlikely that our results are capturing pre-existing trends, as we continue to find a negative association between H1N1 and diarrhea cases after we control for time varying unobserved characteristics by state.
T94 38933-39011 Epistemic_statement denotes We further explore the issue of possible, though unlikely, preexisting trends.
T95 39323-39517 Epistemic_statement denotes 3 , Panel B, illustrates that there is no association between diarrhearelated cases between 2008 and 2007 (before the H1N1 outbreak) and the number of confirmed swine flu cases observed in 2009.
T96 39842-39895 Epistemic_statement denotes As before, we should find no effect of the 2009 H1N1.
T97 39896-40029 Epistemic_statement denotes Otherwise, this would be evidence in favor of unobserved variables predicting the 2009 cross-sectional distribution of the swine flu.
T98 40030-40150 Epistemic_statement denotes In each case, hospitalizations and morbidity data, the estimates for this falsification test indicate true zero effects.
T99 40151-40350 Epistemic_statement denotes These zero estimates and the lack of statistically significant effects provide a much stronger validation of our identification strategy and it is consistent with the visual evidence provided in Fig.
T100 40955-41164 Epistemic_statement denotes First, as a way to start introducing some of the possible mechanisms behind the observed effect of the swine flu (i.e., hand washing) we show that the H1N1 does not affect discharges unrelated to hand washing.
T101 41165-41331 Epistemic_statement denotes Specifically, hospital discharges due to injuries serve as a valid placebo effect and we would expect to find statistically insignificant effects when we estimate Eq.
T102 41366-41621 Epistemic_statement denotes This is precisely what we observe in col- 25 Injuries includes trauma to body, burns, poisoning due to external factors such as falls, traffic accidents, self-inflicted injuries, exposure to inanimate falling, thrown or projected objects, and aggressions.
T103 41906-42182 Epistemic_statement denotes Second, we want to rule out the possibility that we are attributing our main findings to changes in healthcare-seeking behavior, namely, that there were fewer people going to the hospital in areas with higher prevalence of H1N1 in order to avoid contact with sick individuals.
T104 42183-42332 Epistemic_statement denotes We provided evidence against this possibility earlier as we showed that the effects are also observed among morbidity cases, beyond hospitalizations.
T105 42333-42499 Epistemic_statement denotes We explore this using hospital discharges associated with hip-related procedures for all age groups, and hospital discharges (excluding H1N1) for children under five.
T106 42500-42576 Epistemic_statement denotes Hip-related procedures try to capture hospital visits that could be delayed.
T107 42577-42693 Epistemic_statement denotes If these procedures were negatively related to the H1N1, we would find evidence that adults were avoiding hospitals.
T108 42744-42928 Epistemic_statement denotes Similarly, if we observe a statistically significant decline in all types of hospitalizations for children, it would also suggest that parents were not taking their children hospitals.
T109 43106-43228 Epistemic_statement denotes Thus, we can rule out the possibility that our findings come from people avoiding hospitals during the swine flu pandemic.
T110 43549-43686 Epistemic_statement denotes This is important as we can rule out deaths from diarrhea happening at home, rather than at hospitals, for areas of high H1N1 prevalence.
T111 43735-44031 Epistemic_statement denotes In the previous section we have already suggested one possible explanation: the swine flu created a change in hygiene practices that led to more hand washing with soap (or use of antibacterial gels) and this led to fewer diarrhea cases requiring hospitalization, as well as fewer morbidity cases.
T112 44032-44140 Epistemic_statement denotes In this section we provide further evidence in favor of this mechanism and rule out other possible pathways.
T113 44141-44143 Epistemic_statement denotes 28
T114 44144-44249 Epistemic_statement denotes In this subsection, we examine several avenues that could explain the mechanisms underlying our findings.
T115 45037-45180 Epistemic_statement denotes The spread of the H1N1 is not related to these variables ruling them out as possible mechanisms to explain the improvements in health outcomes.
T116 45371-45587 Epistemic_statement denotes Mexican manufacturing data indicate that between 2008 and 2009, there was a 6.4 percentage point increase in production of soaps, cleaners and cosmetics; compared to a 2.3 percentage point increase from 2003 to 2007.
T117 45588-45752 Epistemic_statement denotes 29 In addition to the changes in production of soaps there is other evidence that suggests changes in hand washing behavior might have occurred during the pandemic.
T118 46244-46421 Epistemic_statement denotes These analyses suggest that the linear specification with counts appears to be the preferred specification for our paper (see Appendix Tables 3 and 4 in Supplementary material).
T119 46422-46681 Epistemic_statement denotes 28 Recent papers on infectious diseases are exploring the role of viral interference; a process where individuals infected with the swine flu could become immune to other viruses (e.g., Gröndahl et al., 2014; Ånestad and Nordbø 2011; Casalegno et al., 2010) .
T120 46741-46869 Epistemic_statement denotes Whether the H1N1 served as an "antibody" for the viruses causing diarrhea (e.g., rotavirus) goes beyond the scope of this paper.
T121 47022-47316 Epistemic_statement denotes 30 Although we are uncertain about the methodology, others have indicated that a survey conducted by Nielsen showed that the top two adopted measures by consumers in Mexico during the swine flu outbreak were: 1) the use of face masks, and 2) hand washing with soap and water or hand sanitizers.
T122 47748-47978 Epistemic_statement denotes This supports our hypothesis that the H1N1 pandemic changed hygiene practices, leading to more hand washing with soap or at least more use of hand sanitizers, and this change led to a reduction in hospitalizations due to diarrhea.
T123 48721-48742 Epistemic_statement denotes The pattern is clear.
T124 48872-49044 Epistemic_statement denotes However, at the beginning of the swine flu outbreak in early April we observe a spike in the number of searches of more than five times relative to first weeks of the year.
T125 49186-49293 Epistemic_statement denotes 4 32 We test whether this demand for knowledge is a possible mechanism by including it as an outcome in Eq.
T126 49504-49745 Epistemic_statement denotes The results of column 6 indicate that 1000 cases of the H1N1 are associated with an increase of 3.2 units in Google searches for hand sanitizers and it is statistically different from zero at the 10% level using bootstrapped standard errors.
T127 49873-50123 Epistemic_statement denotes Note that due to low search volume there are no data for eight states, 33 so in column 7 we ran our regression for Google searches replacing the missing values with zeroes (the lowest possible value in the Google Trends index) for those eight states.
T128 52119-52287 Epistemic_statement denotes These analyses indicate that the main mechanism arises from the demand for knowledge regarding hygiene practices and not so much from the other channels examined above.
T129 52288-52480 Epistemic_statement denotes Our key hypothesis is that the 2009 H1N1 shocked or nudged people into changing their behavior (washing their hands) and this behavioral change led to a decline in diarrhea cases for children.
T130 52740-52851 Epistemic_statement denotes Such models would predict a null effect from the seasonal flu but an important reaction from the H1N1 pandemic.
T131 52852-52888 Epistemic_statement denotes To study this question we modify Eq.
T132 53305-53483 Epistemic_statement denotes While both the swine and the seasonal flu could be considered as health shocks, the latter did not exhibit the unexpected magnitude and the uncertain nature of the H1N1 pandemic.
T133 53484-53634 Epistemic_statement denotes Thus we can test whether small, expected health shocks (the seasonal flu) have similar effects to larger and unexpected health shocks (the swine flu).
T134 53971-54115 Epistemic_statement denotes Each case of the seasonal flu is associated with 0.003 additional cases of diarrhea but this parameter is not statistically different from zero.
T135 54206-54303 Epistemic_statement denotes This evidence suggests that small and expected health shocks like the seasonal flu do not matter.
T136 54364-54446 Epistemic_statement denotes This evidence is consistent with theoretical models reviewed by Philipson (2000) .
T137 54447-54549 Epistemic_statement denotes An important contribution of our paper is its capacity to test whether the effects continue over time.
T138 54550-54733 Epistemic_statement denotes In the previous sections we have shown that the onset of swine flu in 2009 is associated with a reduction in diarrheal diseases as measured by hospital discharges and morbidity cases.
T139 54734-54929 Epistemic_statement denotes We have presented robust evidence in favor of the causal nature of these effects, thereby ruling out pre-trends affecting both H1N1 and diarrhea cases and other possible alternative explanations.
T140 55129-55229 Epistemic_statement denotes (2008) the evidence of whether those reductions would be sustained after the campaign ends is scant.
T141 55230-55484 Epistemic_statement denotes 34 While there are papers examining the persistence of the effects of hand washing campaigns (e.g., Cairncross et al., 2005; Wilson and Chandler, 1993) they concentrate mainly on hand washing practices rather than measuring possible declines in diarrhea.
T142 55485-55614 Epistemic_statement denotes Our paper represents a significant advantage as we directly test whether the 2009 pandemic led to sustained declines in diarrhea.
T143 55615-55744 Epistemic_statement denotes To address this issue we add more years to the control and treatment period so that our analysis includes data from 2006 to 2012.
T144 55745-55956 Epistemic_statement denotes By including the years after 2009, we can test whether the subsequent years had a similar impact as 2009, and also whether the effects remain the same when there are fewer cases and concerns about the swine flu.
T145 56166-56326 Epistemic_statement denotes If the 2009 pandemic served as a "natural nudge" then the post-2009 H1N1 cases could be thought as "reminders" following the literature of behavioral economics.
T146 56922-57022 Epistemic_statement denotes This suggests that post-2009 H1N1 cases have, on average, a smaller impact compared to the original.
T147 57222-57387 Epistemic_statement denotes We find evidence of a persistence effect: an increase in cases of the 2009 H1N1 is associated with a decline in the number of diarrhea cases for children under five.
T148 57683-57849 Epistemic_statement denotes This positive sign is not surprising in the absence of behavioral change since 13 percent of the swine flu cases were associated with diarrhea as one of the symptoms.
T149 57850-57979 Epistemic_statement denotes This reinforces our hypothesis that it is the actual health shock of the 2009 H1N1 pandemic that triggered the behavioral change.
T150 57980-58050 Epistemic_statement denotes Next, we consider an event study by replacing the H1N1 variable in Eq.
T151 58241-58436 Epistemic_statement denotes Likewise, if the contemporaneous effect exists only in 2009 and disappears with future H1N1 cases this would be evidence of a nudge: people adjusted their behavior in the presence of a new shock.
T152 58824-59023 Epistemic_statement denotes In this case, it seems possible that further nudges could have larger, or smaller, effects than the first nudge depending on the degree of dynamic complementarities between nudges in periods 1 and 2.
T153 59194-59245 Epistemic_statement denotes The results, however, disappear with the 2012 H1N1.
T154 59246-59344 Epistemic_statement denotes These findings suggest that further reminders help reducing diarrhea cases but for a limited time.
T155 59345-59647 Epistemic_statement denotes Most importantly, in column 4, and analogous to column 2, when accounting for the persistence effect of the 2009 pandemic, we find that the contemporaneous effects become substantially less relevant −much smaller in magnitude and no longer statistically different from zero-but the 2009 effect remains.
T156 59648-59818 Epistemic_statement denotes These results suggest that as a health shock, the 2009 H1N1 pandemic had a contemporaneous and a long-lasting effect in the reduction of diarrhea cases of young children.
T157 60161-60512 Epistemic_statement denotes While other mechanisms are possible, we present evidence supporting the hypothesis that the pandemic was a shock that induced changes in hygiene practices and motivated people living in areas with higher prevalence of the swine flu to acquire information about better hygiene practices and to wash their hands or increase their use of hand sanitizers.
T158 60586-60875 Epistemic_statement denotes First, as reviewed by Cawley and Ruhm (2012) , previous studies emphasizing the role of health behaviors as key inputs 35 When the H1N1 impacts become larger for all periods after 2009 an alternative explanation could come from structural changes in the health system or mass vaccinations.
T159 60876-60942 Epistemic_statement denotes However, we do not observe such pattern in the post-2009 analysis.
T160 60943-61034 Epistemic_statement denotes Furthermore, we have already ruled out vaccinations as a possible mechanism in section 5.1.
T161 61235-61456 Epistemic_statement denotes In that regard, by focusing on gastrointestinal infections in Mexico, our study expands our knowledge of the role of behavioral changes in a much less investigated setting and addresses an important gap in the literature.
T162 61809-62043 Epistemic_statement denotes Furthermore, our paper complements recent advances in behavioral economics by exploring how health shocks, such as pandemics, can act as "natural nudges" that affect the production of health outcomes and generate long-lasting effects.
T163 62044-62108 Epistemic_statement denotes Our findings raise several issues regarding policy implications.
T164 62109-62358 Epistemic_statement denotes First, we show that business-as-usual strategies, such as overall government health expenditures, vaccinations campaigns as well changes in infrastructure (e.g., hospital beds) are unlikely to be behind the reasons for the decline in diarrhea cases.
T165 62548-62815 Epistemic_statement denotes If governments facilitate access to low cost information sources, such as search engines, (or hot lines, TV or radio spots), especially in areas where the disease is more prevalent, our results indicate that the public will use these resources to acquire information.
T166 62816-63069 Epistemic_statement denotes In that setting, health outbreaks or emergencies could have unanticipated positive effects as long as the population is willing to change behaviors under the appropriate environment, e.g., with adequate information, incentives, and social acceptability.
T167 63070-63186 Epistemic_statement denotes Furthermore, our results from Google searches indicate that agents seek information broadly by using search engines.
T168 63187-63297 Epistemic_statement denotes Thus, the information to help address their demand does not need to be provided exclusively by the government.
T169 63298-63387 Epistemic_statement denotes During these emergencies, profit-seeking firms could provide a public health service too.
T170 63388-63615 Epistemic_statement denotes This is consistent with the points made by Mathios (1990, 1995) indicating that when producers are allowed to reveal the advantages of their products, firms could provide key information to consumer who then react to this news.
T171 63616-63900 Epistemic_statement denotes For example, producers and sellers of hand sanitizers or other products that improve hygiene practices could complement government efforts by advertising the benefits of their products, especially when government's health budgets are small as in the case of many developing countries.
T172 63901-64189 Epistemic_statement denotes An open research question is whether market friendly policies, such as low entry costs, could complement government efforts during health emergencies by allowing more firms to enter the market and supply the demand for health products that consumers are seeking, as shown by our findings.
T173 64378-64641 Epistemic_statement denotes Therefore, the question remains whether it is indeed possible to design information messages that could alter and sustain health behaviors analogous to the effects of the H1N1 pandemic in Mexico, but without the obvious adverse consequences of a health emergency.
T174 64642-64827 Epistemic_statement denotes A possible way to identify these messages could be found in the marketing strategies implemented in another Latin America country, Uruguay, as part of a nationwide antismoking campaign.
T175 65075-65246 Epistemic_statement denotes Future research, should explore whether an analogous system of effective messages could be applied to the context of promoting long-lasting and improved hygiene practices.