Alemitu found several suspected measles cases among children in her kebele and reported them to the woreda Health Office. The woreda officials sent a team to investigate and confirmed the measles cases in the kebele. In the process, the team came to identify the following facts, based on the information collected from parents:

• Most of the cases were coming to the Health Post at a late stage, when some children had already developed complications of measles (pneumonia and sight problems, including blindness in one case).
• Most of the cases lived in the remote hard-to-reach areas of the kebele.
• All the cases were in children who had not been immunized with measles vaccine.
• There was a lack of awareness among community members about the importance of seeking early treatment for cases of measles.
• There were problems associated with vaccine storage and cold chain management due to a faulty refrigerator at the Health Post.
• There were problems for Alemitu in collecting and transporting new stocks of vaccine from the health centre, which was eight hours walk away from the Health Post.

Health Extension Practitioners are expected to be managers when health issues need to be sorted out in their communities. They have to take on a number of roles in order to complete their tasks. You will remember that interpersonal, informational and decisional roles are all part of what managers do in this instance. For example

• Alemitu has herself and her ability to communicate and 'read' situations as a resource to help her manage her relationships in the kebele.
• Being able to manage information is key both in terms of educating people and in terms of being well-informed about the actual facts of health situations (the measles outbreak in this case).
• Someone trustworthy and well-informed must take a lead in taking decisions and Alemitu in her role as a Health Extension Worker needs to be professional in doing this.

As part of the response to the measles outbreak, the woreda team recommended a rapid assessment of the knowledge, attitude and health practices (KAP) of the community on measles management at kebele level. The woreda supported Alemitu in collecting data in a KAP survey. They identified elders, religious leaders and traditional health service providers, as well as parents, as particularly informative subjects to study. They collected data after developing interview questions for individuals and groups. Privacy and confidentiality are key ethical considerations in interviewing people on sensitive topics.

The KAP study resulted in the following findings:

• The community was aware of the symptoms of measles and they had a local word for the illness.
• They believed that a child with measles has to stay at home in a quiet environment, not exposed to sun, and must not cross the river.
• Measles was thought to be a self-limiting disease by the community (i.e. children would recover naturally); therefore parents of children with measles need not seek treatment from the formal health service.
• There was a widespread belief that giving an injection to a child with measles would kill the child.

The woreda health officials and Alemitu planned a health education programme (Figure 16.7) targeting the mistaken beliefs identified in the above findings. Particular individuals and groups were identified as the main target for the health education programme. Alemitu identified schools, churches and mosques, community meeting places, kebele meetings, the Health Post and the health centre as suitable settings for health education to take place. The key health education messages were identified to convince the community members that measles is a very serious illness, which can kill a child, or permanently damage its sight and cause severe respiratory problems. A child with measles should be taken to the Health Post or Health Centre for urgent treatment for these complications. Children can be protected from measles by immunization with a single injection of a safe vaccine at nine months of age.

Alemitu's plan included a strategy for monitoring these interventions to assess whether they resulted in changed behaviour concerning measles treatment and immunization. One way in which the monitoring was carried out was to count the number of people (community members, religious leaders, traditional healers, etc.) who attended each of the health education events. Afterwards, Alemitu and the woreda health officials checked to see how many of the unvaccinated children were brought for measles immunization by parents who attended the meetings, or who heard the messages from their neighbours, community leaders and other influential people. They also interviewed community members to ask if their knowledge, attitudes and practices had been changed by hearing the health messages in the campaign.

The results of the evaluation were good. The campaigns under Alemitu's leadership were shown to be very effective. Within two years the measles immunization coverage in the kebele was found to have increased to 96%. There were only five cases of measles among unvaccinated children and all the parents quickly brought the sick child for treatment. Through her work Alemitu set up control of the project by establishing what was going on at the beginning and working through to establish how things had improved. For the success she achieved in her work, the community members and woreda Health Office recognised Alemitu as a 'Change Agent' in her community.

Now you have read about Alemitu's work on immunization and the measles outbreak, you can see how she has been engaged in health management. You will remember from Study Session 2 that the key functions of management are: planning, organising, leading, coordination, monitoring and control. You will recall too that interpersonal, informational and decisional activities are required of someone undertaking a management role.