Barbara Clinton, M.S.W.
Director, Center for Health Services
Vanderbilt University Nashville, Tennessee

For the past 15 years, communities in rural areas of Appalachia and the Mississippi Delta have used home visiting not only to benefit families and young children, but also to revitalize and develop the communities themselves.

This effort had its roots in the 1960s. To make their education more relevant to what was going on in the world around them, medical, law, nursing and undergraduate students from Vanderbilt and other nearby universities, including the historically black Meharry Medical School, began working with rural community leaders to provide free health fairs in rural communities in eastern and western Tennessee.

Twenty-five years ago, many rural southern communities had no health services - no physicians, no clinics, and certainly no mental health services. (In many communities, this is still the case.) The health fairs the students organized provided a boost to local community activists, who built on the momentum generated by the health fairs to rally citizens, raise money, lobby the legislature, and do what had to be done to initiate health services in their communities.

The Center for Health Services began in an environment that recognized that money alone could not solve the systemic economic and social problems so firmly embedded in the rural South. The Center's goal is to meet the needs of rural areas by connecting university resources - students, faculty, and links to funders - with the energy and leadership that are the premier local resource in rural communities. Those active in the early work of the Center for Health Services were sensitive to two principles: first, that health is intimately related to social and environmental factors; and second, that community ownership and community leadership of health interventions are crucial to their success.

For the Center for Health Services, health has a broader meaning than simply the absence of disease. Health includes all those factors which promote wellbeing, including the environment, socio-economic conditions, and people's ability to control their own lives through effective community action. The interrelatedness of health and socio-economic conditions makes it likely that an intervention in the area of health will be more successful when it is not isolated from other social and economic issues. In its work with hundreds of communities over the years, Vanderbilt Center for Health Services became part of a web of community groups and activists in the rural mid-South.

Formally and informally, the Center relies on this network to help plan and evaluate its various projects. In 1982, the Center surveyed administrators of community clinics in the region to find out how health care could be improved if a limited amount of money (a grant of $10,000) was made available to the clinics.

The health providers surveyed wanted to reach isolated, low-income pregnant women who were not using prenatal care. This outreach, they hoped, would lead to earlier entry into prenatal care and thus to healthier babies. Although they knew that inadequate or late entry into prenatal care is linked to low birthweight and infant mortality and that these problems are particularly serious among the poor, among African-Americans, and in rural areas, they also recognized that early access to prenatal care is only part of the story. Low income children suffer from health problems all through their early years. They lose 40 percent more school days because of acute illness than do other children, and they are 20 times more likely than non-poor children to be unable to attend school due to chronic conditions (Starfield,1982). As a result, in 1982, the Center, now an established part of Vanderbilt University, organized a home visiting program that has grown into a network of 19 Maternal Infant Health Outreach Worker (MIHOW) projects in Tennessee, Kentucky West Virginia, Arkansas, and Virginia.

Natural and human resources in rural Appalachia and the Mississippi Delta

To understand the link between home visiting and community development in Appalachia and the Delta, one must understand who lives in the community - and who doesn't. In many rural communities in Kentucky, Tennessee, Virginia, West Virginia, and Arkansas, the natural resources and means of production are owned by people who live someplace else. People who live in New York or London or Toronto own the coal mines, the textile mills, and the garment factories where local people work. They own the forests and the farm land. Living elsewhere, owners are less likely to reinvest in the community directly or through taxes. This helps explain why many rural communities have poor school systems, poor or non-existent transportation systems, and minimal health services. Since natural resources continue to be extracted, the Center's approach has been to revitalize communities by enriching and supporting their premier resource - the people who live there.

Wanted: Local women leaders

In cities, the question of whether home visitors should be professionals or paraprofessionals is a matter for lively debate. In rural areas, with few if any social workers, nurses, physicians, and people with masters degrees in education, the question is moot. When I began doing this work, my husband frequently came with me to visit program sites. In one West Virginia community, he commented that the busiest place in town was the army recruiting renter. With no work available, new high school graduates see joining the service as a major source of training and a ticket to someplace where a decent job might be available.

Although things are changing, the army recruiting centers still don't attract as many women as men. Even today women who become pregnant at an early age often prefer to stay, not wanting to leave the support network of mothers, grandmothers, and aunts who help each other through pregnancy, childbirth, and child rearing. Kinship networks are the traditional mechanism for transmitting wisdom about healthy child rearing practices.

To recruit capable home visitors, our university, as an "outside" agency works in partnership with local people who identify local women leaders. In this context, a "local leader" is probably not the mayor, but rather a strong mother, who is known in her community for her ability to keep a confidence, her openness to new information, her commitment to the community, and her high level of energy. Note that these criteria do not include formal academic achievement.

Once a group of such women has been recruited by a local organization, the university can provide information about child development, communication skills, and local resources. It can provide assistance in fund raising, evaluation, and program design. While this information and these skills can be taught, the university cannot teach honesty, integrity, commitment, and the ability to really connect with another family investing in the training of home visitors with these qualities is a community development strategy that allows local programs to benefit from local leadership and develop it as well.

Home visiting as a primary intervention strategy fits well with this community development orientation. It focuses on the family's strengths. Mothers are approached as peers, on a foundation of equity. Communication emphasizes the mother's achievements. In their own homes, on their own turf, parents are secure in their roles and are better able to incorporate new ideas and changes in routine.

Home visiting also promotes a rapid and comprehensive appreciation of the mother's situation and her needs. Margaret Harrison's Home Start program in Britain and the Netherlands urges volunteer home visitors to "sit on their hands" for the first round of visits, so that they can absorb the rhythm and color of the family Not only is this an expression of respect, but it also assures a better understanding of how to effectively enhance existing caregiving.

Our studies reveal that the quality of the relationship between the caregiver and the home visitor is critically important to the success of the intervention. Specific elements of the relationship that parents say matter most to them are: similarity of background between the home visitor and the mother; home visitors' respect for the confidentiality of the family; and the home visitors' non-authoritarian style of offering advice.

Perhaps most important, quality home visiting does not ignore or disrupt the existing support system. Relatives and neighbors who make up the natural system of helping around children are one of the few remaining examples of "community" in our neighborhoods. MIHOW home visiting appreciates and honors the helping system, while working to enhance health and child rearing.

From home visiting to community organization

The MIHOW Project had two main goals:1) community development and 2) enhancing the life chances of young children. The program developers thought that starting with home visiting would rapidly lead into a group model. Women would come together in groups, sharing their successes, failures, and struggles in dealing with their babies. Eventually, they would begin talking about their communities and what they might do about their communities. "It's too bad that the local school system doesn't have decent books," a newly empowered mother might comment one morning over coffee in her neighbor's kitchen. "What should we do about that?"

However, expanding the home visiting model to include groups was extremely difficult. In Appalachia and the Delta, mothers were not inclined to host other mothers in their homes if they weren't family. We learned to be more sensitive to local customs on this point. Using churches as a meeting place for groups seemed like a wonderful idea to project coordinators in Nashville, but we learned that in our rural communities, most churches stand locked during the week. With an itinerant preacher and no staff, church access is limited most of the time. In addition, discussions that included references to contraception and corporal punishment didn't always meet the standard for appropriate discussion in a particular church. So bringing groups of mothers together in churches was not the answer either.

So then what? What you really want is people in communities who are able to successfully create their own organization and do what needs to be done. That's actually how this aspect of the project evolved. Eventually, small groups of mothers began gathering, when prompted by an attractive experience for their toddlers. In a number of cases, mothers formed their own community organizations, meeting at first in storefront quarters, local libraries, and child care centers.

MIHOW today

In all MIHOW projects today, home visiting with families with young children is an important component of their work. Many of them have evolved and grown; they also offer GED programs, teen parenting prevention programs, and programs to enhance fathering. The menu will vary depending on the agency's stage of development, local needs, and local resources. But home visiting remains an essential and valued service within the agencies.

In our experience, community-based home visiting programs that use trained local mothers to work with pregnant women and parents of small children contribute to community development in six important ways.

• By building parents' confidence. When well-trained local women visit pregnant women and parents of small children in their own homes, they decrease isolation and empower parents. When we have asked mothers what they like about home visiting, many respond, "I know the home visitor won't tell (what I've said to her). She'll keep it to herself." "I appreciate that the home visitor comes from a background like mine." Women who feel this way about their home visitors feel safe in expressing, for example, the ambivalence they may feel about being pregnant. Learning that it is not "crazy" to feel this way when pregnant is a powerful - and empowering - experience. Once the baby is born, the home visitor never leaves a family's house without saying, "You're doing a really important job, and you're doing a good job." This, too, is empowering and also tells the mother that she can do more for her children, and ultimately for the community

• By providing parents with information about available resources and the encouragement or companionship to use them. Many rural families are reluctant to avail themselves of even the modest services that their communities offer. Thus a pregnant woman might respond to a home visitor's observation that she is eligible for WIC by saying, "I would never go to the WIC office. My mother would have a stroke if she knew I went down there." The home visitor might then reply gently, "It's not so bad. I'm going down Friday. I know the WIC nutritionist; let's talk to her."

• By bringing mothers together. Mothers learn from each other. They exchange child rearing and homemaking techniques that have worked for them. But even more important, group meetings reinforce the initial, basic message: "I'm not alone. It's not just me."

• Through parents' impact on the home visiting agency. Parents become a force in the community agency that is sponsoring the home visiting program. Once community agencies begin to work with families in their homes, on their own turf, parents feel more comfortable about criticizing the service they receive. Family voices help service providers live the philosophy we have always espoused-that it is the families we serve who provide program leadership, not us.

• By challenging established authority. In communities with few professionals, professionals can assume a disproportionate amount of power. For instance, many parents feel uncomfortable disagreeing with a doctor. If the local doctor is the only one around, the family knows they will need him or her someday We have found, however, that our trained home visitors, who come into frequent contact with community physicians, think critically about the messages that professionals are giving to families and speak for families when families are reluctant to do so.

  Breastfeeding is a case in point. A major thrust of our program is to promote breastfeeding for its obvious health and psychological benefits to the child and the mother. On a number of occasions, local physicians discouraged breastfeeding on the grounds that it is too burdensome for an overstressed mother. Many hospitals also discourage breastfeeding for protocol and management reasons. Of course formula manufacturers discourage breastfeeding by providing free formula to the mothers of newborns. Standing up to this pressure can be difficult for a family What happens when a physician discourages breastfeeding, and the home visitor encourages it? There might actually be a discussion about breastfeeding. It might be a first, not only for the home visitor but for the physician, when the home visitor says, "Here's the evidence in favor of breastfeeding. I learned this in my training." Informed discussion enhances community development.

  The modeling that occurs when parents begin to speak out is an even more direct link to long-term community development. This phenomenon is of course not limited to rural communities. Staff of the Boston Committee for Public Housing, a network of human services programs located in public housing developments, observe that when young children see their mothers speak at a meeting, they get a new sense of their mother's power outside the family and, by extension, a sense of their own potential. We work in communities where many mothers did not have a high school graduation or an elaborate wedding. Never having had the experience of being honored, a mother finds it more difficult to raise her hand at the school board meeting and say, "You know, I don't understand why there's no hot water in the school." But when she does, the effect is powerful. Her child thinks, "I could do that too when I grow up."

• By helping families recognize the need to work together for community development. Most families with young children struggle to meet immediate needs and short-term goals, with limited time or energy for community life. Yet in the rural communities where we work, services like health clinics and active PTA's happen only if community residents make them happen. Home visitors can help families see that the needs of their children are also the needs of the community. The recognition that "It's not just me" is then expanded to "It's all of us." The basic, obvious, powerful truth in community development is: "lf we work together, we can do it."

References

Starfield, B. (1982). Family income, ill health and medical care of U.S. children. Journal of Public Health Policy. 224-259.

The impact of MIHOW

A number of investigations point to the success of the MIHOW community development approach. The first, conducted from 1982-88 and sponsored by the Ford Foundation, was a quasi-experimental study. Information was gathered from vital statistics data provided by state departments of health, and from observations and interviews with participating and comparison families. We found that though the financial barriers to health care were not overcome quickly or easily, the MIHOW participants completed their pregnancies with more medical care than their counterparts managed to secure. MIHOW mothers were more likely to report that they were consistent about good health habits than were comparison mothers, and they were more likely to breastfeed (33.3 percent compared to 22.5 percent). When their children were one and two years old, MIHOW mothers outscored their comparison counterparts on the total scores and on most subscale scores of the Caldwell HOME Inventory (Clinton, 1992).

In a qualitative study (Clinton,1990) sponsored by the Bernard van Leer Foundation, participants in the MIHOW program provided information through focus groups and personal interviews. Almost all of the participants said they had learned more about health as a result of their participation, and many also gave examples of improved decision making on family planning, which they attributed to the program's influence. One MIHOW mother observed, "I learned how to take care of my baby, what to feed him and the things to do, such as reading to him, singing to him, and having a time for just him and me to be alone." Another said "I'm getting things slowly but surely accomplished. I'm learning better parenting skills and doing well in GED; I'm ready to take my tests." Participants also said that their sense of purpose and hope for the future had improved as a result of their participation in MIHOW. Participants said that their involvement with MIHOW had helped reduce their sense of isolation and had increased their assertiveness with welfare and legal systems.

In a recent study conducted in Virginia and West Virginia (Maloney, 1995), we found that MIHOW mothers received significantly more help from friends, parent groups, and social groups than a comparison group drawn from neighboring counties. A significantly higher percentage of MIHOW participants also said that they knew how to help themselves or someone they know obtain the following community resources:

• affordable medical care (81 percent of MIHOW participants compared to 62 percent of the comparison group);
• transportation to medical care (84 percent to 62 percent);
• well-baby medical services (98 percent to 72 percent);
• assistance with alcoholism, drug abuse, or depression (72 percent to 46 percent);
• support groups (42 percent to 22 percent).

In its publications, the program has documented numerous examples of how the community development/advocacy tone of the MIHOW program encourages activism on behalf of communities. Home Visitor Debbie Withrow of New River Health Association in West Virginia described a MIHOW mother of whom she is especially proud, a woman who had been considered "mentally disabled." "Now she's gotten her drivers license, works, deals with her son's teachers, and has been a support person for other family members who have had babies and are also (considered) very limited," observed Ms. Withrow in The MIHOW Networker. Kentucky Home Visitor Pat Haynes noted in an interview for The MIHOW Networker, "I meet moms who are down and out like I was in the past, with nobody to talk to, and who don't know how to take care of their babies. . . (I tell them) I'm here to comfort you when you just need somebody to talk to. I've been kicked. I've been beaten. I've been through the welfare system just like you have, but I came out of that, and you can, too."

MIHOW mothers have reported that participation in parent groups helped them to interact more positively with their children and increased their social support. Participants and former participants serve on committees, advisory boards, or boards of directors of the local MIHOW sponsoring agencies. They have been partners with staff in developing community programs for parenting education, family planning, child abuse prevention, and job training, verifying the earlier findings that determined that MIHOW had "a powerful and positive impact on the participating families, on the women providing the services, on the leaders managing local programs, and on the local organization sponsoring the intervention " (Clinton, 1992).

References

Clinton, B. (1990). Against the Odds: Parenting in Disadvantaged Communities. A report to the Bernard van Leer Foundation.

Clinton, B. (1992). The Maternal Infant Health Outreach Worker Project: Appalachian communities help their own. In Larner, M., Halpcrn, R. And H:ukavy, O. (Eds.), Fair Start for Children: Lessons Learned from Seven Demonstration Projects. New Haven: Yale University Press.

Maloncy, E. (1995). Evaluating Empowerment of Women in The Maternal Infant Health Outreach Worker (MIHOW) Home Visiting Project in Rural Appalachia.

Zero to Three February/March 1997 21

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