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The MIHOW model is a strong example of how peer mentoring networks benefit children by supporting parents.  Research supporting primary areas of impact (e.g. maternal health, breastfeeding) are listed below.

Research in Progress

Tennessee Randomized Control Trial

The Logistics
Vanderbilt University partnered with Catholic Charities of Middle Tennessee to conduct a randomized control trial to find out how well the MIHOW model works with Hispanic families. Study recruitment began in summer of 2018. Study staff will recruite 100 Hispanic pregnant women in the Clarksville area to participate. They will be assigned to either receive (1) only educational packets or (2) educational packets and the MIHOW intervention (home visits and group opportunities).

The study will track families through pregnancy and until the child turned 6 months old. Data is collected at 5 time points: enrollment, prenatally (35 weeks) and then 2 weeks, 2 months, and 6 months postpartum. The data collector does not know which families are receiving the MIHOW intervention.

West Virginia Research Study

The Logistics
The purpose of the study in WV is to evaluate the effectiveness of the MIHOW program by implementing a quasi-experimental, matched control design among families in West Virginia. MIHOW is currently being delivered in four counties in WV: Fayette, Mingo, Monongalia, and Ohio. In the current evaluation, researchers from WVU will compare data collected from mothers receiving MIHOW services in those counties with those of mothers enrolled in Women, Infants, and Children (WIC) in similar counties in West Virginia who are not part of MIHOW nor who are participating in another home visiting program.

 Recruitment began in November 2016 and the study is expected to last for three years.


Case Study

The Ohio County MIHOW program at Northern Panhandle Head Start was chosen to participate in a Home Visiting Applied Research Collaborative Case Study of Local Programs. Click here to view the case study and read about all the great work Ohio County MIHOW is doing.



The Efficacy of Using Peer Mentors to Improve Maternal and Infant Health Outcomes in Hispanic Families: Findings from a Randomized Clinical Trial by Melanie Lutenbacher, Tonya Elkins, Mary Dietrich, and Anais Riggs

Introduction The Maternal Infant Health Outreach Worker (MIHOW) program is a home visiting program, utilizing peer mentors to improve maternal/child health outcomes in underserved communities. Findings are presented from a randomized clinical trial (RCT) testing the efficacy of the MIHOW model in a sample of Hispanic women in Tennessee. We hypothesized maternal and infant outcomes would be better in women assigned to MIHOW than women assigned to the minimal education intervention (MEI) group (receipt of educational materials). Methods Women entered the study during pregnancy (< 26 weeks gestation) and were followed through 6 months postpartum. A total of 188 women were enrolled and randomly assigned (MEI = 94; MIHOW = 94), with 178 women completing the study (MEI = 87; MIHOW = 91). Results Positive and statistically significant (p < 0.01) effects of MIHOW were observed on breastfeeding self-efficacy and exclusivity, levels of depressive symptoms and parenting stress, safe sleep practices, and infant stimulation in the home. No statistically significant differences were noted in number of prenatal visits. Discussion Results expand limited empiric evidence and provide strong support of the effectiveness of MIHOW on improving health outcomes in this sample of Hispanic mothers and their infants. MIHOW is a viable option for providing culturally sensitive services to immigrant and underserved families.

Lutenbacher, M., Elkins, T., Dietrich, M. S., & Riggs, A. (2018). The Efficacy of Using Peer Mentors to Improve Maternal and Infant Health Outcomes in Hispanic Families: Findings from a Randomized Clinical Trial.  Maternal and child health journal , 1-13.

The Maternal Infant Health Outreach Worker Program in Low-income Families by Tonya Elkins, Maria del Pilar Aguinaga, Caitlin Clinton-Selin, Barbara Clinton, and Gerald Gotterer

Vanderbilt University Medical Center’s Maternal Infant Health Outreach Worker program (MIHOW) is a community-based intervention dedicated to enhancing birth outcomes and healthy child development. Trained neighborhood women provide home and group services to underserved families in rural and inner city communities. This report describes MIHOW’s history and work in Tennessee, Kentucky, West Virginia, Mississippi, and Louisiana.

Elkins, T., del Pilar Aguinaga, M., Clinton-Selin, C., Clinton, B., & Gotterer, G. (2013). The maternal infant health outreach worker program in low-income families. Journal of health care for the poor and underserved24(3), 995-1001.

Women Leading to Make a Difference: An Inside Look at a Strength-based Home Visiting Program in Rural Appalachia   by Kathy J. Bialk

The Maternal Infant Outreach Worker Program (MIHOW) is a strength-based home visitation program that uses trained lay women indigenous to the community to mentor and teach parents who are economically disadvantaged or live in geographically isolated areas about healthy and positive pregnancy and parenting up until the child turns age three. This qualitative case study conducted in rural Appalachia at two program sites examined how women involved in the West Virginia MIHOW program – program leaders, home visitors, and mothers – came to recognize their strengths and use them to achieve life aspirations. In addition, this study explored how MIHOW program participants perceived themselves in various aspects of their lives and how the program contributed to positive social change for women, their families, and their communities. Findings were interpreted in relation to extant literature on strength-based approaches, home visitation, and women as leaders. Theme one pertains to the role of the importance of being explicit about strengths and making it pervasive throughout the entire program. Recognizing strengths and carrying out the strength-based approach was core for MIHOW program leaders and home visitors as they wholeheartedly practiced it in their work and their lives, whereas mothers’ recognition of their strengths was less clear. The second theme shows that MIHOW program staff and mothers achieved many of their life aspirations, as well as established new visions and overcame obstacles. The third theme shows that women participating in MIHOW were making a difference by simultaneously leading from in front (as role models) and from beside (as collaborative team members), which included the factors of authentically walking the walk of the strength-based approach, listening and observing with an open mind, collaborating with humility, and advocating for and with mothers. Findings were also interpreted through an examination of Robert K. Greenleaf’s servant leadership principles and the theoretical frame of social justice feminism. The combination of Robert K. Greenleaf’s (2002) servant leadership and social justice feminism was exemplified in MIHOW’s leadership from in front and from beside as it provided a respectful, supportive, encouraging, and egalitarian environment, which for many program staff and mothers increased their self-advocacy beliefs, fostered their leadership growth, empowered them to be the “leaders they wanted to be,” and transformed them into “movers and shakers” in their communities. 

Bialk, K. J. (2016). Women Leading to Make a Difference: An Inside Look at a Strength-based Home Visiting Program in Rural Appalachia. (Doctoral dissertation). Retrieved from Marshall Digital Scholar. Theses, Dissertations and Capstones. (1020)

Evaluating Empowerment of Women in the Maternal Infant Health Outreach Worker (MIHOW) Home Visiting Project in Rural Appalachia  by Erin Maloney

When measuring the empowerment of participants in a study, researchers face two initial challenges. First, they must define empowerment in a way that is accurate for the population measured. At the same, they must assure that they study design is not dis-empowering to its participants. The Maternal Infant Health Outreach Worker (MIHOW) Project, a home visiting project for pregnant women and mothers in rural Appalachia and the Mississippi Delta under the direction of the Center for Health Services at Vanderbilt University faced these challenges in designing an evaluation to measure the empowerment of its participants in rural, southwestern Virginia from 1990 to 1993. This paper examines participants' empowerment compared to that of non-participants and also explores what aspects of the evaluation were empowering to the women interviewed.  MIHOW participants scored significantly better than non-participants near the 12-month birthdays of their children on three of the empowerment measures -- Knowledge of Community Resources, Availability of Family Support, and Helpfulness of Family Support -- while non-participants scored significantly betten than MIHOW participants on Use of Community Resources. The survey's Consent for Research Study and use of self-report were regarded as empowering while two demographic questions -- asking for social security number and whether a pregnancy was planned -- were considered dis-empowering.

Maloney, E. (1995). Evaluating empowerment of women in the MIHOW home visiting project in rural Appalachia. (Unpublished report).  Nashville, TN: Vanderbilt University

The Maternal Infant Health Outreach Worker Project: Appalachian Communities Help Their Own by Barbara Clinton

In the early 1980s, the Ford Foundation launched a grants program called Child Survival/A Fair Start for Children (CS/FS) that addressed issues related to birth and infant health and development among families that were poor and underserved by traditional human services. This book reports on each of seven CS/FS projects, describing the concerns and living conditions of the families served; the project objectives, curriculum, and staff; the methods and findings of project evaluation; and the program elements continued in the community after the initial funding ended. It also provides a cross-project view of the process of program implementation, the costs of the services, and the overall effectiveness of the program.  Chapter 2, "The Maternal Infant Health Outreach Worker Project: Appalachian Communities Help Their Own" (Barbara Clinton), details how the MIHOW program came to exist and outlines the demonstration project. The project provided MIHOW services to more than 40 women in several Appalachian communities and compared their outcomes to a comparison group of mothers in the same communities. Project measures included birth outcomes, breastfeeding, family environment (HOME Inventory), and infant development (Denver Developmental Screening Test).

Clinton, B. (1992). The Maternal infant health outreach worker project: Appalachian communities help their own.  In M. Larner, R. Halpern, and O. Harkavy (Eds.), Fair Start for children: Lessons learned from seven demonstration projects, 23-45. New Haven, CT: Yale University Press

Against the Odds: Parenting in Disadvantaged Communities by Barbara Clinton

This report discusses the results of a qualitative evaluation of the Maternal Infant Health Outreach Worker (MIHOW) project which served over 500 low-income women from 1982 through 1990. The MIHOW project provides outreach services to low-income families in rural communities in Tennessee, Kentucky, Virginia, and West Virginia. Working in partnership with Vanderbilt University, locally based community organizations provide training and supervision to local women leaders, all of whom are uniquely qualified to support their peers and to implement high quality child development services. Forty-six participants responded to open-ended questions which were defined through focus groups. The report describes the poverty of the participants and their lack of education, health care, and employment. The extended family is often a source of support for mothers, but if the mother is unmarried, she is often rejected by her family. Although fathers are not active in the program, they show some interest in becoming involved. The MIHOW worker is able to develop and maintain a relationship with the client because of a shared history, sound information, confidentiality, and a warm personality. The MIHOW project has impacted participants in the following ways: (1) combatting isolation and loneliness; (2) developing a relationship with a caring person (the MIHOW worker); (3) fostering assertiveness; (3) improving self-esteem and goal setting; (4) making sounder health decisions for both mother and child; (5) improving children's skills; and (6) helping parents to gain insights into their children's behavior. Recommendations focus on relationships between workers and mothers, education and work needs, and additional group sharing meetings for participants. Numerous black and white photographs illustrate the text. Study questions are appended.

Clinton, B. (1990). Against the Odds: Parenting in Disadvantaged Communities. Report to the Bernard Van Leer Foundation.  The Hague, Netherlands