BACKGROUND AND SIGNIFICANCE

The COVID-19 pandemic significantly increased remote visits for health care and supportive education, whether by telephone or video, across the medical spectrum. Although this increase has been documented for healthcare systems (Doximity, 2020; Patel et al., 2021; Shaver, 2022; Weiner et al., 2021), the changes are understudied for public health, particularly health promotion programs. There are Ten Essential Public Health Services that outline the core activities public health systems should carry out to improve community health, and information technology plays a vital role in supporting these services (Public Health Accreditation Board, 2022). One of the essential services is to communicate effectively to inform and educate people about health, factors that influence it, and how to improve it. Another emphasizes the need to build and maintain strong organizational competencies (Public Health Accreditation Board, 2022). Unlike the implementation of remote health services within hospitals and health systems, state public health programs support organizations of varying sizes and capacities that deliver public health services. These include not only local county health departments (LHDs), but also community-based organizations that deliver public health services, including health promotion activities. There is wide variation in the information technology (IT) support available for health promotion programs and activities. In addition to the complexities of supporting core public health services, other organizations can be involved in information management for local health departments. For example, the city or county IT department most commonly performs functions related to LHD IT maintenance and system security (National Association of County and City Health Officials, 2019). State health agencies also play a primary role in IT acquisition and support.

While there is a body of literature supporting health promotion workforce development (Action Collaborative on Clinician Well-Being and Resilience & National Academy of Medicine, 2024) and emerging literature on best practices for remote services (Telehealth.HHS.gov, n.d.), little to no attention has been given to the IT workforce that is needed to support both the health promotion workforce and those receiving the remote services. A decade ago, even basic internet access was not ubiquitous; a 2016 study showed that 9% of LHDs in the United States had limited broadband/high-speed Internet (Shah et al., 2016). Gaps in capacity and training are such that there is “an urgent need to strengthen the informatics infrastructure and capacity of local health departments (LHDs) in the United States” (Khurshid et al., 2020, p. 323). Even though resources have grown over the past decade, concerns about public health IT capacity remain.

Furthermore, there are significant capacity differences between larger and more urban and rural health departments. Evidence of the disparities predates the COVID pandemic. Of the variety of systems and IT functions that are necessary for core public health services, large LHDs (serving more than 500,000 people) are more likely than LHDs serving smaller populations to have implemented the majority of them (National Association of County and City Health Officials, 2019). LHDs serving fewer than 50,000 people need to perform basic IT functions, including immunization registries and electronic disease reporting, leaving little capacity for things like electronic health records and health information exchanges (National Association of County and City Health Officials, 2019), much less supporting remote services at the participant level. Recently, several papers have been published on public health surveillance functions (Shah et al., 2016). Following the COVID-19 pandemic, there has been a surge in research on the adoption of telemedicine (Brociner et al., 2022; Hare et al., 2022; Reisinger-Kindle et al., 2021). However, there is a paucity of research on the capacity to support patient-facing public health programs in the era of telehealth and remote services.

One such public-facing public health program is the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which provides public health services to low-income pregnant and postpartum individuals, as well as children under the age of 5. Local WIC programs serve nearly 7 million individuals each year, making it one of the largest direct service public health programs (U.S. Department of Agriculture (USDA), Food and Nutrition Service (FNS), 2023). WIC provides nutrition and health screening, breastfeeding and health promotion, supplemental foods, and nutrition education. Although traditionally services have been delivered in person, the COVID-19 pandemic necessitated a switch to remote service delivery, most often by telephone (USDA, FNS, 2023).

The American Rescue Plan Act of 2021 (Pub. L. No. 117–2, 135 Stat. 4, 2021) gave USDA the authority to grant waivers to support innovations and modernization in WIC. The USDA has since allowed state agencies to opt into waivers to modernize WIC through building or enhancing remote services. Waivers were not accompanied by any additional funding or resources to support remote services (USDA, FNS, n.d.-b), but rather depend on county health departments and local community-based organizations to have the necessary IT resources and capacity to initiate and sustain high-quality remote services (USDA, FNS, n.d.-a). The waivers remain in effect through September, 2026. In Oregon, there are a limited number of WIC state staff who provide application support to local agency WIC staff for the WIC Management Information System, which is managed at the State level. A state supported texting program is also available. However, there is no standardized platform for remote video-based visits, and the local agencies that provide this option select their own platform. Technical support is largely dependent on local IT staff.

Beyond organizational limitations at the State and local levels, WIC participants may also experience barriers to remote services. Oregon ranks 21st among states in BroadbandNow’s annual rankings of internet coverage, speed, and availability (BroadbandNow, 2025). Twenty-nine percent of households earning less than $20,000 per year in Oregon do not have internet access (BroadbandNow, 2025). While 67% of Oregon residents live in urban areas, ten of Oregon’s 36 counties are considered frontier, meaning that they have 6 or fewer people per square mile. For example, in one of the frontier counties, only 47.3% of residents have access to a minimum of 25 Mbps speed internet, which is inadequate for internet-intensive activities (BroadbandNow, 2025) or supporting multiple users in a household. This variation in population density and internet access highlights the need to understand how IT capacities differ across county contexts. The goal of this project was to describe the current landscape of IT capacity that serves WIC local agencies in Oregon. This project was part of a larger study examining the readiness to deliver and receive tele-WIC services across Oregon.

METHODS

A State WIC staff member sent an email invitation to all local agency WIC coordinators, requesting that they pass the survey on to the IT staff who support their program. The survey contained 27 items, including 4 open-ended questions, and respondents were given 2 weeks to complete it.

The survey was informed by a literature review of telehealth readiness concepts (Alliance for Building Capacity, 2002; Demiris et al., 2004; Jennett et al., 2005; Khoja et al., 2007; Légaré et al., 2010; Uscher-Pines et al., 2020). There were three focus areas: IT staff roles and capabilities, IT perception of WIC staff and participant needs, and IT recommendations for tele-WIC implementation. Because no WIC-specific instruments were available, concepts and questions were primarily adapted from the work of Jennett et al. (2005), Khoja et al. (2007), and Demiris et al. (2006).

The survey was collected via Qualtrics (Qualtrics, n.d.). Descriptive statistics were conducted with IBM SPSS Statistics for Windows (IBM Corp., 2023). Two researchers reviewed answers to the four open-ended questions. Each researcher selected quotes from the responses, and those that were independently selected by both were included to illustrate the respondents’ common sentiments.

The project was approved for expedited review by the Institutional Review Board of the Oregon Health Authority. A study information sheet was displayed as the first page of the online survey, accompanied by a checkbox to indicate consent to participate in the study. No incentives were offered for participation.

RESULTS

Of the 31 local WIC agencies invited to participate, 25 IT staff responded. Two local agency coordinators reported that their agency had no permanently employed IT staff and therefore no one to give the survey to.

IT staff roles and capacity. Survey respondents’ roles varied greatly, with 72% of IT support staff reporting that their organization was a county health department, and 12% providing the entire county government with IT support. The remaining were from non-profit organizations and an educational service district. The majority described themselves as IT director, IT manager, or technology support, with several describing their role as business or systems analyst. The number of employees supported by IT staff ranged from 25 to 2500. Similarly, the number of total IT staff in organizations varied from just 1 to a total of 80. Supporting multiple departments was common among IT staff; for example, when asked to list the departments supported (in addition to public health), one respondent replied, “Sheriff’s Office, Public Works, Elections, Asset & Taxations, Land Management, Human Resources, County Counsel.”

Respondents reported many responsibilities, including acquiring software and hardware, training people to use and support their use of hardware and software, regulatory compliance for information security, as well as installing and configuring the network and computing environments.

IT staff were asked about common challenges faced by their organization when adopting new technologies. Competing priorities for funding and time, lack of funds to support technology adoption, data privacy, confidentiality, and security were selected most frequently. A lack of administrative support, as well as staff reluctance towards new technology, were identified by just under half of the respondents as common challenges.

IT perception of WIC staff and participant needs. When asked about providing technical support for video or app-based tools for WIC visits, the IT staff perceptions differed depending on who needed help: WIC staff or WIC participants. While 74% said that they would provide technical support to staff most of the time, 55% reported that they would not expect to support WIC participants if WIC adopted video or app-based remote services. Instead, they identified either WIC local agency staff or state staff as being the primary source of technical support for WIC participants.

One IT staff respondent expressed that “My largest concern would be determining how [IT] staff would be responsible for helping non-staff end-users access the services. IT would not be interested in becoming a helpdesk for an entire community.” Another county IT office reported that they could not provide support, but also worried about WIC staff providing support, saying, “X [Our] County IT cannot support a hodgepodge mix of video or app-based tools for WIC services. IT is also not staffed to support WIC participants. County WIC staff should not be burdened in providing technical support for their clients [WIC participants], which would distract their focus in providing WIC services.”

IT recommendations. Familiarity and confidence with platforms that could be used for remote WIC services were assessed. IT staff were asked to look at a list of platforms and rate the degree to which they would recommend each for WIC to use. Of the list of options, including basic phone, platforms like Zoom, WebEx, and MS Teams, to email, and text. Respondents cited the telephone most often. This reflects the finding that when WIC went to remote delivery during COVID nationally, it was primarily through telephone (USDA, 2023).

When asked about considerations for choosing a platform, one respondent provided a nuanced view of the challenges: “We must only use software with a BAA [Business Associate Agreement] in place. We cannot afford to pay for multiple solutions. Currently, Zoom is our only paid-for service, and not all employees have a licensed version of this due to costs. Moving to other platforms could be costly. Our existing platforms, and those of our clients, may not exist on other platforms outside of Zoom or be limited to a technology vendor (FaceTime). We must make sure client information stays protected throughout as well, no unauthorized sharing or unauthorized PHI [protected health information] receipt.”

The perception of surveyed IT staff is that WIC participants’ digital skills and access to the internet are challenges when it comes to delivering remote services. For example, one respondent noted that “WIC participant literacy in using the tools and the real-time cybersecurity implications are the two primary concerns. This could open up identity theft and impersonation attacks against both WIC staff and participants if not implemented correctly. Current regulations are not currently supporting dynamic use of this type of technology without any means of confirming identity and security.” Quality of internet access is also a concern, as noted by one respondent: “The internet in my county is less than ideal, and many families don’t even have it.”

DISCUSSION AND CONCLUSIONS

IT staff felt prepared to support WIC staff on matters related to software troubleshooting and training, internet connectivity issues, as well as understanding and addressing security and privacy concerns. However, there isn’t a clear plan for who would reliably and consistently offer IT support for WIC participants to be able to use any video or app-based provision of WIC services. This isn’t only about tasks like downloading and using an application; additional concerns were raised around privacy and security that may require a higher level of technical support. These data suggest that the capacity and resources for IT staff to support remote visits and telehealth are limited.

Our finding that WIC agencies in rural areas reported minimal to no IT staff supports prior work, which finds differences between information technology staffing and capacity across counties. Harris et al. (2016) report that rural local health departments have fewer staff and resources than urban LHDs. Rural LHDs have limited access to technology and to information that is primarily available digitally. “Smaller LHDs are half as likely to have access to current information on evidence-based public health practices and current research compared with larger LHDs. Small/rural health departments are also less likely to adopt and use new media, such as Facebook and Twitter, which represent a promising strategy for meeting” (Harris et al., 2016, p. 176). The public health essential service needs to utilize appropriate and timely communication channels to reach its intended populations (Public Health Accreditation Board, 2022).

Investment in health promotion needs to extend beyond hiring and training health promotion staff or developing education materials. Although there is recent funding for the WIC Workforce Development Initiative, there is no mention of local agency IT staff (USDA, National Institute of Food and Agriculture, n.d.). Building foundational IT capacity (Public Health Accreditation Board, 2022) is essential if one expects to sustain the broad use of remote services with WIC participants. When grants are designed for digital modernization, such as WIC modernization grants or WIC e-solution grants, there needs to be a portion of the grant funding designated specifically for building local IT capacity to support its use, as well as improving the general digital literacy of WIC participants. Ironically, while funds are often available to purchase digital tools, they are rarely available to support individuals in using those tools effectively, placing an undue burden on county IT staff.

Equitable use of technologies to access public health services relies on both affordable internet access and support for using digital tools. One in eight Oregon households (The White House, n.d.) relied on the subsidies provided by the now sunsetted Affordable Connectivity Program (ACP) (Federal Communications Commission, n.d.) to connect with broadband services. Without investment in broadband infrastructure, affordable access for low-income families, and robust community-based digital literacy training, a reliance on technology may exacerbate existing health disparities.

ACKNOWLEDGMENTS, COMPETING INTERESTS, FUNDING AND ALL OTHER REQUIRED STATEMENTS.

IRB FWA# 00000520, approval PH IRB 20-20 Phase I

Funding: WIC internal funding provided

No conflicts of interest