Open Access Publications

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Open access publications by faculty, postdocs, and graduate students in the Biden School of Public Policy & Administration.

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Where power and scholarship collide: Gender and coauthorship in public administration research
(Public Administration Review, 2025-01-14) Smith, Amy E.; Riccucci, Norma M.; Isett, Kimberley R.; DeHart-Davis, Leisha; Sims, Rebekah St. Clair
Publishing is a source of capital and power in academia, and coauthoring is a common way to publish. However, studies in public administration have not yet examined the structure of coauthorship patterns, how these patterns have evolved over time, or the extent to which these patterns are gendered. We use bibliometric data to examine coauthorship in public administration scholarship over four decades with a particular focus on gendered patterns. Descriptive statistics, regression, and social network analysis suggest that when women are first authors, the research team is more likely to contain other women and while women are increasingly represented in coauthorship structures, men-only groups of coauthors continue to persist. These findings have implications for the coauthoring practices of individual scholars, perceptions of coauthorship in hiring, tenure, and promotion decisions, and efforts in the field to promote diversity, equity, and inclusion. Evidence for practice - Coauthorship patterns and the extent to which these patterns are gendered should be of interest to public administration scholars because collaborations are important in the production of scientific research, affect individual researcher productivity, and, increasingly, can be factors in funding opportunities. - Given the high value placed on social equity in public administration, the inclusiveness of collaboration with respect to gender is important. - Individual scholars should be mindful of how coauthorship provides access to research networks. In this context, considering gender diversity in research teams is important. - In tracking bibliometric measures, journals should consider not only gender diversity in authorship of published articles, but also of those submitting to the journal.
Blending the two communities: concurrent evidence use in state-level policy processes
(Public Management Review, 2025-01-07) Isett, Kimberley R.; Hicks, Diana; Kingsley, Gordon
The evidence-based paradigm is one way to ensure public resources are put to effective use. But the uptake of scientific evidence has been limited. We analyse US state reports on autonomous vehicles and the opioid crisis response to explore how evidence is used in state-level processes. We find evidence of three knowledge types -scientific, practice, and political - visible in the reports and extend existing work on knowledge types in use to illustrate not just that they are used, but that they are used in conjunction with each other. These findings require a re-examination of the way ‘evidence’ is discussed in the literature.
Steering the future: expert knowledge and stakeholder voices in autonomous vehicle policy reports
(Policy and Society, 2025-01-11) Hicks, Diana; Kingsley, Gordon; Isett, Kimberley R.
The anticipated arrival of autonomous vehicles has created considerable uncertainty for US states because they govern roads. In response, states activated their policy advisory systems. While policy advising at the national level has been studied, less is known about the sub-national level. Similarly, more is known about the use of scientific knowledge by policymakers than about the full range of knowledge deployed in policy advising. This study analyzes reports written for states to help them make sense of an emerging technology in preparation for governance. Committees, university researchers, staff at Department of Transportation, and legislative staff produced different types of reports, for example, more and less academic, focused more or less on topics associated with governance or engineering. Our analysis reveals that state policy advisory systems used two types of processes—convening and expert—and employed three types of expertise—academic, practical, and political—to help prepare to govern this emerging technology. The study provides insight into how states mobilized expertise to address uncertainty around an emerging technology, showing how different actors balanced the need for credible technical knowledge with legitimate stakeholder engagement.
Democracy at Risk in the United States: Strategic Perspectives and Role of Universities and Communities
(Transylvanian Review of Administrative Sciences, 2024-12-11) Aristigueta, Maria P.
This paper discusses the backsliding of democratic systems that are occurring throughout the world and focuses on the decline in the United States of America that began in 2006. It incorporates the important benefits of democracy and what role public administration, non-profit organizations, and higher education can and should play to sustain, maintain, and enhance democratic institutions. Included are also the future of democracy in the USA, threats presented by the binary political system, 2024 presidential election results, and critical importance of constitutional structure. Although the future of democracy remains in question in the USA, the paper concludes with signs of hope that our democratic system will prevail.
Insurability and government-funded mitigation: safer but costlier
(The Geneva Papers on Risk and Insurance - Issues and Practice, 2024-11-26) Liu, Dahui; Nozick, Linda; Millea, Meghan; Kruse, Jamie; Davidson, Rachel; Trainor, Joseph; Li, Junkan; Williams, Caroline
Hurricanes significantly harm homeowners through physical damage and long-term financial strain due to rising insurance costs, property value loss, and repair expenses. This paper focuses on the interrelated decisions of the government mitigation funding of residential acquisitions and retrofit subsidies and of price restrictions on the insurance market in eastern North Carolina to determine the financial effects on stakeholders. The introduction of these policy interventions have impacts that propagate through the system due to risk adjustments, homeowner take-up behaviour, and insurer profit-maximising behaviour. This study uses an integrated game theoretic model to demonstrate that there are cost-effective government spending levels that reduce residential loss from hurricane damage. When insurance prices are capped at preintervention levels, the number of households and their distribution of losses, which has been altered through mitigation, leads to increased insurer insolvency. When insurance prices are allowed to adjust after mitigation, some homeowners find insurance is no longer affordable. This highlights the tradeoff between ensuring insurer stability and expanding homeowner insurance accessibility.
Energy Service Security for Public Health Resilience: Perception and Concerns in Western Upper Peninsula of Michigan
(Rural Sociology, 2024-10-07) Tiwari, Shardul; Ketola, Zoē; Schelly, Chelsea; Boyer-Cole, Eric
The Western Upper Peninsula of Michigan includes six rural counties and one Tribal Nation. The region is characterized by long winters, legacies of the extractive mining economy, and the infrastructural features of extreme rurality, including aging housing and low health service density. The region also faces exceptionally high electricity prices. There is limited research on the public health implications of energy service disruption in rural regions resulting from the increasing intensity and frequency of weather events caused by climate change. This article presents research findings examining the readiness of health facilities in this area to manage the rising intensity, severity, and frequency of severe weather that could disrupt energy services. The study also considers how this knowledge can guide decision-making to improve energy service access and maintain resilient public health services in the region. This exploratory study utilized a qualitative approach that combines semi-structured interviews with public health stakeholders and a short survey to triangulate the findings from health facilities. Given the pivotal role of dependable energy services in community health, these findings underscore the community's perception of self-reliance as both an asset and a hurdle. This perception aligns with the realities of rural communities at the “end of the line” regarding critical infrastructure, which also serves as a formidable barrier to social organization and infrastructure access during energy service disruptions that can severely impact public health. Practitioner Points 1. People living in the Western Upper Peninsula of Michigan perceive themselves as self-reliant, which can hinder socially organized responses to disasters. 2. Energy access is a key component for providing public health services, and the perception of self-reliance may limit proactive planning for infrastructure access to support public health needs during a disruption. 3. Focusing on energy services in rural communities is critical to developing resilience.
Taking Stock of Recent Progress in Livelihood Vulnerability Assessments to Climate Change in the Developing World
(Climate, 2024-07-08) Zainab, Atoofa; Shah, Kalim U.
Over the past few decades, the use of vulnerability assessments has grown substantially to support rural communities in developing countries. These studies aim to help these communities achieve their livelihood goals, such as sustainable resource use and adaptation to global changes, by evaluating their susceptibility to climate change impacts. This systematic review critically examines the extensive body of literature on Livelihood Vulnerability Index (LVI) assessments related to climate change impacts in developing countries. By synthesizing findings from various studies, this review highlights patterns and methodologies used to understand the effects of climate change on vulnerable populations. Key focus areas include geographical distribution, methodological approaches, and the frameworks utilized in vulnerability assessments. The review identifies prominent frameworks, such as the LVI and LVI-IPCC, which integrate indicators of sensitivity, exposure, and adaptive capacity to evaluate climate risks. Findings reveal a concentration of studies in Asia and Africa, with a strong emphasis on agricultural and coastal ecosystems. Methodologically, there is a notable reliance on stratified random sampling to accurately capture community and household-level vulnerabilities. A detailed comparative analysis of the LVI, LVI-IPCC, and Sustainable Livelihood Framework (SLF) is also presented, highlighting their characteristics, benefits, and limitations. The review underscores the need for methodological refinements to better address temporal and regional variations in vulnerability. It concludes with recommendations for future research, integrating broader climate scenarios, exploring sectoral interdependencies, and adopting dynamic approaches to enhance the accuracy and applicability of vulnerability assessments.
Risk Factors for Homelessness Among Post-9/11 Era Veterans
(Armed Forces & Society, 2024-07-25) Metraux, Stephen; Kolaja, Claire A.; Crone, Baylee; Byrne, Thomas; Rull, Rudolph P.; Porter, Ben
This study examined the associations between a broad range of individual characteristics and homelessness among 49,323 post-9/11 era Veterans. Questions concerning the roles of premilitary, military and post military factors in Veteran’s vulnerability to homelessness have persisted despite the considerable attention given to Veteran homelessness, and has highlighted the absence of longitudinal studies that could contribute to the empirical understanding of risk and protective factors among this population. The Veterans in this study group completed Millennium Cohort Study surveys during their military service and subsequently, when they transitioned back to civilian life. Among these Veterans, 1,071 (2.2%) reported becoming homeless after separating from the military. Results from multivariate models provide limited empirical support for direct links between aspects of military service and homelessness that are widely used to explain why Veterans become homeless. Instead, many risk factors for homelessness found here mirror risk factors among the general population. We also find a persistent association between sexual orientation and risk for homelessness, and decreased risk for homelessness among female Veterans. These findings challenge popular conceptions of why Veterans become homeless and contribute to understanding the dynamics of becoming homeless among this current Veteran cohort.
Homelessness In Delaware: An Assessment
(Delaware Journal of Public Health, 2023-06-12) Metraux, Stephen; Peuquet, Steven W.
The authors provide an assessment of trends and dynamics of homelessness in Delaware since 2007, when the last systematic study of this topic was released. Using population data on homelessness in the state, the authors present evidence that, after a period of apparent stability, homelessness in Delaware is currently at levels that are unprecedentedly high, while providers of homeless services have not adapted to this change. As a first step to addressing this alarming trend, the authors call for stakeholders to regroup and develop a coordinated, statewide approach to address this problem.
A comparative assessment of household power failure coping strategies in three American cities
(Energy Research and Social Science, 2024-05-19) Andresen, Adam X.; Kurtz, Liza C.; Chakalian, Paul M.; Hondula, David M.; Meerow, Sara; Gall, Melanie
Household power outage experiences vary based on outage characteristics and the household's ability to cope with a disruption. While disaster management scholarship has produced methods to predict where the most significant impacts of a hazard may occur, these methods do not anticipate secondary effects, such as those from power outages. This research is necessary as the expected risks associated with power outages will increase in the United States due to climate change, increasing electricity demand, and aging infrastructure. To understand households' power outage experiences, we collected 896 surveys from three cities in the United States: Detroit, MI; Miami, FL; and Phoenix, AZ. Participants were recruited through Amazon's Mechanical Turk (MTurk) service to complete a survey. We hypothesized that racial/ethnic minority groups, specifically non-white households and lower-income households experienced more frequent and prolonged power outages. We also hypothesized that the same groups were more likely to have experienced more significant adverse effects, such as throwing away perishable food and not receiving assistance. We found that non-white households in Phoenix and Detroit were more likely to experience longer outages than white households; however, this association was not present in Miami and was not statistically significant in any city. Income was not a major factor in predicting food waste or assistance received during the longest self-reported outage. Further assessments in varying geographical contexts and more generalizable samples are necessary to increase understanding of how households experience power outages.
Profiling national institutional archetypes for climate change technology implementation: application in small islands and least developed countries
(Mitigation and Adaptation Strategies for Global Change, 2024-04-19) Shah, Kalim U.
In developing countries, when the implementation success of new climate adaptation and mitigation technologies fall short of expectations, the typical “suspects” cited are lack of funding or country expertise and allusions to “lack of institutional capacity.” The premise of this study is that the national institutional environment is the fundamental prerequisite for successful technology implementation, and despite much effort, a diagnostic approach to assessing this prerequisite is missing. Here, I propose an approach to do this, based on an understanding of the dynamics that interconnect country-level legal, regulatory and market mechanisms, societal norms, and inter/intra governmental structures. I estimate levels of country structural and systems supports, operating environment, implementer acceptance and country tractability. A preliminary test of the approach was completed through a survey of experts involved in the United Nations Technology Needs Assessment programs in Least Developed and Small Island Developing Countries. It was found that countries fall into four fundamental archetypes. A country’s archetype suggests characteristics of the institutional environment that help to explain the potential for technology implementation success. A further implication is that some countries that typically would not be considered very similar may possess similar country institutional environments. One consequence of this is that archetype-based groups could work together and learn from each other more effectively.
Assessing the Connectivity of Urban Green Spaces for Enhanced Environmental Justice and Ecosystem Service Flow: A Study of Tehran Using Graph Theory and Least-Cost Analysis
(Urban Science, 2024-02-05) Alavi, Seyed Ali; Esfandi, Saeed; Khavarian-Garmsir, Amir R.; Tayebi, Safiyeh; Shamsipour, Aliakbar; Sharifi, Ayyoob
This research aims to analyze the relationship between environmental justice and urban green space connectivity in Tehran, Iran. The evaluation of green space connectivity in this study is conducted through two distinct cost layers: one aimed at enhancing existing connections and another focused on establishing new green spaces. Key factors influencing connectivity, extracted from the relevant literature, were identified to facilitate this analysis. Employing graph theory and least-cost analysis, the results determined critical resistance factors, current connectivity and cost status, the varying degrees to which different districts benefit from green space ecosystem services, and the most effective routes for establishing green corridors. Research findings highlight significant disparities in access to these services, particularly in the underserved central districts of Tehran. Moreover, spatial analysis reveals a higher potential for enhancing east–west ecosystem service corridors due to the higher density of green hubs and lower costs in this orientation, while north–south connectivity faces more challenges. By exploring land use/land cover, and physical and socio-economic factors affecting urban green space connectivity, this study provides urban and environmental planners with a novel methodology and comprehensive insights for effective decision making, resource allocation, and land use planning.
Smart Cities and Urban Energy Planning: An Advanced Review of Promises and Challenges
(Smart Cities, 2024-01-31) Esfandi, Saeed; Tayebi, Safiyeh; Byrne, John; Taminiau, Job; Giyahchi, Golkou; Alavi, Seyed Ali
This review explores the relationship between urban energy planning and smart city evolution, addressing three primary questions: How has research on smart cities and urban energy planning evolved in the past thirty years? What promises and hurdles do smart city initiatives introduce to urban energy planning? And why do some smart city projects surpass energy efficiency and emission reduction targets while others fall short? Based on a bibliometric analysis of 9320 papers published between January 1992 and May 2023, five dimensions were identified by researchers trying to address these three questions: (1) energy use at the building scale, (2) urban design and planning integration, (3) transportation and mobility, (4) grid modernization and smart grids, and (5) policy and regulatory frameworks. A comprehensive review of 193 papers discovered that previous research prioritized technological advancements in the first four dimensions. However, there was a notable gap in adequately addressing the inherent policy and regulatory challenges. This gap often led to smart city endeavors underperforming relative to their intended objectives. Overcoming the gap requires a better understanding of broader issues such as environmental impacts, social justice, resilience, safety and security, and the affordability of such initiatives.
Factors Associated with Antihypertensive Therapy Prescription in Youth Delaware Medicaid Recipients with Primary Hypertension Diagnosis
(American Journal of Hypertension, 2023-10-21) Baker-Smith, Carissa M.; McDuffie, Mary J.; Nescott, Erin P.; Akins, Robert E.
BACKGROUND Higher neighborhood deprivation is associated with hypertension diagnosis in youth. In this study, we assess if there is an association between neighborhood deprivation and antihypertensive therapy prescription among insured youth with a primary hypertension diagnosis. METHODS Using a retrospective cross-sectional design, we assessed the proportion of youth with a diagnosis of primary hypertension prescribed antihypertensive therapy. We evaluated the proportion of youth prescribed antihypertensive therapy and compared prescribing patterns by area deprivation index (ADI), age, sex, obesity diagnosis, race, ethnicity, and duration of Medicaid coverage. RESULTS Of the 65,452 non-pregnant Delaware Medicaid recipients, 8–18 years of age, 1,145 (1.7%) had an International classification of diseases (ICD)-9/ICD-10 diagnosis of primary hypertension; 165 of the 1,145 (14%) were prescribed antihypertensive therapy. Factors associated with a greater odds of prescription by multivariable logistic regression were age, obesity diagnosis, and duration of Medicaid full benefit coverage. Odds of antihypertensive therapy prescription did not vary by race, ethnicity, or ADI. CONCLUSIONS Antihypertensive therapy prescription rates are poor despite national guideline recommendations. Among youth receiving Delaware Medicaid between 2014 and 2019, prescription proportions were highest among youth of older age, with an obesity diagnosis, and among youth with longer duration of Medicaid benefit coverage. Although high area deprivation has been shown to be associated with the diagnosis of hypertension, high vs. low area deprivation was not associated with greater antihypertensive therapy prescription among youth with primary hypertension. Our finding of a mismatch between hypertension diagnosis and antihypertensive therapy prescription highlights a potential disparity in antihypertensive therapy prescription in youth. Graphical abstract available at: https://doi.org/10.1093/ajh/hpad098
Integrating bioplastics into the US plastics supply chain: towards a policy research agenda for the bioplastic transition
(Frontiers in Environmental Science, 2023-10-16) Shah, Kalim U.; Gangadeen, Isaiah
Bioplastics have the potential to fill the role of conventional plastics but with lowered environmental and ecological impacts. But bioplastic production suffers from high production costs and as an immature technology, it proves less competitive than its petrol-based counterpart. Debates about the social versus private benefits of bioplastics are also cited. The literature argues that various bio-feedstock sources can produce high-quality drop-in plastics and that scaling up bioplastic production will provide the cost competitiveness needed to transition away from petroplastics. However, the market remains uncoordinated and lacks a strategic and comprehensive plan for the plastic transition. Moreover, the science-to-policy literature on bioplastics is very limited, providing scarce evidence or analysis to policymakers attempting to argue for bioplastics industrialization and integration. In this study we highlight this missing link particularly in the North American context in order to encourage further inquiry on these matters. Using Stern’s policy framework gap analysis approach, our evaluation identifies gaps in existing policy frameworks pertinent to bioplastics supply chains. On this basis we identify and prioritize five pointed areas for policy focus to advance bioplastics sector growth and integration. These are developing a strategy to sustainably coordinate and promote biomass production; incentivizing bioplastic investments and production; incentivizing bioplastic substitution; and enhancing the end-use management. Additionally, research is needed to support the technical performance of bioplastics, industrialization methods, supply chain integration, and the impact of exogenous factors.
Introduction: Managed retreat and environmental justice in a changing climate
(Journal of Environmental Studies and Sciences, 2021-05-15) Siders, A. R.; Ajibade, Idowu
In response to global climate change, managed retreat has emerged as a controversial adaptation strategy. The purposeful movement of people and communities away from hazardous places raises numerous social and environmental justice concerns that will become even more pressing as retreat occurs more frequently and at larger scales. This special issue contributes to an emerging body of literature on managed retreat by providing a range of perspectives and approaches to considering justice in managed retreat. The assembled papers represent diverse voices (including perspectives from individuals whose communities are currently relocating or considering relocation), disciplines (including oral histories, legal analyses, and cultural heritage considerations), and lenses through which to consider the justice implications of managed retreat. They describe completed, in-progress, and foiled relocations. They suggest opportunities for improvement through improved evaluations and broader collaborations. While each presents a unique lens, key themes emerge around the need for transparent and equitable policies, self-determination of communities, holistic metrics for assessing individual and community well-being, the importance of culture both as something to be protected and an asset to be leveraged, and the need to address historical and systemic injustices that contribute to vulnerability and exposure to risk.
The Moderating Effect of Vaccine Hesitancy on the Relationship between the COVID-19 Vaccine Coverage Index and Vaccine Coverage
(Vaccines, 2023-07-04) Tolley, Annalise Julia; Scott, Victoria C.; Mitsdarffer, Mary Louise; Scaccia, Jonathan P.
To examine COVID-19 vaccination barriers in the US, this study drew on publicly available county-level data (n = 3130) to investigate the impact of vaccine hesitancy on the relationship between county-level social/structural barriers and vaccine coverage. A hierarchical regression was performed to establish the relationship between the COVID-19 Vaccine Coverage Index (CVAC) and vaccine coverage, assess the moderating effect of vaccine hesitancy on this relationship, and explore the influence of ethno-racial composition on vaccine coverage. A significant, negative relationship (r2 = 0.11, f2 = 0.12) between CVAC and vaccine coverage by county was established (step 1). When vaccine hesitancy was introduced as a moderator (step 2), the model significantly explained additional variance in vaccine coverage (r2 = 0.21, f2 = 0.27). Simple slopes analysis indicated a significant interaction effect, whereby the CVAC–vaccine coverage relationship was stronger in low hesitancy counties as compared with high hesitancy counties. Counties with low social/structural barriers (CVAC) but high hesitancy were projected to have 14% lower vaccine coverage. When county-level ethno-racial composition was introduced (step 3), higher proportions of white residents in a county predicted decreased vaccination rates (p < 0.05). Findings indicate that CVAC should be paired with vaccine hesitancy measures to better predict vaccine uptake. Moreover, counties with higher proportions of white residents led to decreases in vaccine uptake, suggesting that future intervention strategies should also target whites to reach herd immunity. We conclude that public health leaders and practitioners should address both social/structural and psychological barriers to vaccination to maximize vaccine coverage, with a particular focus on vaccine hesitancy in communities with minimal social/structural barriers.
Emergency Management Performance Grant (EMPG) funding allocations and relevance for US disaster policy
(Risk, Hazards and Crisis in Public Policy, 2023-05-12) Gerber-Chavez, Logan; Montano, Samantha; Savitt, Amanda; Corbin, Tanya B.; Downey, Davia C.
The Emergency Management Performance Grant (EMPG) program has long been a cornerstone of state and local emergency management preparedness efforts. Through the EMPG program, the Federal Emergency Management Agency (FEMA) administers grants to state and local emergency management agencies to accomplish a wide range of tasks such as the development of response and recovery plans, the creation of emergency operation centers, and the hiring of staff, among other activities required to be effective. EMPG provides the predominant federal funding for this mission, and many agencies depend on these funds for their operations. Despite the importance of EMPG, there is a dearth of empirical research about the program. This study explores this gap by evaluating how EMPG funds were distributed across United States counties from 2014 to 2020. Using FEMA and US Census data, we conducted a county-level analysis using robust regression statistical analysis to determine factors affecting funding awards. Findings indicate that high population, high diversity, a strong economy, and high risk (measured using both the National Risk Index score and the number of federal disaster declarations per county) increased the likelihood that a county would receive EMPG funds, with high-risk urban counties rather than rural counties receiving more funding.
Understanding the social impacts of power outages in North America: a systematic review
(Environmental Research Letters, 2023-05-09) Andresen, Adam X.; Kurtz, Liza C.; Hondula, David M.; Meerow, Sara; Gall, Melanie
As demand for electricity increases on an already strained electrical supply due to urbanization, population growth, and climate change, the likelihood of power outages will also increase. While researchers understand that the number of electrical grid disturbances is increasing, we do not adequately understand how increased power outages will affect a society that has become increasingly dependent on a reliable electric supply. This systematic review aims to understand how power outages have affected society, primarily through health impacts, and identify populations most vulnerable to power outages based on the conclusions from prior studies. Based on search parameters, 762 articles were initially identified, of which only 50 discussed the social impacts of power outages in North America. According to this literature, racial and ethnic minorities, especially Blacks or African Americans, those of lower socioeconomic status, children, older adults, and those living in rural areas experienced more significant impacts from previous power outages. Additionally, criminal activity increased during prolonged power outages with both pro-social and anti-social behaviors observed. Providing financial assistance or resources to replace spoiled goods can reduce crime. Future research on this topic must consider the financial effects of power outages, how power outage impacts seasonally vary, and the different durations of power outage impacts.
Association of Area Deprivation With Primary Hypertension Diagnosis Among Youth Medicaid Recipients in Delaware
(Jama Network Open, 2023-03-15) Baker-Smith, Carissa M.; Yang, Wei; McDuffie, Mary J.; Nescott, Erin P.; Wolf, Bethany J.; Wu, Cathy H.; Zhang, Zugui; Akins, Robert E.
Key Points: Question: Is there an association between neighborhood measures of deprivation and hypertension diagnosis in youth? Findings: In this cross-sectional study of 65 452 Delaware Medicaid-insured youths aged 8 to 18 years between 2014 and 2019, residence in neighborhoods with a higher area deprivation index was associated with primary hypertension diagnosis. Meaning: These findings suggest that there is an association between greater neighborhood deprivation and a diagnosis of primary hypertension in youths, which may be an important factor to consider in assessing the presence and prevalence of hypertension in youths. Abstract: Importance: The association between degree of neighborhood deprivation and primary hypertension diagnosis in youth remains understudied. Objective: To assess the association between neighborhood measures of deprivation and primary hypertension diagnosis in youth. Design, Setting, and Participants: This cross-sectional study included 65 452 Delaware Medicaid-insured youths aged 8 to 18 years between January 1, 2014, and December 31, 2019. Residence was geocoded by national area deprivation index (ADI). Exposures: Higher area deprivation. Main Outcomes and Measures; The main outcome was primary hypertension diagnosis based on International Classification of Diseases, Ninth Revision and Tenth Revision codes. Data were analyzed between September 1, 2021, and December 31, 2022. Results: A total of 65 452 youths were included in the analysis, including 64 307 (98.3%) without a hypertension diagnosis (30 491 [47%] female and 33 813 [53%] male; mean [SD] age, 12.5 (3.1) years; 12 500 [19%] Hispanic, 25 473 [40%] non-Hispanic Black, 24 565 [38%] non-Hispanic White, and 1769 [3%] other race or ethnicity; 13 029 [20%] with obesity; and 31 548 [49%] with an ADI ≥50) and 1145 (1.7%) with a diagnosis of primary hypertension (mean [SD] age, 13.3 [2.8] years; 464 [41%] female and 681 [59%] male; 271 [24%] Hispanic, 460 [40%] non-Hispanic Black, 396 [35%] non-Hispanic White, and 18 [2%] of other race or ethnicity; 705 [62%] with obesity; and 614 [54%] with an ADI ≥50). The mean (SD) duration of full Medicaid benefit coverage was 61 (16) months for those with a diagnosis of primary hypertension and 46.0 (24.3) months for those without. By multivariable logistic regression, residence within communities with ADI greater than or equal to 50 was associated with 60% greater odds of a hypertension diagnosis (odds ratio [OR], 1.61; 95% CI 1.04-2.51). Older age (OR per year, 1.16; 95%, CI, 1.14-1.18), an obesity diagnosis (OR, 5.16; 95% CI, 4.54-5.85), and longer duration of full Medicaid benefit coverage (OR, 1.03; 95% CI, 1.03-1.04) were associated with greater odds of primary hypertension diagnosis, whereas female sex was associated with lower odds (OR, 0.68; 95%, 0.61-0.77). Model fit including a Medicaid-by-ADI interaction term was significant for the interaction and revealed slightly greater odds of hypertension diagnosis for youths with ADI less than 50 (OR, 1.03; 95% CI, 1.03-1.04) vs ADI ≥50 (OR, 1.02; 95% CI, 1.02-1.03). Race and ethnicity were not associated with primary hypertension diagnosis. Conclusions and Relevance; In this cross-sectional study, higher childhood neighborhood ADI, obesity, age, sex, and duration of Medicaid benefit coverage were associated with a primary hypertension diagnosis in youth. Screening algorithms and national guidelines may consider the importance of ADI when assessing for the presence and prevalence of primary hypertension in youth.

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