An elastic net penalized small area model combining unit- and area-level data for regional hypertension prevalence estimation

Hypertension is a highly prevalent cardiovascular disease. It marks a considerable cost factor to many national health systems. Despite its prevalence, regional disease distributions are often unknown and must be estimated from survey data. However, health surveys frequently lack in regional observations due to limited resources. Obtained prevalence estimates suffer from unacceptably large sampling variances and are not reliable. Small area estimation solves this problem by linking auxiliary data from multiple regions in suitable regression models. Typically, either unit- or area-level observations are considered for this purpose. But with respect to hypertension, both levels should be used. Hypertension has characteristic comorbidities and is strongly related to lifestyle features, which are unit-level information. It is also correlated with socioeconomic indicators that are usually measured on the area-level. But the level combination is challenging as it requires multi-level model parameter estimation from small samples. We use a multi-level small area model with level-specific penalization to overcome this issue. Model parameter estimation is performed via stochastic coordinate gradient descent. A jackknife estimator of the mean squared error is presented. The methodology is applied to combine health survey data and administrative records to estimate regional hypertension prevalence in Germany.