# Untreated, uncontrolled and below-target hypertension in southern Africa: a population-based prevalence and care cascade assessment in rural Lesotho

## TL;DR

This study in rural Lesotho finds significant gaps in hypertension treatment and control, highlighting the need for better diagnostic accuracy and adherence to treatment protocols.

## Contribution

The study provides a detailed assessment of untreated, uncontrolled, and below-target hypertension in rural Lesotho and identifies associated risk factors.

## Key findings

- 18.3% of participants were diagnosed with hypertension, with 24.9% of those untreated.
- Among treated individuals, 53.5% were controlled, 26.3% uncontrolled, and 20.2% below target.
- Factors like age, diabetes, and medication adherence were linked to hypertension outcomes.

## Abstract

Hypertension programmes have expanded substantially in low-income and middle-income countries, yet treatment and control rates remain insufficient. Programme scale-up may lead to suboptimal health outcomes and resource allocation if diagnostic accuracy, monitoring and treatment protocol adherence are inadequate. This study aimed to estimate the prevalence of untreated, uncontrolled and below-target hypertension in rural Lesotho, and to identify factors associated with each condition.

We conducted a population-based cross-sectional study nested within the Community-Based Chronic Care Lesotho (ComBaCaL) cohort study (NCT05596773). Adult cohort participants ≥18 years were eligible for home-based standardised blood pressure (BP) measurement. Hypertension was defined by averaged elevated BP measurements or current use of antihypertensive medication. Uncontrolled hypertension was defined as on-treatment BP ≥140/90 mm Hg, and below-target hypertension as on-treatment systolic BP <110 mm Hg. Multivariate regression models were conducted to identify associated factors.

Between 8 September 2023 and 10 February 2025, 8236 adult participants were screened, with 18.3% (n=1505) diagnosed with hypertension. Of those diagnosed, 75.1% (n=1130) were on treatment and 24.9% (n=375) untreated. Among those on treatment, 53.5% (n=605) were controlled, 26.3% uncontrolled (n=297) and 20.2% (n=228) below target. Female sex, age ≥65 years, diabetes and a history of stroke or myocardial infarction were associated with lower odds of being untreated, while smoking and alcohol consumption increased these odds. Taking ≥3 antihypertensive drugs and non-adherence were associated with a higher risk of uncontrolled hypertension. Dual antihypertensive therapy was associated with a lower risk of being below target, while a history of stroke or myocardial infarction increased this risk.

Despite higher-than-expected hypertension treatment and control rates, substantial gaps remain, including untreated, uncontrolled and below-target hypertension, underscoring the need to strengthen diagnostic accuracy, monitoring and adherence to treatment protocols, with particular attention to high-risk groups.