Geographic clustering of hypertension and diabetes prevalence and care in Lesotho: a pooled spatial analysis of community-based studies

Background The growing burden of hypertension and diabetes in Africa requires efficient allocation of health resources. Geospatial analysis in low-resource, rural settings remains scare, limiting understanding of spatial disparities and healthcare needs. We aimed to identify spatial clustering of hypertension and diabetes prevalence and care cascade outcomes in Lesotho and assessed whether clustering is explained by individual-level risk-factors. Methods We pooled data from three community-based studies from 2021 to 2024 in Butha-Buthe district, Lesotho, which screened adults for hypertension and diabetes and recorded household geolocation. Spatial Scan Statistics identified geographical clusters of prevalence, treatment, and control. Regression model residuals were analysed to understand if clustering remained after adjustment for risk-factors. Findings Among 18,072 adults (median age 44 years, 62.8% female), 26.3% (4737/18,022) had hypertension, 67.1% (3178/4736) were on treatment and 50.2% (2378/4733) were controlled. Among adults ≥45 years, 12.2% (961/7857) had diabetes, 48.8% (469/961) were on treatment and 29.4% (283/961) were controlled. We identified high-risk clusters of hypertension and diabetes, particularly in (peri-)urban areas. Clusters of poor treatment and control were not consistently linked to geographic accessibility. Clustering was largely explained by the geographic distribution of individual-level risk factors, including age, sex, and overweight, with no residual clustering after adjustment. Interpretation Strategies to identify and manage high-risk individuals are needed across the entire region to achieve non-communicable disease targets in Lesotho, ensuring equitable delivery of prevention, treatment and care. Funding Swiss Agency for Development and Cooperation, World Diabetes Foundation, European and Developing Countries Clinical Trials Partnership, Moritz Straus Foundation, Swiss National Science Foundation.