Development of a Panvascular Health Promotion and Risk Stratification Tool for Community Screening: Grounded in Four-Level Disease Prevention Theory

Introduction

Panvascular disease encompasses the systemic involvement of multiple vascular territories, including a complex network of arteries, veins, and lymphatic vessels, driven primarily by atherosclerosis as its core pathological feature.^1,2 Unlike approaches targeting isolated vascular territories, this concept emphasizes the systemic and interconnected nature of atherosclerosis and its profound impact on vital organs, such as the heart, brain, kidneys, and extremities.³ As a leading cause of global mortality and disability, panvascular disease demands urgent attention.⁴ In China, cardiovascular diseases—the leading cause of death in 2020—accounted for 48.00% of rural and 45.86% of urban deaths, with incidence rates continuing to rise.^5,6 Early diagnosis is crucial for timely interventions that mitigate morbidity and mortality.^7,8 Recognizing this, China’s Ministry of Science and Technology in 2021 initiated national research to develop screening and evaluation methods for panvascular disease management, marking the first strategic scientific effort to address it at a policy level.⁹

Effective prevention and management should be initiated at the earliest stage.¹⁰ Internationally, disease prevention strategies, including those for cardiovascular conditions, adhere to a four-level health prevention and management framework: primordial (promoting active, healthy activities), primary (managing high-risk factors), secondary (achieving early detection, diagnosis, and treatment), and tertiary (controlling disease progression and relapse).¹¹ While widely adopted, applying this framework to panvascular disease remains challenging. Existing screening tools for atherosclerotic conditions—such as assessment tools based on blood pressure, cholesterol levels, or biomarkers—typically focus on single diseases and require specialized, costly equipment such as carotid ultrasound, cardiac computed tomography, ankle-brachial index, and fundus photography.^12–14 Moreover, panvascular disease is multifactorial, influenced by genetics, lifestyle, and environmental factors,¹⁵ yet current tools often apply uniform standards that fail to quantify individualized risks or provide tailored intervention guidance amid diverse cardiovascular profiles.

These limitations highlight the need for a sensitive, simple-to-use, and cost-effective screening tool to provide rapid screening in diverse community settings, where health promotion and disease prevention are essential for individual health management.^16,17 To address this need, this study aimed to develop a standardized, easy-to-use panvascular disease screening tool through comprehensive literature review, focus group discussions, and expert consultations, which not only enables risk stratification and early identification of panvascular diseases but also serves as a straightforward public health education instrument for community residents to improve their awareness of vascular health.

Materials and Methods

Screen Tool Development

The panvascular health promotion and screening tool was developed through a multi-phase process involving literature research, focus group discussions, and expert consultations. This approach ensured the tool’s scientific foundation, practicality, and alignment with four-level disease prevention principles.

Literature Review

From March to May 2024, three researchers (Chief Physician of Cardiology, Master of Developmental Psychology, Master of Clinical Psychological Counseling) conducted a comprehensive literature search in databases including China National Knowledge Infrastructure, Wanfang, VIP, Springer, PubMed, and Web of Science. Search terms included “panvascular disease” OR “panvascular medicine”; and “panvascular disease” OR “panvascular medicine” AND “risk factors” OR “screening tools” OR “biomarker”. Literatures published in the past decade were included, covering core evidence-based studies (original research, systematic reviews, and meta-analyses) and panvascular disease-related clinical practice guidelines, expert consensuses, scientific statements, and thematic reviews. Non-peer-reviewed articles, duplicate studies, studies with small sample sizes, and those with inadequate description on study design were excluded. This literature screening was performed to determine the pathophysiological cycle, risk factors, mechanisms of action, and biomarkers of panvascular disease. The review identified traditional and innovative vascular risk indicators, forming the initial item pool aligned with the four-level prevention framework. The detailed flowchart of literature screening is presented in Figure 1.

Figure 1 Flowchart of literature screening for the development of the panvascular health promotion and risk stratification tool.

Focus Group Discussion

In April 2024, 11 medical staff from the Fenglin Community Health Service Center in Xuhui District, Shanghai, China, including the director, deputy director, family physicians, community nurses, and public health physicians, were invited to participate in a semi-structured interview. The interviews explored the current usage, advantages and disadvantages, and suggestions for improvement of various chronic disease screening tools in the community (such as colorectal cancer, osteoporosis, and osteoarthritis, etc). Insights from these sessions, combined with literature findings, guided the creation of an initial 118-item preliminary draft of the panvascular screening tool. The complete list of these 118 initial items and their data sources are presented in Supplementary Table S1.

Expert Consultations

Between June and August 2024, consultations were conducted with nine local senior experts in panvascular and related fields, including cardiovascular disease, cerebrovascular disease, vascular surgery, endocrinology, and public health specialists. The expert inclusion criteria were, 1) at least 10 years of clinical experience in panvascular and related fields, with publications on panvascular related academic articles or reviews; 2) an associate senior professional title or above, or an intermediate professional title if with a master’s and doctoral degree; 3) voluntary participation in on-site expert consultation and subsequent correspondence.

The first round involved an on-site meeting where experts reviewed the draft screening tool’s development objectives, future application scenarios, and components. They independently evaluated each item’s importance, feasibility, and rationality of design and key health assessment measurements using a structured questionnaire. A total of 118 initial screening items were included in the first-round evaluation, and strict screening criteria were applied. Items with an importance score ≥4, a feasibility score ≥4, and rationality recognized by ≥80% of experts were retained, while items with low scores, redundancy, poor community operability, or deviation from clinical panvascular orientation were excluded.

From July to August 2024, three senior experts who had conducted community health research and were familiar with the panvascular disease were consulted again through online one-to-one format on the revised questionnaire. The second-round consultation further optimized the retained items, eliminated non-core indicators inconsistent with the four-level prevention framework, and finally formed the 31-item final version of the screening tool.

Statistical Analysis

All data collected from consultations were entered into Excel and analyzed using SPSS 25.0 (IBM, USA). A two-tailed P value < 0.05 was set as the threshold for statistical significance. The expert response rate assessed enthusiasm. Continuous variables were presented as mean ± standard deviation (mean ± SD) and categorical variables were expressed as frequency and percentage (n, %). The expert authority coefficient (Cr) was calculated as Cr = (Ca+Cs)/2, where Ca is the judgment basis score and Cs is the familiarity score (both on a 1–5 scale). A threshold of Cr > 0.70 was defined to indicate a relatively high level of expert authority for the consultation. Opinion coordination was evaluated using the coefficient of variation (CV) and Kendall’s coefficient of concordance (W), with the statistical significance of Kendall’s W examined by the Chi-square test.

Results

Development of Panvascular Health Promotion and Risk Stratification Screening Tool

The developmental process and key stages of the panvascular health promotion and risk stratification tool are summarized in Figure 2. The tool was designed to translate physiological, pathological, and biomarker characteristics of panvascular disease across the human life cycle into vascular-related measurements such as events, behaviors, and symptoms that can be quickly assessed and easily tested (Table 1). This facilitates data collection in natural, non-clinical, community-based settings. Grounded in the four-level prevention framework, the tool delineates cumulative health risks across primordial, primary, secondary, and tertiary prevention and management categories, enabling stratified risk assessment for panvascular conditions.

Table 1 Developmental Concepts of Panvascular Prevention and Management Screening Tool

Figure 2 Process for developing the panvascular health promotion and risk stratification tool.”Item” refers to the assessment indicator included in the screening tool for panvascular disease risk stratification.

Expert Characteristics

Nine senior experts participated, with ages in the range of 39–62 years (mean ± SD: 51.63 ± 6.34) and clinical experience in the range of 10–40 years (27.75 ± 8.35). Educational backgrounds included one master’s degree and eight PhD degrees. Professional titles comprised two associate seniors and seven senior experts. The on-site consultation process (first round) with nine experts lasted 2 hours and 10 minutes. The online consultations (second round) held one-on-one with three experts lasted 26, 28, and 31 minutes, respectively.

Expert Attitude, Authority, and Coordination Evaluation

Both consultation rounds achieved a 100% effective response rate, reflecting high motivation and positive attitudes toward screening tool development. In the first round, the Ca was 0.60, Cs was 0.87, and Cr was 0.72. The second round yielded a Ca of 0.70, Cs of 0.89, and Cr of 0.80. For the first round, CV ranged from 0.00–0.68, with Kendall’s W = 0.347 (P < 0.001), suggesting that the experts’ opinions were well coordinated. In the second round of expert consultation, each expert had their own respective focus, so the CV value was not calculated.

Processes of Expert Consultations

The first round generated nine experts who had 67 suggestions for improvements, mainly focusing on streamlining the content, including deleting unnecessary living habits, simplifying unnecessary biochemical measurements, and deferring related examinations to be performed after the screening process. It also emphasized improving the localization and understandability of questionnaires. At the same time, experts agreed with the original intention to create the screening tool but expressed concerns on tool’s performance parameters and future evaluation metrics.

The second round produced 28 suggestions for improvement, emphasizing clarification of the four-level risk stratification, prioritization of measurements, and a clear recommendation for controlling the number of risk factors to ≤ 30. Following this requirement, we further screened the remaining items, excluded items that could not be integrated into the stepwise screening pathway (tertiary → secondary → primary/primordial prevention), and ultimately retained 31 core items that met clinical relevance, community feasibility, and four-level prevention logic requirements. The excluded items were mainly attributed to low clinical importance, overlapping risk connotations, poor adaptability to community rapid screening, deviation from clinical-centered and panvascular disease-oriented framework, inconsistency with the four-level prevention and stepwise screening structure, or unnecessary biochemical or lifestyle indicators not critical for risk stratification.

Formation of Panvascular Health Promotion and Risk Stratification Tool

The final panvascular disease community screening tool is a closed-ended questionnaire primarily based on yes/no responses, comprising a total of 31 items that correspond exactly to the core screening questions across three sequential steps, with the four-level prevention and management framework embedded in the stepwise design (Table 2). Specifically, step 1 (tertiary prevention and management) includes 13 items targeting major panvascular events. Step 2 (secondary prevention and management) involves 9 items assessing panvascular high-risk characteristics, with both steps designed for exclusive yes/no responses. Step 3 (primordial and primary prevention and management) contains 9 items evaluating general panvascular risk factors, which are closed-ended questions combining yes/no responses for categorical indicators and graded scoring for quantitative measurements. Medical personnel will go through these steps in descending order of disease severity, assessing the risk for tertiary, secondary, primary, and primordial prevention and management. A “stop when positive” principle was applied when performing the first and second steps of screening. In the tertiary prevention and management step, a “Yes” answer to any of these conditions will result in a classification into the tertiary risk group, with no requirement for further screening. Similarly, in the secondary prevention and management step, a “Yes” answer to any of these conditions will result in a secondary classification, with no requirement for further screening. In the primary and primordial prevention and management step, decisions are made based on the patient’s cumulative score. Ultimately, this tool allows participants to complete the screening process in the shortest possible way.

Table 2 Screening Steps and Risk Determination by the Panvascular Health Promotion and Risk Stratification Tool

Based on the screening design and scoring rules, participants were stratified into four prevention and management groups by their total screening scores, with detailed stratification criteria and interpretations as presented in Table 3:

Table 3 Explanations of the Four-Level Prevention and Management Groups Categorized by the Panvascular Health Promotion and Risk Stratification Tool

The primordial prevention group (0–2 points) includes individuals with normal panvascular structure and no relevant risk factors. The primary prevention group (3–8 points) comprises those without pathological changes but with modifiable vascular risk factors. The secondary prevention group (9–12 points) consists of participants with reversible panvascular lesions or high-risk characteristics. The tertiary prevention group (≥13 points) covers individuals with severe panvascular pathological changes and a history of acute serious vascular events.

Application scenarios for this tool were set as follows: (1) Medical personnel conduct rapid screening of residents outside community health service centers, with no restrictions on location, and the entire questionnaire can be conducted in the form of questioning-answering format; (2) Medical personnel conduct rapid screening of residents within community health service centers, and the central screening location can be set up in various chronic disease screening centers or health management centers, or can be set up in the triage office, during the pre-diagnosis stage. For the height, weight, blood pressure, blood lipids, and blood sugar examined in the tool, relevant instruments and equipment can be used for accurate data collection and evaluation. The screening tool uses standardized clinical terminology to ensure accuracy, with brief annotations provided for complex terms. During administration, medical staff explain relevant items to residents in plain language for better understanding.

For screening within community health service centers (including sites), assessment of the tertiary and secondary prevention and management can be quantitatively evaluated, with each event scored as 13 points and 9 points, respectively. Points can be accumulated and combined across steps to reach a final score. The final score can be used to categorize risk levels based on the grading criteria. A higher score indicates a greater risk, and the relevant scored events can serve as a reference for the next step of clinical diagnosis.

Based on the screening purpose and the above-mentioned application scenario design, we named the screening tool panvascular health promotion and risk stratification tool, which takes panvascular health as the management focus and goal. This tool can effectively mobilize community residents and guide them to actively pay attention to panvascular health. To achieve its expected results, the tool involves educating individuals on panvascular health and stratifying them into different risk categories. Based on the screening results, residents will be guided to seek further answers and health services.

Discussion

This study presented the development of a community-adapted panvascular health promotion and risk stratification tool, and herein we discuss its development rationale, practical design considerations, clinical application value and limitations, with a focus on comparative analysis with existing screening approaches.

Development of Screening Tool

We reviewed the physiological and pathological characteristics of panvascular diseases and developed the draft screening tool. We identified and matched the characteristics associated with different degrees of panvascular diseases. This approach ensured the solid scientific basis for disease severity stratification. After focus group discussion and expert consultations, the finalized screening tool integrates information, such as genetics, lifestyle, demographics, common physiological measurements, current medical illnesses, and panvascular clinical events, to comprehensively assess an individual’s panvascular disease risk.

During development, we addressed practical issues raised by community medical staff and prioritized operational feasibility in non-clinical settings, with simple equipment and low-cost data collection as core requirements.^29,30 We avoided unnecessary consumable tests to reduce screening costs for large-scale community use. For example, non-consumable devices are preferred for blood glucose and lipid testing. When unavailable, medical history or health records can be used, and body mass index (calculated from height and weight) can serve as a provisional reference to guide residents for free confirmatory tests at community centers and avoid inaccurate risk stratification.

Expert consultation is a standard method for healthcare questionnaire validation.³¹ Two-round expert consultation verified the tool’s scientific rigor and clinical logic. Experts suggested item streamlining and clearer risk stratification correspondence, and approved the 31-item final version while recommending future community validation.

We developed the screening tool while focusing on two considerations. First, the tool is designed for rapid community risk identification rather than definitive diagnosis of panvascular health status.³² The selected items corresponded to easily identifiable clinical events across pathological stages, and expert-reviewed process ensured its scientific validity. For ambiguous yes/no responses during scoring, we adopted the principle of “overestimating risk to avoid missed detection”, which might cause temporary anxiety but favor early disease identification and prevention. When screening is performed outside community health service centers (eg., outdoor health promotion sites) where blood pressure, blood lipids, and other key indicators rely solely on self-report results without instrumental measurement, participants should be re-screened at community health centers using standard medical instruments for accurate tests.³³

Second, the performance of this screening tool was not evaluated by the traditional methods, such as calculation of reliability coefficient and validity coefficient.³⁴ The purpose of our tool is not to provide a definitive disease diagnosis or to compare with a traditional gold standard, but to promote public awareness on panvascular health and actively seek services to increase the usage frequency of dedicated healthcare centers to validate the efficacy of our screening tool. In addition, we can compare the risk stratification results with this screening tool and final clinical diagnosis by physicians to estimate the clinical application of this screening tool and make further improvements when necessary.^35,36

Unlike existing panvascular screening tools that rely on expensive specialized equipment and single-disease-oriented, uniform assessment criteria, this tool achieves stepwise, individualized risk stratification through a questionnaire-based design combined with basic physical and laboratory tests (blood pressure, blood lipid measurement), making it more suitable for large-scale community screening with limited resources.

Suggestions for Clinical Application and Further Improvement of the Screening Tool

This tool is designed for broad outpatient and pre-hospital community screening, especially for residents without recent health assessments. It identifies panvascular risks and guides residents to seek formal diagnosis and treatment at community health centers, driving proactive public health services.

However, our screening tool cannot be used alone. First, necessary coordination and encouragement of local residents to participate in the screening should be implemented. For example, our institute has simultaneously developed 96 items on public education on panvascular health and disseminated them to the community through the WeChat application (a social medial platform similar to Instagram), thereby establishing a friendly atmosphere welcoming the community to acquire information on panvascular health. At the same time, we have developed more than 10 simple and attractive assessment programs, each with 3 to 5 questions, to simplify the screening tool, which can draw attention from residents and enable them to complete the self-assessment for a quick checkup. Studies have shown that two-way interactive test-type education can promote public education more effectively than the one-way output knowledge test-type.³⁷ By integrating screening procedures with simple communication on healthcare related information, the tool enables simultaneous risk evaluation and health education, which enhances its practical value in community-based health promotion. Since the above content is applicable to all communities, development organizations may promote its use among a wide range of different communities as a preliminary panvascular education and screening tool.

Secondly, necessary basic equipment and service should be prepared in the physician’s office to ensure correct diagnosis and management recommendations for residents in all age ranges, with all possible risk stratification results (from primordial to tertiary prevention). The American Heart Association has proposed eight elements of cardiovascular health recommendations and an updated proposal on heart-renal-metabolism syndrome regulation, which provides clear management approach.^11,38 The concept of health ecology in whole-health intervention also addresses the importance of paying special attention to diseases according to lifestyle behaviors. All these illnesses, including cardiovascular disease, cardio-renal-metabolic syndrome, and panvascular disease, should be considered in light of social determinants of health within an ecological framework model.³⁹ Under these guidelines, we will be able to carry out systematic, comprehensive, and effective health interventions. With this philosophy, our institute has guided established community health centers, integrated medical and preventive clinics, family doctor health management clinics, and panvascular disease health management clinics to cover all levels of prevention and management populations. At the same time, the items included in the primordial and primary prevention and management can be applied during the secondary and tertiary health screening to promote and strengthen panvascular health in these high-risk populations.

In the next step, we will apply this screening tool in the clinical practice to test its feasibility in the community settings. We will also revise and improve the performance of this screening tool, based on the feedback on the probability and frequency of residents actively seeking panvascular health services, and the consistency of the final clinical diagnosis and risk stratification from our screening tool, with the goal of achieving better panvascular health in society.

Limitations

Our screening tool has several limitations. We developed this screening tool after consulting the local experts but did not select experts from other areas of the country, which could limit the generalizability and wide application of the screening tool. In the development stage of this screening tool, we did not invite and seek feedback from local community residents. These residents could have provided opinions and suggestions on the tool’s functionality, content design, application scenarios, and promotional information to improve its practicality and acceptance in the community setting. Future large-scale studies should be performed to address these limitations.

Conclusions

We developed a standardized, community-adapted panvascular health promotion and risk stratification tool with clear hierarchical logic and strong clinical practicability. As both a screening instrument and health education medium, it enables early identification of high-risk individuals and improves public vascular health literacy. Large-scale, multi-population validation is needed to confirm its clinical utility and generalizability.