Introduction
A public health campaign is defined as an organized, targeted, and time-limited activity aimed at maintaining and improving health and preventing disease in the wider community or in specific population groups. Such campaigns are run by healthcare institutions, associations, and healthcare professionals and conducted among members of the public, usually in public spaces, with the aim of making healthcare services and health education as accessible as possible. (1)
The public health campaign “One Step Ahead of Disease” is targeted at the general adult population and focuses on the identification of risk factors for all cardiovascular diseases (CVD), particularly peripheral artery disease (PAD), as well as education on healthy lifestyle practices and disease prevention, while also providing participants with counselling regarding the potential need for further diagnostic evaluation and treatment. Particular emphasis is placed on the early detection of PAD, which remains insufficiently recognized, diagnosed, and treated. The campaign aims to improve population health and includes free health assessments, counselling, and education on healthy lifestyle practices. Such campaigns are essential for early disease detection and prevention, as well as for increasing public awareness of health-related issues. Each campaign includes measurement of blood pressure (BP), ankle-brachial index (ABI), blood glucose, and cholesterol levels, with additional HbA1c measurements when clinically indicated.
CVDs have been widely recognized as a leading public health issue both globally and in Croatia, and they represent the most common group of noncommunicable diseases, being responsible for as many as 20.5 million deaths worldwide every year. One favorable fact is that the majority of CVDs can be prevented by avoiding modifiable risk factors, potentially preventing up to 80% of premature deaths. Elimination of risk factors such as smoking, alcohol consumption, unhealthy diet, and insufficient physical activity, together with the timely detection and treatment of hypertension, dyslipidemia, and diabetes, can substantially improve cardiovascular health and reduce cardiovascular morbidity and mortality. (2)
In Croatia, CVDs have also been the leading cause of mortality for decades. In 2024, 20 341 people in Croatia died from CVDs, accounting for 39.8% of all deaths, and CVDs were also responsible for 24% of all premature deaths, defined as deaths occurring before the age of 65 years. Compared with European Union countries, Croatia ranks among countries with mortality rates above the EU average, with a standardized mortality rate of 591.7 per 100 000 inhabitants. (3)
Peripheral artery disease refers to atherosclerotic changes affecting the peripheral arteries, most commonly those of the lower extremities, resulting in arterial narrowing and, eventually, arterial occlusion. PAD is the third most common form of atherosclerotic cardiovascular disease, after coronary artery disease and cerebrovascular disease. The risk of PAD increases substantially with advancing age and exposure to cardiovascular risk factors: unhealthy lifestyle habits, older age, arterial hypertension, diabetes, dyslipidemia, smoking, and a family history of atherosclerotic disease. PAD remains underrecognized, both as a disease entity and as a marker of overall cardiovascular risk, resulting in increased morbidity and mortality from coronary and cerebrovascular disease, as well as increased overall cardiovascular mortality. The disease most commonly develops from approximately 40 years of age onward, with prevalence and severity increasing with age. In 20-50% of individuals, PAD is either asymptomatic or has its symptoms frequently attributed to other conditions, most commonly musculoskeletal disorders. Patients often present at an advanced stage of the disease (with established ulceration and gangrene), and a consequent need for limb amputation is not uncommon. Early recognition and appropriate treatment of PAD can help restore mobility, reduce the risk of amputation, myocardial infarction, and stroke, and ultimately save lives. (4)
In Croatia, approximately 2000 people die from PAD each year, and approximately 6000 PAD-related hospitalizations occur annually. The most severe consequences of PAD are amputations: over the past five years, an average of approximately 1300 (lower-limb) amputations related to PAD have been performed annually in Croatia. (3)
Measurement of the ankle-brachial index (ABI) is a non-invasive, relatively simple, readily available, and easily performed method for the screening and progression monitoring of both symptomatic and asymptomatic PAD. It plays an important role in establishing a timely diagnosis and initiating appropriate treatment. Identification of asymptomatic individuals, combined with lifestyle modification and, where appropriate, pharmacotherapy, can reduce cardiovascular morbidity and mortality. (5)
Participants and methods
The Croatian Institute of Public Health (CIPH), in collaboration with the Section of Interventional Radiology of the Croatian Society of Radiologists (sIRcro), and under the auspices of the Ministry of Health of the Republic of Croatia, launched the public health campaign “One Step Ahead of Disease” to raise public awareness of PAD and facilitate the early identification of risk factors and disease onset. At the local level, the campaign works in collaboration with primary healthcare centers, although collaboration with hospitals and similar healthcare institutions is also present. Prior to each campaign, the local organizer informs the public about the upcoming activity through posters, family physicians, community nurses, and local media. A press conference is organized and attended by local media outlets, representatives of the organizing institution and of the local government, and representatives of the CIPH. The local organizer provides an appropriate venue for conducting the campaign, while the required number of healthcare professionals is provided jointly by the local organizers and the CIPH. Blood pressure (BP), ankle-brachial index (ABI), blood glucose, and cholesterol levels are measured as part of the campaign; HbA1c is additionally measured when clinically indicated. Each participant receives educational and promotional materials on CVD prevention. Participants also receive counselling on healthy lifestyle practices and the prevention of cardiovascular disease, especially PAD, as well as on the potential need for further diagnostic evaluation and treatment. All abnormal findings are reviewed and explained to the participants, while also providing them with written instructions containing advice on contacting family physicians, who may then refer participants for further diagnostic evaluation and treatment.
Over the duration of the campaign from September, 2024 to 9 May, 2026, a total of 14 “One Step Ahead of Disease” public health actions were conducted in 12 cities or settlements. One action was conducted in the majority of locations, with two actions taking place in the following locations: Benkovac, Brač, Dugi Otok (Božava and Sali), Koprivnica, Orahovica, Osijek, Požega, Pula, Rijeka, Split, Šibenik, and Zadar.
Results
A total of 2190 individuals were screened, of whom 65% were women and 35% were men. The largest proportion of participants belonged to the 60-69-year age group (32%), followed by those aged 70-79 years (26%) and 50-59 years (18%), with these age groups accounting for 76% of all participants (Table 1). The mean age of participants was 61 years, with a mean age of 60 years among women and 64 years among men.
| Age group | Male | Female | Total |
|---|---|---|---|
| 10-19 | 7 | 34 | 41 |
| 20-29 | 10 | 47 | 57 |
| 30-39 | 30 | 83 | 113 |
| 40-49 | 44 | 157 | 201 |
| 50-59 | 129 | 256 | 385 |
| 60-69 | 262 | 431 | 693 |
| 70-79 | 237 | 338 | 575 |
| 80-89 | 45 | 74 | 119 |
| 90-99 | 4 | 2 | 6 |
| Total | 768 | 1422 | 2190 |
Normal BP values were recorded in 61% of participants, whereas elevated BP values (≥140/90 mmHg) were observed in 39% (44% of men and 36% of women) (Table 2). As many as 9% of participants had highly elevated BP values of ≥180/≥110 mmHg. Some participants with elevated BP were already receiving treatment but had inadequately controlled BP, whereas others represented newly identified cases.
Normal ABI values (1.00-1.40) were recorded in 92.7% of participants, while 2.2% had pathological findings and 3.5% had borderline ABI values. Among men, 8.4% had pathological or borderline ABI values, compared with 4.4% among women (Table 3).
Blood glucose and cholesterol levels were measured in 824 participants during the final four campaign actions. The sex and age distribution of these participants were very similar to that of the overall study population. Elevated blood glucose levels were identified in 28% of participants (Table 4), while elevated cholesterol levels were observed in 34% (Table 5). Elevated blood glucose levels were more common among men than women, whereas elevated cholesterol levels were more common among women. Some participants with elevated glucose or cholesterol levels were already receiving treatment but had inadequately controlled values, while a smaller proportion represented newly identified cases.
Discussion and conclusion
A substantial proportion of participants had elevated BP, blood glucose, and cholesterol levels, highlighting the need for continuous education in health literacy regarding treatment adherence, regular medication use, and the importance of regular medical follow-up. A considerable number of individuals with pathological ABI findings suggestive of established PAD were also identified, and these participants were immediately referred to their family physicians with documentation on the relevant findings and recommendations for further diagnostic evaluation and treatment. We believe that the approach of bringing the healthcare system directly into local communities improved healthcare accessibility, informed citizens, and increased their awareness of cardiovascular risk factors, thus providing them with an opportunity to make better judgements and decisions regarding their own health. Local organizers emphasized the importance of conducting such preventive activities, educating the population, and strengthening collaboration among healthcare institutions, and the especially highlighted the importance of the role of the CIPH as the national umbrella institution for prevention that is responsible for organizing and coordinating such preventive campaigns and for establishing and promoting interdisciplinary collaboration, in this case with primary healthcare services. Local organizers also indicated the importance of continued organization of such activities. This project was innovative in terms of its use of ABI measurement, as previous public health prevention campaigns in Croatia had not routinely included this parameter and therefore had not specifically addressed the issue of PAD awareness. Over the course of the campaign, healthcare professionals working in primary healthcare also became more familiar with the importance of PAD and the clinical value of ABI measurement.
Organization of and participation in public health campaigns can substantially contribute to improving the overall health of the population and reducing the risk of CVD. Citizens should be encouraged to regularly participate in such activities in order to improve their health and quality of life. This is something that Dr Andrija Štampar already discussed in his principles of public health, which included the statement: “The physician’s primary place of action is where people live, not in the doctor’s office.” (6) Through this campaign, the CIPH and its collaborators have put this principle into practice, thus contributing to the reduction of inequalities in access to prevention and healthcare and helping restore confidence in a healthcare system that seeks to reach every individual. Similar results have been reported in other public health campaigns, including the public health campaign conducted in Zagreb on the occasion of World Heart Day in 2014, which also demonstrated a high prevalence of cardiovascular risk factors among participants. (7) The findings of the present campaign establish the need for a stronger and continuous approach to modifiable risk factors for cardiovascular diseases as well as to lifestyle modification. The findings also demonstrate the need for more frequent public health campaigns of this type in order to focus on preventing the most common risk factors and improve health literacy in the general population.
According to evaluation data from the Croatian Hypertension League’s “Hunt for the Silent Killer” campaign, as many as 78% of participants expressed an intention to change at least one unhealthy habit following participation in the public health campaign, which represents an important indicator of the effectiveness of such campaigns in promoting positive health behaviours. (8) The value of such public health activities also lies in their accessibility, as they take place not only in urban areas but also in smaller rural communities, where healthcare services are often less accessible. This is reflected in the consistently high participation rates and high levels of participant satisfaction during the campaigns.
The value of this public health campaign has also been recognized by the medical community, and we are pleased to report that the “One Step Ahead of Disease” project won second place in the category of Best Preventive Healthcare Project at the HealthComm Forum on 10 June, 2026.
In conclusion, the aim of the campaign was to identify cardiovascular risk factors among participants, provide counselling on healthy lifestyle practices, and explain the need for further diagnostic evaluation and treatment to individuals with abnormal findings. In the long term, we expect this public health campaign to result in improved health literacy among the population, better adherence to prescribed medications, improved self-management of health, greater healthcare accessibility, and, ultimately, better overall population health.