Risk Assessment of Varicose Veins Among Teachers in Al-Ahsa, Saudi Arabia

Background Varicose veins (VV) are abnormally swollen, tortuous, and prominent veins caused by insufficient venous valves leading to venous congestion and elevated venous pressure. Prolonged standing at work has been proposed to be an important risk factor for varicose veins. Teachers are prone to have varicose veins due to prolonged standing. The aim of this study was to assess the risk of varicose veins among teachers in Al-Asha, Saudi Arabia. Method This was a cross-sectional study conducted among teachers of primary, secondary, and high schools in Al-Ahsa, of both genders, between April 2022 and June 2022. The participants were interviewed and examined for the presence of signs and symptoms of the disease. Finally, the collected data were analyzed using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, version 26.0 for Windows) software. Result Out of 399 participating teachers with a mean age of 43.2 ± 12.9 years, 216 (54.1%) were males and the remainder were female. The commonest symptom was pain in the legs, which was exacerbated by work (43.1%). Most of the participants were working for more than 16 years (43.6%) and standing for less than six hours per day (72.7%). The most pointed sign was spider legs-shaped veins (23.8%). However, the least collective sign was paleness in the ulcer area after healing (1.8%). A total of 140 teachers had a family history of varicose veins, 74 of them (18.5%) were diagnosed with varicose veins previously. We summarize our result as female teachers who have a family history of VV have more risk to develop the disease. Conclusion The prevalence of varicose veins was high among teachers in Al-Ahsa, Saudi Arabia. According to our study, teachers have a significant chance of developing the condition since their working style contributes to its progression. Further actions need to be made in order to increase awareness and prevent its complications.


Introduction
Varicose veins (VV) are abnormally swollen, tortuous, and apparent veins caused by insufficient venous valves leading to venous congestion and elevated venous pressure. They are more frequent in the lower extremities due to saphenous vein insufficiency [1]. The incidence of varicose veins increases with old age, overweight, pregnancy, constipation, smoking, positive family history of VV, history of venous thrombosis, and heavy lifting [1][2].
Prolonged standing at work has been proposed to be an important risk factor for varicose veins [3][4]. As a result, we conclude that the type of one's employment and one's body posture are two of the most important risk factors for varicose veins [5]. Teachers, traffic police, bus conductors, salespeople, nurses, and construction workers are among the highest occupations in developing varicose veins due to their requirements of standing for a long time [1]. Prolonged standing may result in an injury to the valves in superficial and deep veins, which leads to an abnormally opposite direction of blood flow from deep to superficial veins [6]. Pain, itching, heavy sensation in the legs, skin discoloration, and prominent veins are among the most prevalent complaints of such people [7]. Thrombophlebitis and bleeding are the most direct effects, whereas indirect problems include skin color changes, lipodermatosclerosis, atrophie blanche, edema, varicose eczema, and venous ulceration [8]. Besides these physical complications, it has a negative psychological and financial impact. It can result in low self-esteem and social isolation, consequently 1 2 2 2 2 2 increasing the risk of depression. Furthermore, patients' everyday activities may be disrupted due to the restricted standing time they have or the limited walking distance, which leads to a lowering in their productivity [9][10]. Certain preventative steps may be taken to reduce the risk of varicose veins such as raising the legs above the level of the heart for several minutes a day, walking regularly, maintaining body weight, and wearing a compression stocking [11].
The prevalence of VV varies between 10% and 60% globally, and it is higher in Asia than in the Western world, with Saudi Arabia having a prevalence of 62% [12]. In Saudi Arabia, there were insufficient studies that delineate the association between VV and the nature of occupation or the number of hours sitting or standing at work, as well as lifestyle variables like smoking and exercising [12][13][14]. So, our aim is to assess the risk of varicose veins among teachers in Al-Ahsa, Saudi Arabia.

Materials And Methods
A cross-sectional study was conducted at 12 schools selected randomly in Al-Ahsa between April 2022 and June 2022. Institutional ethical approval was obtained before conducting the study from King Faisal University. The questionnaire was distributed by the participants face-to-face with leg examination. A total of 399 school teachers were selected for the study after obtaining their consent. The purpose of the study was explained to all the participants. All their queries and concerns were addressed before administering the questionnaire.
The questionnaire is taken from Robin Man Karmacharya's research [6]. It consists of three parts. The first part consisted of personal and demographic information such as age, gender, weight, and height. The second part consisted of workplace-related information, which included the duration of service and work responsibilities. The third part consisted of information regarding varicose veins, which include the symptoms and examination of the leg findings.

Inclusion criteria
Male and female teachers working in Al-Ahsa, teaching any grade (primary, secondary, and high schools) at any age.

Exclusion criteria
Teachers who have taught for less than four years.

Data analysis
The data were entered into Microsoft Excel and then analyzed using the Statistical Package for the Social Sciences Version (SPSS Inc., Chicago, IL, version 26.0 for Windows). All data were expressed as frequency and percentage. Significance was determined using the t-test and chi-square test. Linear regression analysis was done to calculate the odds ratio with a 95% confidence interval (CI). P < 0.05 was considered statistically significant. After data were extracted, it was revised, coded, and fed to statistical software IBM SPSS version 22. All statistical analysis was done using two-tailed tests. P-value less than 0.05 was statistically significant. Descriptive analysis based on frequency and percent distribution was done for all variables, including teachers' demographic data, teaching grade, teaching years, standing hours, and body mass index (BMI). Teachers' medical and family history of varicose veins, as well as a smoking habit, were also tabulated. Clinical symptoms and signs of varicose veins were graphed. Cross tabulation was used to assess the relation and distribution of varicose vein signs and symptoms by standing hours and teaching years and to identify factors that are associated with VV among teachers. Relations were tested using Pearsons' chisquare test and exact probability test for small frequency distributions.

Results
A total of 399 teachers fulfilling the inclusion criteria completed the study questionnaire. Teachers' ages ranged from 20 to 60 years with a mean age of 43.      Figure 1 shows varicose vein signs detected on clinical examination of teachers, Al-Ahsa, Saudi Arabia. The most found signs were spider legs-shaped veins (23.8%), followed by swelling and limp in the leg veins (17.8%), leg scar (11.8%), change in the leg skin color (11.5%), eczema or rash on the legs (11.3%), swelling in the legs or ankle (11.3%), and pain when touching the leg veins (9.3%) while 50.6% had no signs.

FIGURE 1: Signs of varicose veins by clinical examination among the participants
The distribution of varicose vein signs and symptoms by teaching year is presented in Table 4. The most reported symptoms among teachers for four to seven years were leg scars (17.6%) and spider legs-shaped veins (17.6%) while the most among teachers for more than 16 years were spider legs-shaped veins (23.6%) and swelling and limp in the leg veins (19.5%) with no statistical significance (P=.598). As for signs, the most reported for teachers having taught for four to seven years were pain in the legs increases especially during work (38.2%) and feeling of heaviness in the legs (32.4%). Pain in the legs increases especially during work was the most reported symptom (50.6%) for those who taught for more than 16 years (P=.445).

Discussion
Varicose veins are considered one of the most common manifestations of vascular disorders. The incidence of the disease is increasing, with multiple factors like age, sex, and prolonged standing [15]. Accordingly, the study aims to assess the risk of varicose veins among teachers in different schools in Al-Ahsa. This aim was addressed through a cross-sectional study with questionnaires. Our study shows that 53.6% of the participants belonged to the age group of 40 to 49, a relatively older age. Regarding gender, 54.1% of the participants were male and 45.9% were female. The majority of the participants taught for more than 16 years. More than three-fourths had a high BMI. Varicose veins were previously diagnosed in 18.5% of the participants. Likewise, a study conducted in Riyadh on the prevalence of varicose veins among nurses shows that 11% were previously diagnosed with the disease [16]. However, a higher prevalence is seen among teachers in Abha [12]. This difference might be because of the lifestyle differences between each city. In terms of symptoms, 43.1% of the teacher had leg pain during work. Similarly, 66% of nurses in different hospitals in Lebanon had leg pain during work [17]. Hence, pain is the most common presentation of varicose veins [18]. In addition, nocturnal cramps represented 28.1% of the participants. Likewise, in traffic police in Nepal, nocturnal cramp is about 32% [6]. The least presenting sign is itching. In terms of signs, the most presenting one is spider legs-shaped veins on the leg, which represent 23.8%. Similarly, 26% of city police in Belagavi have spider-shaped veins [19]. Furthermore, 17.8% of participants had swelling in the leg and pain. Surprisingly, dilated veins were the most common sign in traffic police of Nepal, representing 5.5%. Moreover, the third most common symptoms are leg scar (11.8%) followed by a change in skin color (11.5%) [6].
In our study, 11 teachers were between the ages of 20 and 29; none of them had been diagnosed with VV previously. A total number of 73 teachers aged 50+ years participated in this study; 18 of them were diagnosed with VV (24.7%). The percentage of teachers that were diagnosed with VV was less for those aged 40-49 (19.2%). However, the total number of teachers that participated in our study aged 40-49 was the highest (214 teachers). Old age is considered a risk factor for developing venous disease. As age increases, the prevalence of venous disease gets higher. This is due to the weakening of the calf muscles, which leads to increased pressure on superficial veins accompanied by the gradual deterioration of vessel walls over time [1]. In the United States, a study conducted to assess the prevalence of venous disease showed that the prevalence of VV among individuals younger than 30 years was less than 1% for men and less than 10% for women [20].
In the current study, there was a significant difference between male and female teachers regarding the diagnosis of VV. The percentage of diagnosed male teachers was 14.8%, whereas it was 23% for female teachers. Female gender was considered a risk factor for VV in the Kunie et al. study [21]. Similarly, several previous studies revealed that females are more prone to develop VV than males [20,[22][23][24]. One of the major factors that contribute to the higher incidence of VV in women is pregnancy [25]. A higher incidence of VV is shown in parous women in comparison to nulliparous women [1].
Most of the teachers that participated in our study had taught for more than 16 years (total number of 174).
Our results showed that 16.1% of those teachers were diagnosed with VV. Teachers that had taught for four to seven years were 34 in number, 8.8% were diagnosed with VV, which is the lowest percentage. However, the diagnosis of VV in relation to teaching years was insignificant in our study. Regarding standing hours per day, our result showed that 21.1% of the teachers who stood for more than seven hours per day were diagnosed with VV while the percentage was 17.6% for those who stood for less than seven hours. The standing position has been reported as an aggravating factor for VV in the European population in a study done by Krijnen et al. [26]. In Iran, a study among nurses reported four times increased odds of having VV for those who stood for more than four hours as compared to those who stood for less time [27].
Our study showed that 31.4% of teachers who have a family history of VV were diagnosed with the same condition, which is significantly different from those who don't have a family history (11.6%). Even though specific genes haven't been identified yet, several studies demonstrated family history as an important risk factor for venous diseases [23,[28][29][30][31]. Our result didn't show a statistically significant difference in teachers who smoked or those who had a high body mass index (BMI) in relation to the diagnosis of VV. This result is inconsistent with a study that involved 1806 patients with lower limb venous insufficiency and showed that smoking more than 10 cigarettes per day was associated with a higher prevalence of venous insufficiency [32]. Furthermore, previous studies identified obesity as a risk factor for VV [20,22].
This study didn't include every school in Al-Ahsa, so it might not be representative of the prevalence of VV among all teachers in Al-Ahsa. Another limitation is that the measurement of hours spent in standing, height, and weight was self-reported. This could lead to an overestimation or underestimation by the participants. Lastly, participants didn't undergo a Doppler ultrasound during the interview, which is an important objective measure to determine their vascular condition.

Conclusions
Varicose veins is a common condition that has a high prevalence in females more than in males. Furthermore, teachers spend a lot of hours standing, which makes them vulnerable to developing this condition. As a result, further actions need to be taken in order to increase the level of education among teachers through mass media, campaigns, and further research studies to decrease its incidence and complications.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Research Ethics Committee at King Faisal University issued approval KFU-REC-2022-MAR-EA000514. Having reviewed the details submitted by the applicant regarding the abovenamed research project, the Research Ethics Committee at King Faisal University grants its ethical approval to the protocol. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.