Prevalence of Varicose Veins Among Nurses in Different Departments in Jazan Public Hospitals, Saudi Arabia: A Cross-Sectional Study

Varicose veins (VV) in the lower limbs are the most prevalent vascular condition in humans. They can cause significant signs and symptoms and, in extreme cases, death. This study aims to investigate the prevalence and identify the risk factors for varicose veins among nurses working in multiple departments at Jazan King Fahd Central Hospital and Prince Muhammad bin Nasser Hospital. A cross-sectional study was conducted by sending a questionnaire to female and male nurses in these hospitals. This study included 482 nurses, 415 (86.1%) of whom were female and 67 (13.9%) male. The prevalence of varicose veins among the nurses of both hospitals was 76 (15.8%), compared with 406 (84.2%) not diagnosed with varicose veins. The prevalence of varicose veins was 67 (88.2%) in female nurses, compared with 9 (11.8%) in male nurses. The risk factors associated with varicose veins were ethnicity (p = 0.007), carrying heavy items (p = 0.001), lack of exercise (p = 0.031), family history (p = 0.001), use of hormonal therapy (p = 0.001), use of contraceptive pills (p = 0.0035), type of delivery (p = 0.002), number of children (p = 0.004), and hours sitting per shift (p = 0.002). The comorbidities associated with varicose veins were deep vein thrombosis (p = 0.001), hypertension (p = 0.002), chronic constipation (p = 0.006), diabetes (p = 0.001), kidney disease (p = 0.001), rheumatoid arthritis (p = 0.001), coronary artery disease, and severe occupational injury to the lower extremities (p = 0.001). Nurses are responsible for most of the health system's services. Increasing the number of nursing workers for patient care, encouraging physical exercise, and lowering the pension age appear to be required to avoid the occurrence and development of varicose veins among nurses.


Introduction
Varicose veins (VV) in the lower limbs are the most prevalent vascular condition in humans, causing significant signs and symptoms and, in extreme cases, death [1,2]. VV is indicated by a 3 to 4 mm dilatation of the subcutaneous veins [3]. There are several types of vein diseases, including reticular, telangiectasia, and trunk veins [4]. VV may cause pain in the afflicted limbs and aesthetic difficulties, which often require surgery or other intensive treatments and deplete the healthcare budget [5]. The vein is constructed of tiny valves that prevent blood flow from reversing. The malfunction of these valves allows the reversal of blood flow to reverse and accumulate in the veins, increasing their prominence and enlargement [6,7].
Numerous factors may contribute to the valves' weakening and failure, including genetics, venous thrombosis, and the loss of the elastic tissue of the venous wall [8]. In the lower limbs, varicose veins symptoms may be localized to the afflicted region or can be widespread, affecting the whole lower leg. Localized symptoms such as pain, burning, and itching are prevalent, but leg pains, heaviness, weariness, and edema are also typical. The symptoms are typically intense during prolonged periods of standing and subside when patients sit and raise their legs [9]. Complications from varicose veins are rare. However, clots in the deep blood veins of the legs can sometimes expand. The afflicted leg is painful and swollen in such circumstances, and any chronic leg discomfort or swelling requires medical treatment. Because it may indicate a blood clot, it is medically referred to as thrombophlebitis. Additionally, the skin around varicose veins may develop painful ulcers, particularly around the ankles. Usually, a discolored area on the skin extends prior to the formation of an ulcer. Veins that are extremely near to the surface of the skin may rupture, often resulting in relatively minimal bleeding [10].
The examination of varicose veins should be conducted while standing in good light to determine the degree and size of the varicose veins and the presence of other venous disorders. The presence or absence of venous hypertension-related skin injuries is the most critical medical concern [11]. Continuous-wave Doppler testing is an excellent tool for identifying saphenofemoral and saphenopopliteal junction reflux in varicose vein patients. In comparison with a duplex ultrasound exam, continuous-wave Doppler testing should be suggested to manage varicose veins due to its shorter evaluation time and ease of use in the clinical setting [12]. If the patient exhibits no symptoms or pain, therapy may be unnecessary; however, if the patient shows   1  2  2  2  2   2  2  3 signs and symptoms, treatment may be essential to alleviate aches and pains and address concerns such as leg ulcers, skin discoloration, or swelling. Several therapies include surgery, endovascular therapy, and compression therapy [12].
Nurses are critical components of healthcare systems, and lower leg varicose veins may result in performance instabilities and increased economic expenditures by people and society to remedy the imposed damage. The issue is essential, as it may imperil work production, health in old age, various underlying thrombotic events, and other grave consequences [13]. This study aims to investigate the prevalence and identify the risk factors for varicose veins among nurses working in multiple departments at Jazan King Fahd Central Hospital and Prince Muhammad bin Nasser Hospital.

Study design and area
A cross-sectional study was conducted at King Fahd Central Hospital and Prince Muhammad bin Nasser Hospitals in Jazan province. Jazan (also called Gizan) is one of the 13 provinces of the Kingdom of Saudi Arabia (KSA). It is located in the southwest of the KSA and is highly populated with 1.5 million residents.

Identification of study participants
The sample size was calculated using the Raosoft online calculator, and it was estimated to be 482 nurses.
The sampling was divided into males and females and stratified according to different departments at King Fahd Central Hospital and Prince Muhammad bin Nasser Hospital.

Inclusion and exclusion criteria
All hired nurses of both genders working in administrative or clinical positions were included in the study. Pregnant nurses and nurses under the age of 18 years were excluded.

Data collection process
The demographic (age, gender, and ethnicity), behavioral (smoking daily or exercising), physical (height), and work-related variables (sitting and standing periods during work hours and handling heavy objects) sections of the questionnaire were all subjectively assessed by the participants. Health-related data (comorbidities, hormonal therapy/contraceptive use, number of gravida/parities, etc.) were also included in the questionnaire. We started collecting data after receiving approval from the Institutional Review Board (IRB) of the Jazan Health Ethics Committee; the approval number is 2197.

Data analysis
The data obtained were analyzed using the Statistical Package for Social Sciences (SPSS) software (IBM Corp., Armonk, NY). Before entering the data into SPSS, it was cleaned and described using descriptive statistics. To specify categorical variables such as gender and race, frequencies/percentages were employed. The mean and standard deviation explained quantitative variables such as weight, height, and birth rate. The chi-square or Fisher's exact test determines the associations between the outcomes and any categorical variables. A p-value of 0.05 was used for statistical significance.  Based on the work departments of the nurses, 40.90% of the participants worked in the medical ward, 19.30% in the emergency department, 7.50% in the intensive care unit, 6.60% in the cardiac care unit, and 25.7% in other departments ( Figure 1). The risk factors associated with varicose veins were ethnicity (p=0.007), lifting heavy objects (p = 0.001), lack of exercise (p = 0.031), family history (p = 0.001), use of hormonal therapy (p = 0.001), use of contraceptive pills (p = 0.0035), type of delivery (p = 0.002), and number of children (p = 0.004). All these risk factors indicate statistically significant associations with varicose veins. The varicose vein predictors that were not statistically significant (p > 0.05) were gender, social status, place of work, number of shifts, years of work, and smoking. The comorbidities associated with varicose veins were deep vein thrombosis (p = 0.001), hypertension (p = 0.002), chronic constipation (p = 0.006), diabetes (p = 0.001), kidney disease (p = 0.001), rheumatoid arthritis (p = 0.001), coronary artery disease, and severe occupational injury to the lower extremities (p = 0.001). All these diseases had statistically significant associations with varicose veins (

Discussion
In our study, the prevalence of varicose veins among nurses was 15.8%. The prevalence of varicose veins was higher in female nurses compared to male nurses. Varicose vein prevalence reported in previous research has differed widely, ranging from 2% to 56% in males and 1% to 73% in females [14,15]. A cross-sectional survey was conducted in 2020 in Saudi Arabia with 366 nurses, with 322 females (88.0%) and 44 males (12.0%). There were 40 (11%) patients with a confirmed diagnosis of varicose veins, of whom 39 were female and one male [16]. However, because our study included a large differential in the number of female and male nurses who participated, these findings cannot be inferred.
Varicose veins were common in nurses who worked at King Fahd Central Hospital, 53.9%, compared with 46.1% at Prince Muhammad bin Nasser Hospital. This could be attributed to the difference in workload, the number of staff, and the number of patients. Both hospitals are located in Jazan City, southwest of KSA. Among the study participants, 40.90% worked in the medical ward, 19.30% in the emergency department, 7.50% in the intensive care unit, 6.60% in the cardiac care unit, and 25.7% in other departments. Most nurses work in the medical ward because both hospitals receive many inpatients daily.
In our study, the risk factors for varicose veins were ethnicity, lifting heavy objects, lack of exercise, family history, use of hormonal therapy, use of contraceptive pills, type of delivery, and number of children. All these risk factors showed a statistically significant association with varicose veins. The varicose vein predictors that were not statistically significant in this study (p > 0.05) were gender, social status, place of work, number of shifts, hours standing per shift, years of work, and smoking. Age, sex, and ethnic origin were shown to be risk factors for varicose veins in most previous research [17]. In our study, the number of shifts and standing hours were not risk factors for varicose veins in King Fahd Central Hospital and Prince Muhammad bin Nasser Hospitals. There is a difference between our study and the previous studies, which could be attributed to the difference in workload, lifestyle, social life, and type of socks. Nurses in our study worked only eight hours per shift, some wore bandage socks while on the job, and 35.5% of nurses had only worked for one to four years. AlBader et al. found that based on shifts per week (p = 0.23) and standing hours (p = 0.09) [16].
Ethnicity was considered a risk factor for varicose veins in this study, as 88.2% of nurses who had varicose veins were Arabian, compared with 10.5% Asian and only 1.3% African. However, these findings were not valid and could not be inferred since the number of participating nurses significantly varied by ethnicity. Mekky et al. reported that varicose veins were investigated in 504 female cotton workers in England and 467 female cotton workers in Egypt. Varicose veins were far more prevalent in the English mill population than in the Egyptian community [18].
The nurses with a family history had more varicose vein incidents (64.5%) than the nurses who did not have a family history (35.5%). Cornu-Thenard et al. studied 143 families, including 67 patients and their parents and 67 controls and their parents. A total of 402 patients were tested. The findings indicated that inheritance had a significant impact on the development of varicose veins (p = 0.001). Children had a 90% chance of acquiring varicose veins if both parents had the illness, 25% for men and 62% for females if only one parent had it, and 20% for neither parent [19].
In this research, 68.4% of participants diagnosed with varicose veins usually lift objects that weigh 23 kg or more during work time and lift heavy objects such as electronic devices and equipment like kidney machines and oxygen tanks. Moreover, carrying the patient to transfer him from one ward to another ward increases pressure on the lower limbs and leads to vascular wall and valvular damage. The research by Tabatabaeifar et al. corroborated our study in that the prolonged lifting of large things was associated with varicose veins and a higher risk of surgical therapy [20]. In our study, 63.2% of nurses who did not play sports and had varicose veins, compared with 36.8% of nurses with varicose veins who did. Abou-ElWafa et al. reported that varicose veins were substantially more frequent among nurses with the following characteristics: over the age of 25, married, no sports, and obese [21]. The use of hormonal therapy included conjugated equine estrogens with or without medroxyprogesterone acetate. In addition, contraceptive pills containing estrogen and progesterone or progesterone alone increased the incidence of varicose veins [22,23].
The nurses who delivered vaginally had a higher chance of developing varicose veins than the nurses who delivered through C-sections. Additionally, the females with children had a greater risk than the females who did not. This is because when a female is pregnant, progesterone levels rise, and the uterine wall expands, increasing blood volume and potentially resulting in valve failure. Jawien et al. reported that varicose veins were more prevalent in women than in males. The number of pregnancies (more than two pregnancies) considerably separated women with and without varicose veins [24].  [27].
In our study, the comorbidities associated with varicose veins were deep vein thrombosis (p = 0.001), hypertension (p = 0.002), chronic constipation (p = 0.006), diabetes (p = 0.001), kidney disease (p = 0.001), rheumatoid arthritis (p = 0.001), coronary artery disease, and severe occupational injury to the lower extremities (p = 0.001). This conclusion was consistent with the report by Bermudez et al. that insufficiency in deep veins was higher in traumatized limbs than in non-traumatized limbs [28]. Varicose veins are a sign of persistent venous hypertension or high blood pressure in the veins. High blood pressure in veins irreversibly destroys valves and weakens vein walls. This illness may cause swelling, soreness, heaviness, exhaustion, and other symptoms like leg ulcers and blood clots.
Nurses are responsible for most of the health system's services. Increasing varicose intensity can impair work output, threaten physical and mental health -particularly in older adults -and impose high costs on individuals and healthcare systems. Based on the results of this study, increasing the number of nursing workers for patient care, encouraging physical exercise, and bringing the pension age forward appear to be required to avoid the occurrence and severity of varicose veins.

Limitations
The study's limitations include the tiny sample size. The cross-sectional design precluded the investigation of variations in varicose veins over time. Additionally, we were unable to ascertain the participants' lifestyle and exercise habits. Furthermore, this research included nurses from two hospitals only; therefore, the findings may not be generalizable to other populations.

Conclusions
This cross-sectional study contributes to the knowledge of the prevalence and risk factors for varicose veins. Our study has revealed a low prevalence of varicose veins among nurses working at King Fahd Central Hospital and Prince Muhammad bin Nasser Hospital. The prevalence of varicose veins was higher in females than in males. The varicose vein risk factors were ethnicity, lifting heavy objects, lack of exercise, family history, use of hormonal therapy, use of contraceptive pills, type of delivery, the number of children, and hours sitting per shift. The comorbidities associated with varicose veins were deep vein thrombosis, hypertension, chronic constipation, diabetes, kidney disease, rheumatoid arthritis, coronary artery disease, and severe occupational injury to the lower extremities. Nurses are responsible for most health system services, and hiring more nursing workers for patient care, promoting physical exercise, and lowering the pension age seems to be required to prevent the occurrence and development of varicose veins.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Jazan Health Ethics Committee, Saudi Arabia issued approval No. 2197. The Jazan Health Ethics Committee has reviewed and approved the above-mentioned study. 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.