Prevalence of Varicose Veins and Its Risk Factors among Nurses Working at King Khalid University Hospital Riyadh, Saudi Arabia: A Cross-Sectional Study

Abstract

This quantitative observational cross-sectional study assessed the prevalence and level of risk scores for varicose veins among nurses, and the association between varicose veins and sociodemographic, occupational, and lifestyle risk factors. Using simple random sampling, from August–December 2022, 250 nurses from different departments at King Khalid University Hospital completed a validated self-administered questionnaire and underwent an observational physical examination. Most nurses (191) had low-risk scores for varicose veins, 46 nurses had moderate-risk scores, and 13 nurses had high-risk scores. From the outpatient clinics, 61.5% of nurses had significant high-risk scores for varicose veins. Those with a statistically significant association had a family history of varicose veins (p < 0.001) and other chronic medical conditions (p = 0.04). Physical activity, especially race-walking/running (p = 0.006), showed a statistically significant association with the varicose veins score. The years as a staff nurse were statistically significant among the occupational risk factors (p = 0.003). The adjusted multivariable regression model showed three significant predictors: a positive family history, running/walking, and total years as a staff nurse (p < 0.001, p = 0.02, and p < 0.001, respectively). Nurses working at outpatient clinics, positive family history, years as a staff nurse, and other chronic conditions are risk factors for varicose veins, while race-walking/running is a protective factor.

Full text

Citation: Baghdadi, L.R.; Alshalan,
G.F.; Alyahya, N.I.; Ramadan, H.H.;
Alshahrani, A.M.; Alqahtani, J.A.;
Aljarbaa, M.O. Prevalence of Varicose
Veins and Its Risk Factors among
Nurses Working at King Khalid
University Hospital Riyadh, Saudi
Arabia: A Cross-Sectional Study.
Healthcare 2023,11, 3183. https://
doi.org/10.3390/healthcare11243183
Academic Editors: Rosario Caruso,
Arianna Magon, Irene Baroni,
Alessandro Stievano and Susan
Ka Yee Chow
Received: 26 October 2023
Revised: 16 November 2023
Accepted: 15 December 2023
Published: 16 December 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
healthcare
Article
Prevalence of Varicose Veins and Its Risk Factors among Nurses
Working at King Khalid University Hospital Riyadh, Saudi
Arabia: A Cross-Sectional Study
Leena R. Baghdadi 1, * , Ghadah F. Alshalan 2, Norah I. Alyahya 2, Hend H. Ramadan 2, Abrar M. Alshahrani 2,
Jumana A. Alqahtani 2and Maha O. Aljarbaa 2
1Department of Family and Community Medicine, College of Medicine, King Saud University,
Riyadh 11362, Saudi Arabia
2College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia;
441200618@student.ksu.edu.sa (G.F.A.); 441200319@student.ksu.edu.sa (A.M.A.);
441200371@student.ksu.edu.sa (J.A.A.); 441200276@student.ksu.edu.sa (M.O.A.)
*Correspondence: lbaghdadi@ksu.edu.sa; Tel.: +966-11-467-0836
Abstract:
This quantitative observational cross-sectional study assessed the prevalence and level
of risk scores for varicose veins among nurses, and the association between varicose veins and
sociodemographic, occupational, and lifestyle risk factors. Using simple random sampling, from
August–December 2022, 250 nurses from different departments at King Khalid University Hospital
completed a validated self-administered questionnaire and underwent an observational physical
examination. Most nurses (191) had low-risk scores for varicose veins, 46 nurses had moderate-
risk scores, and 13 nurses had high-risk scores. From the outpatient clinics, 61.5% of nurses had
significant high-risk scores for varicose veins. Those with a statistically significant association
had a family history of varicose veins (p< 0.001) and other chronic medical conditions (p= 0.04).
Physical activity, especially race-walking/running (p= 0.006), showed a statistically significant
association with the varicose veins score. The years as a staff nurse were statistically significant
among the occupational risk factors (p= 0.003). The adjusted multivariable regression model showed
three significant
predictors: a positive family history, running/walking, and total years as a staff
nurse (
p< 0.001
,p= 0.02, and p< 0.001, respectively). Nurses working at outpatient clinics, positive
family history, years as a staff nurse, and other chronic conditions are risk factors for varicose veins,
while race-walking/running is a protective factor.
Keywords:
varicose veins; nurses; occupational disease; risk factors; protective factors; occupational
health; lifestyle factors
1. Introduction
The worldwide prevalence of lower extremity varicose veins is 10% to 30% [
1
,
2
].
Swollen, bulging, or enlarged blood vessels that generally develop on the legs and feet are
known as varicose veins. They can occur in other parts of the body and are blue or dark
purple in color with a lumpy, swollen, or otherwise unattractive appearance. This is one of
the world’s most frequent peripheral vascular disorders [
3
]. Varicose veins are not painful
in the early stages. Aesthetics are the primary reason patients seek medical help [4].
The initial sign is discomfort, including tiredness and heaviness in the legs and
nocturnal cramps. Swelling of the lateral and medial ankles and dorsum of the foot, dull or
burning pain, and paresthesia are some of the symptoms that follow. Spider veins or wiggly
shaped tiny swellings under the skin surface are apparent changes on the lower limbs. The
swellings are soft and painless, and their size is determined by the position of the limb [
4
].
Risk factors are high vascular blood pressure from prolonged standing, a sedentary lifestyle,
pregnancy, gender, and a positive family history [
5
]. Obesity is not considered a risk factor
Healthcare 2023,11, 3183. https://doi.org/10.3390/healthcare11243183 https://www.mdpi.com/journal/healthcare

Healthcare 2023,11, 3183 2 of 15
by itself, although those with obesity class III reported significant limb symptoms, which
are indicative of chronic venous insufficiency [
6
]. In Saudi Arabia, there are few studies
about the prevalence of and risk factors for varicose veins. A cross-sectional study in
Riyadh showed a high prevalence of varicose veins (47.6%) among 380 females, with
associated factors such as increased age, positive family history, high body mass index
(BMI), educational level, the number of pregnancies, and use of oral contraceptives [
7
].
Other studies focused on occupational risk factors for varicose veins in jobs that require
standing for long periods of time. In Abha, Saudi Arabia, 42% of teachers had varicose veins,
and women had a greater prevalence (37%) compared to men (14%). According to the study,
primary school teachers were 39.9% more likely to develop varicose veins than middle-
and high-school teachers [
8
]. A Taiwanese study identified hairdressers as another risk
group for varicose veins and focused on long periods of standing at work. They reported
that 24.2% of participants had lower extremity varicose veins. For hairdressers
≥
45 years
old, occupational effects were the major risk factor for varicose veins, while family history
was a risk factor for hairdressers
≤
45 years old [
9
]. A study about healthcare workers
in Italy found a higher prevalence of venous pathology in nurses and auxiliaries (54.5%)
compared to administrative staff (31.6%) and a greater prevalence among females (46.8%)
compared to males (24.6%). Therefore, the end results suggest that the combined effects of
occupational risk factors like prolonged standing plus other risk factors such as age, family
history, and number of pregnancies are likely to cause varicose veins [
10
]. Some studies
focused on nurses as a group at higher risk of varicose veins, as they stand for long periods
during their duty hours. A recent study in Jazan revealed a low prevalence of varicose
veins among nurses working at King Fahad Central Hospital and Prince Muhammad
bin Nasser Hospital. Risk factors found to have statistically significant associations with
varicose veins were ethnicity, lifting heavy objects, lack of exercise, family history, use of
hormonal therapy, use of contraceptive pills, type of delivery, and parity [
11
]. A study in
Riyadh showed that varicose veins were prevalent in 11% of the total participants (366).
There were 40 (39 females and one male) participants with varicose veins, which suggests
a low prevalence of varicose veins among nurses working in four separate departments
(dermatology, intensive care unit, general surgery, and emergency), with no significant
relation between the nature of each department’s practice and the prevalence of varicose
veins. Positive family history, age, marital status, long shifts, and lifting heavy items were
all significant risk factors for the development of varicose veins among nurses [
12
]. On
the other hand, a study in Egypt revealed that
18.4% (37 out
of 201) of nurses have lower-
limb varicose veins. A higher prevalence of varicose veins was found among employees
in emergency and intensive care units (ICU)/operation rooms who were employed for
≥5 years
with >6 daily working hours. The incidence of varicose veins is higher among
nurses with chronic constipation, on oral contraceptives, or having had
≥
3 pregnancies [
13
].
In an Iranian study that had nurses with
≥
2 years of service from three general hospitals,
it was concluded that varicose veins were prevalent in varying degrees in 72.4% of the
nurses, with a higher incidence in women than men [
14
]. Standing for long periods of
time was found to be a strong risk factor for varicose veins in 46% of nurses at Nepal’s
Dhulikhel hospital, with the highest prevalence in the teaching faculty and the lowest in
the orthopedic ward [
15
]. In India, a study evaluated the risk of varicose veins in nurses
working in the ICU and other departments. Nurses working in critical care had a higher
risk (9.78) than nurses working in general wards (5.18). The study found that there was
an association with other risk factors like age, duration of duty, years of working, and
sources of information about varicose veins [
16
]. In the Udaipur study, 24.17% of 364 nurses
had varicose veins, and female nurses had a higher prevalence than males [
17
]. A Korean
study found that the prevalence of varicose veins was 16.2% among nurses at different
departments. Nurses working in the operating room had the highest occurrence (36.4%) of
varicose veins despite wearing compression stockings, followed by those working in an
outpatient clinic (26.9%). No sex-related differences were found in this investigation [
18
].
In East China, a study among female nurses reported that the prevalence of varicose veins

Healthcare 2023,11, 3183 3 of 15
was 32.4% of the total population. Furthermore, varicose veins in the lower extremities
show a linear association with age and working years [19,20].
Although there are a few studies on the prevalence of varicose veins among healthcare
workers in Saudi Arabia, there is a lack of evidence about the severity of developing
varicose veins and its link to several predisposing factors, such as lifestyle and occupational
health risk factors. Understanding the association between factors predisposing nurses to
severe levels of varicose veins will help in raising public awareness about occupational
disorders in our culture, lowering the incidence, or at the very least, delaying the onset or
preventing the problem from deteriorating. The recognition of the significance of lifestyle
modification, in light of the Saudi Vision 2030, is indicative of a fundamental understanding
of the imperative need to promote health and well-being amongst the populace by focusing
on promoting preventive care. With a steadfast commitment to enhancing the standard
of living and increasing the average life expectancy from 74 years to 80 years, the Vision
envisions transformative measures aimed at achieving these objectives [
21
]. In line with
the 2030 Saudi Vision, it is crucial to address the health concerns of nurses, including the
prevalence of varicose veins [
22
]. Therefore, the aim of this study was to assess the level
of risk scores for varicose veins among nurses and to find out the association between the
levels of scores for varicose veins and several risk factors, including sociodemographic,
lifestyle, and occupational risk factors.
2. Materials and Methods
A quantitative observational cross-sectional study was conducted among nurses
working at King Khalid University Hospital (KKUH) in Riyadh, Saudi Arabia. The study
was conducted from August 2022 to December 2022. Data were collected from nurses
working in different departments using a validated self-administered questionnaire and
observational physical examination [
16
]; content validity was assessed in their study by
distributing it to experts in medicine, surgery, and medical-surgical nursing. Adjustments
were made based on the experts’ opinions and suggestions. To determine its reliability,
the varicose vein risk assessment tool was computed using the Karl Pearson correlation
coefficient (Inter-Rater method). The computed reliability of the tool was r = 0.99, indicating
that the tool is reliable.
2.1. Study Participants
The sample size was calculated based on a previously published study using the
prevalence of varicose veins [
13
]. By using n = (z
α
/2)
2×
p(1
−
p)/d
2
equation where
p= 0.184, d = 5%, z
α
for 95% = 1.96, n= (1.96)
2×
0.184 (1–0.184)/0.05
2
=230.7~231, and
assuming a non-response is 10%, the sample size is equal to ~255. A pvalue < 0.05 is
considered statistically significant.
A total of 255 nurses of various ages and nationalities were recruited from different
departments at KKUH. Nurses who were pregnant, had undergone treatment for varicose
veins, and worked for <1 year (n = 5) were excluded from the study. Thus, the final number
of recruited nurses was n= 250.
2.2. Data Collection Process
The simple random sampling technique was used to collect data daily for one month
in August 2022 during the working hours of the inpatients, outpatients, emergency, and
ICU departments. A list of potential participants was obtained from the nurse databases
provided by the King Saud University Medical City (KSUMC) Nursing Affairs Research and
Innovation Department. Each individual on the list was assigned a unique identification
number. Using a random number generator, 250 participants were selected from the
population list. The eligible participants were contacted when the study’s purpose was
explained and were invited to voluntarily participate in the study.
Our data collection included two parts: an English self-administered demographic
questionnaire modified by the researchers, which was divided into four parts (sociode-

Healthcare 2023,11, 3183 4 of 15
mographic information, medical conditions, lifestyle, and occupational risk factors), and
a validated varicose vein assessment tool based on an observational physical examina-
tion [
16
]. It consists of 23 questions, and point scores (correct answer was given a score of
1 and
the wrong answer was given a score of 0) were assigned to each question. The total
maximum score was 23, and the levels of the scores were categorized as low
(score 1–7)
,
moderate (score 8–16), and high (score 17–23). The physical examination was conducted by
the same researcher after receiving training from a consultant vascular surgeon at KKUH.
The study was approved by the King Saud University-College of Medicine Institutional
Review Board (Registration No. of the study: E-22-6963). Nurses who agreed to participate
gave informed written consent before they were administered the questionnaire. The
data collection procedure included an interview via a questionnaire and an observational
checklist to assess the likelihood of the participants developing various veins. The checklist
has two sections. The first section of the observational checklist evaluated the presence of
swelling, tenderness of the lower legs, hardening, change in color, bulging, enlargement or
dilatation of the vein, the presence of a spider web, redness, thrombophlebitis, thickness
or dryness of the lower legs, and ulceration or irregular pigmentation at or around the
ankle. The second section evaluated the presence of fatigue, pitting edema, itching around
one or more veins, heaviness or throbbing of the legs, burning sensations, pain or muscle
cramping of the lower leg, inflammation of the skin, and restless legs syndrome.
2.3. Data Analysis
Data were analyzed using SPSS v.24.0 (IBM, Chicago, IL, USA, US statistical software).
Descriptive statistics (mean, standard deviation, frequencies, and percentages) were used to
describe the quantitative and categorical variables. A suitable Chi-square test and Fisher’s
exact test were used to conduct bivariate statistical analyses. Multivariable-adjusted binary
logistic regression was used to predict a moderate/high risk of varicose veins. The statistical
significance and precision of the data were reported using a p-value of <0.05 and a 95%
confidence interval (CI).
3. Results
A total of 250 nurses participated in the study, including 235 female nurses (94.0%)
and 15 male nurses (6.0%). Their mean age was 36.54 years (
±
7.73 years), and their mean
BMI was 26.6 kg/m
2
(
±
4.27 kg/m
2
). The majority of participating nurses had worked
for 6–10 years (31.2%). More than half (68.8%) of the nurses were married, and all nurses
resided in Riyadh. They mostly lived in the north (43.6%) and center of Riyadh (43.2%).
The nurses’ educational levels ranged from a diploma to a master’s degree and doctorate,
and 72.0% of the nurses had a bachelor’s degree. The nurses’ information about varicose
veins came from a variety of sources, and many of them listed multiple resources. The
highest percentages of information came from books (76.8%), healthcare personnel (74.8%),
and the internet (74.8%). Table 1shows the distribution of sociodemographic characteristics
of nurses in relation to the departments where they work.
Table 1.
Sociodemographic characteristics of the nurses by the departments in which they work
(N = 250).
Characteristics Inpatient Dept.
n (%)
Outpatient Dept.
n (%)
Emergency Dept.
n (%)
ICU Dept.
n (%)
Total Nurses
n (%)
Age (years) Mean 37.64 ±6.84 Mean 36.32 ±8.14 Mean 34.27 ±6.69 Mean 41 ±7.86 Mean 36.54 ±7.53
<30 8 (13.6%) 25 (42.4%) 15 (25.4%) 11 (18.6%) 59 (100.0%)
30–40 45 (34.4%) 46 (35.1%) 24 (18.3%) 16 (12.2%) 131 (100.0%)
>40 21 (35.0%) 19 (31.7%) 6 (10.0%) 14 (23.3%) 60 (100.0%)
Gender
Females 67 (28.5%) 84 (35.7%) 43 (18.3%) 41 (17.4%) 235 (100.0%)
Males 7 (46.7%) 6 (40.0%) 2 (13.3%) 0 (0.0%) 15 (100.0%)

Healthcare 2023,11, 3183 5 of 15
Table 1. Cont.
Characteristics Inpatient Dept.
n (%)
Outpatient Dept.
n (%)
Emergency Dept.
n (%)
ICU Dept.
n (%)
Total Nurses
n (%)
Nationality
Saudi 7 (19.4%) 22 (61.1%) 5 (13.9%) 2 (5.6%) 36 (100.0%)
Non-Saudi 67 (31.3%) 68 (31.8%) 40 (18.7%) 39 (18.2%) 214 (100.0%)
Ethnicity
Arabian 9 (23.7%) 23 (60.5%) 4 (10.5%) 2 (5.3%) 38 (100.0%)
Asian 65 (30.7%) 67 (31.6%) 41 (19.3%) 39 (18.4%) 212 (100.0%)
Marital status
Single 22 (28.2%) 34 (43.6%) 16 (20.5%) 6 (7.7%) 78 (100.0%)
Married 52 (30.2%) 56 (32.6%) 29 (16.9%) 35 (20.3%) 172 (100.0%)
Level of education
Diploma in
practical nursing 19 (30.6%) 19 (30.6%) 10 (16.1%) 14 (22.6%) 62 (100.0%)
Bachelor’s degree 51 (28.3%) 70 (38.9%) 34 (18.9%) 25 (13.9%) 180 (100.0%)
Master’s degree
and doctorate 4 (50.0%) 1 (12.5%) 1 (12.5%) 2 (25.0%) 8 (100.0%)
Total experience as
staff nurses
1–5 years 10 (21.7%) 21 (45.7%) 9 (19.6%) 6 (13.0%) 46 (100.0%)
6–10 years 26 (33.3%) 26 (33.3%) 16 (20.5%) 10 (12.8%) 78 (100.0%)
11–15 years 17 (27.0%) 26 (41.3%) 9 (14.3%) 11 (17.5%) 63 (100.0%)
>15 years 21 (33.3%) 17 (27.0%) 11 (17.5%) 14 (22.2%) 63 (100.0%)
Average family
income (SAR)
<5000 16 (38.1%) 20 (47.6%) 3 (7.1%) 3 (7.1%) 42 (100.0%)
6000–10,000 47 (28.8%) 46 (28.2%) 35 (21.5%) 35 (21.5%) 163 (100.0%)
>10,000 11 (24.4%) 24 (53.3%) 7 (15.6%) 3 (6.7%) 45 (100.0%)
BMI (kg/m2)Mean 26.46 ±4.37 Mean 25.13 ±3.86 Mean 24.79 ±4.67 Mean 26 ±4.3 Mean 26.6 ±4.27
Underweight 1 (16.7%) 1 (16.7%) 3 (50.0%) 4 (16.7%) 6 (100.0%)
Normal 27 (23.7%) 48 (42.1%) 23 (20.2%) 16 (14.0%) 114 (100.0%)
Overweight 30 (33.7%) 30 (33.7%) 13 (14.6%) 16 (18.0%) 89 (100.0%)
Obesity 16 (39.0%) 11 (26.8%) 6 (14.6%) 8 (19.5%) 41 (100.0%)
Family history of
varicose veins
Yes 23 (29.9%) 29 (37.7%) 12 (15.6%) 13 (16.9%) 77 (100.0%)
No 51 (29.5%) 61 (35.3%) 33 (19.1%) 28 (16.2%) 173 (100.0%)
Information about
varicose veins from
Family members 23 (29.1%) 31 (39.2%) 14 (17.7%) 11 (13.9%) 79 (100.0%)
Friends and peers 26 (22.4%) 48 (41.4%) 19 (16.4%) 23 (19.8%) 116 (100.0%)
Healthcare
personnel 49 (26.2%) 71 (38.0%) 35 (18.7%) 32 (17.1%) 187 (100.0%)
Books 56 (29.2%) 73 (38.0%) 30 (15.6%) 33 (17.2%) 192 (100.0%)
Journals 38 (32.2%) 38 (32.2%) 23 (19.5%) 19 (16.1%) 118 (100.0%)
Newspaper 23 (30.7%) 27 (36.0%) 13 (17.3%) 12 (16.0%) 75 (100.0%)
Internet sources 47 (25.1%) 69 (36.9%) 36 (19.3%) 35 (18.7%) 187 (100.0%)
Social media
(Twitter, Facebook,
etc.)
36 (29.8%) 45 (37.2%) 19 (15.7%) 21 (17.4%) 121 (100.0%)

Healthcare 2023,11, 3183 6 of 15
Table 1. Cont.
Characteristics Inpatient Dept.
n (%)
Outpatient Dept.
n (%)
Emergency Dept.
n (%)
ICU Dept.
n (%)
Total Nurses
n (%)
Smoking
Yes 4 (21.1%) 11 (57.9%) 3 (15.8%) 1 (5.3%) 19 (100.0%)
No 70 (30.3%) 79 (34.2%) 42 (18.2%) 40 (17.3%) 231 (100.0%)
Varicose vein risk
score
Low risk 64 (33.5%) 64 (33.5%) 35 (18.3%) 28 (14.7%) 191 (100.0%)
Moderate risk 7 (15.2%) 18 (39.1%) 8 (17.4%) 13 (28.3%) 46 (100.0%)
High risk 3 (23.1%) 8 (61.5%) 2 (15.4%) 0 (0.0%) 13 (100.0%)
Total 74 (29.6%) 90 (36.0%) 45 (18.0%) 41 (16.4%) 250 (100%)
BMI: Body mass index; Dept.: Department; ICU: Intensive care unit; SAR: Saudi Arabian riyal.
Most nurses (n = 191) had low-risk scores for varicose veins, 46 nurses had moderate-
risk scores, and 13 nurses had high varicose vein risk scores (74.4%, 18.4%, and 5.2%,
respectively). The number of nurses working in the inpatient departments was 74 (29.6%),
those in outpatient clinics were 90 (36.0%), those in the emergency department were
45 (18.0%),
and those in the ICU were 41 (16.4%). Among the four departments, the highest
prevalence of high-risk scores for varicose veins was found among nurses working in
outpatient clinics, followed by inpatient departments (61.5% vs. 23.1%, p= 0.03) (Graph
1). Among the sociodemographic and medical factors, there were statistically significant
associations with a positive family history of varicose veins and other chronic medical
conditions (p< 0.001, and p= 0.04, respectively) (Table 2).
Table 2.
Varicose vein risk scores and their associations with sociodemographic factors and medical
conditions.
Variables Low Risk Moderate/High Risk Statistical Test p-Value
Age (years)
3.12 0.21
<30 42 (71.2%) 17 (28.8%)
30–40 106 (80.9%) 25 (19.1%)
>40 43 (71.7%) 17 (28.3%)
Gender
0.93 F0.53
Females 178 (75.7%) 57 (24.3%)
Males 13 (86.7%) 2 (13.3%)
Ethnicity
0.71 0.40
Arabian 27 (71.1%) 11 (28.9%)
Asian 164 (77.4%) 48 (22.6%)
Level of education
1.57 F0.46
Diploma in practical nursing 44 (71.0%) 18 (29.0%)
Bachelor’s degree 141 (78.3%) 39 (21.7%)
Master’s degree and doctorate 6 (75.0%) 2 (25.0%)
Average family income (SAR)
0.73 0.70
<5000 34 (81.0%) 8 (19.0%)
6000–10,000 124 (76.1%) 39 (23.9%)
>10,000 33 (73.3%) 12 (26.7%)

Healthcare 2023,11, 3183 7 of 15
Table 2. Cont.
Variables Low Risk Moderate/High Risk Statistical Test p-Value
BMI (kg/m2)
1.37 F0.74
Underweight 4 (66.7%) 2 (33.3%)
Normal 90 (78.9%) 24 (21.1%)
Overweight 67 (75.3%) 22 (24.7%)
Obesity 30 (73.2%) 11 (26.8%)
Parity
0.03 0.86
Nulliparous 85 (75.2%) 28 (24.8%)
Multipara 93 (76.2%) 29 (23.8%)
Gravidity
0.10 0.76
Nulligravida 76 (76.8%) 23 (23.2%)
Multigravida 102 (75.0%) 34 (25.0%)
Use of hormonal therapy
2.38 F0.50
Hormonal therapy 6 (66.7%) 3 (33.3%)
Oral contraceptives 16 (76.2%) 5 (23.8%)
Hormonal therapy and oral
contraceptives 2 (50.0%) 2 (50.0%)
None 154 (76.6%) 47 (23.4%)
Family history of varicose veins
14.56 <0.001 *
Yes 47 (61.0%) 30 (39.0%)
No 144 (83.2%) 29 (16.8%)
Smoking
0.70 F0.58
Yes 16 (84.2%) 3 (15.8%)
No 175 (75.8%) 56 (24.2%)
Diabetes mellitus
0.00 F1.00
Yes 13 (76.5%) 4 (23.5%)
No 178 (76.4%) 55 (23.6%)
Hypertension
1.40 0.24
Yes 16 (66.7%) 8 (33.3%)
No 175 (77.4%) 51 (22.6%)
Coronary heart diseases
n/a n/a
Yes 0 (0%) 0 (0%)
No 191 (76.4%) 59 (23.6%)
Heart failure
n/a n/a
Yes 0 (0%) 0 (0%)
No 191 (76.4%) 59 (23.6%)
Deep vein thrombosis
0.78 F0.42
Yes 1 (50.0%) 1 (50.0%)
No 190 (76.6%) 58 (23.4%)
Chronic constipation
0.16 F0.56
Yes 2 (66.7%) 1 (33.3%)
No 189 (76.5%) 58 (23.5%)
Asthma
3.56 0.06
Yes 16 (61.5%) 10 (38.5%)
No 175 (78.1%) 49 (21.9%)
Hyperthyroidism
0.76 F0.34
Yes 3 (60.0%) 2 (40.0%)
No 188 (76.7%) 57 (23.3%)
Hypothyroidism
3.13 F0.13
Yes 10 (58.8%) 7 (41.2%)
No 181 (77.7%) 52 (22.3%)

Healthcare 2023,11, 3183 8 of 15
Table 2. Cont.
Variables Low Risk Moderate/High Risk Statistical Test p-Value
Obesity
0.00 0.95
Yes 20 (76.9%) 6 (23.1%)
No 171 (76.3%) 53 (23.7%)
Kidney Failure
n/a n/a
Yes 0 (0%) 0 (0%)
No 191 (76.4%) 59 (23.6%)
Cancer
1.58 F0.59
Yes 5 (100%) 0 (0%)
No 186 (75.9%) 59 (24.1%)
# Other chronic conditions
5.29 F0.04 *
Yes 4 (44.4%) 5 (55.6%)
No 187 (77.6%) 54 (22.4%)
BMI: Body mass index;
F
: Fisher’s exact test was used when expected counts were less than 5; * Indicates
statistically significant p-values (p< 0.05); n/a: not applicable; # Other chronic conditions: polycystic ovarian
syndrome, thyroiditis, migraine, epilepsy, dyslipidemia, incompetent saphenous right and left veins, irritable
bowel syndrome, and supraventricular tachycardia; SAR: Saudi Arabian riyal.
According to lifestyle factors, physical activity, especially race-walking/running
showed a statistically significant preventive association with varicose vein scores
(p< 0.006)
(Table 3). Regarding occupational risk factors, the total years of experience as a staff nurse
showed a statistically significant result (p< 0.003) (Table 4). Three significant predictors
remained in the multivariable-adjusted regression model. The most influential predictor
of moderate/high risk of varicose veins is a family history of varicose veins. Participants
who reported family history are 3.57 times more likely to have a moderate/high risk of
varicose veins, controlling for other factors. Race-walking/running as physical activity is
associated with a significant reduction in varicose vein risk; those who race-walk or run
for exercise have 4.35 times lower odds of moderate/high risk compared to those who do
not do these activities, controlling for other factors. The total experience of 6–10 years in
nursing is associated with significantly lower odds of varicose veins compared to 1–5 years
of experience, which have 6.25 times lower odds, controlling for other factors (Table 5).
Table 3. Prevalence of varicose vein risk scores and their associations according to lifestyle factors.
Variables Low Risk Moderate/High Risk Statistical Test p-Value
Dietary variables
Caffeinated drinks (coffee, tea, energy
drinks)
0.60 F0.91
Never 11 (73.3%) 4 (26.7%)
1–3 times per week 42 (77.8%) 12 (22.2%)
4–6 times per week 24 (72.7%) 9 (27.3%)
Everyday 114 (77.0%) 34 (23.0%)
Sugar-sweetened drinks (soft beverages)
2.04 F0.57
Never 40 (81.6%) 9 (18.4%)
1–3 times per week 106 (76.8%) 32 (23.2%)
4–6 times per week 16 (76.2%) 5 (23.8%)
Everyday 29 (69.0%) 13 (31.0%)

Healthcare 2023,11, 3183 9 of 15
Table 3. Cont.
Variables Low Risk Moderate/High Risk Statistical Test p-Value
Donuts, cakes, candy, and chocolate
1.47 F0.72
Never 38 (76.0%) 12 (24.0%)
1–3 times per week 126 (76.8%) 38 (23.2%)
4–6 times per week 15 (83.3%) 3 (16.7%)
Everyday 12 (66.7%) 6 (33.3%)
Fast food
0.28 F0.98
Never 35 (76.1%) 11 (23.9%)
1–3 times per week 134 (76.6%) 41 (23.4%)
4–6 times per week 14 (77.8%) 4 (22.2%)
Everyday 8 (72.7%) 3 (27.3%)
# Physical activities variables
Leisure physical activity
7.82 F0.01 *
Yes 184 (78.3%) 51 (21.7%)
No 7 (46.7%) 8 (53.3%)
Light-intensity physical activity
0.61 0.44
Yes 19 (70.4%) 8 (29.6%)
No 172 (77.1%) 51 (22.9%)
Moderate physical activities
1.27 0.26
Yes 113 (79.0%) 30 (21.0%)
No 78 (72.9%) 29 (27.1%)
Vigorous physical activities
0.13 0.72
Yes 99 (77.3%) 29 (22.7%)
No 92 (75.4%) 30 (24.6%)
Race-walking/Running
9.25 F0.006*
Yes 185 (78.4%) 51 (21.6%)
No 6 (32.9%) 8 (57.1%)
Running
4.68 0.03 *
Yes 60 (85.7%) 10 (14.3%)
No 131 (72.8%) 49 (27.2%)
Swimming
0.01 F1.00
Yes 7 (77.8%) 2 (22.2%)
No 184 (76.3%) 57 (23.7%)
F
Fisher’s exact test was used when expected counts were less than 5; * Indicates statistically significant p-values
(<0.05); # Physical activities were classified based on the World Health Organization 2020 guidelines on physical
activity and sedentary behavior: Leisure physical activity: activity performed by an individual that is not required
as an essential activity of daily living and is performed at the discretion of the individual. Examples include
recreational activities such as going for a walk and gardening; Light-intensity physical activity: on a scale relative
to an individual’s personal capacity, light-intensity physical activity is usually 2–4 on a rating scale of perceived
exertion scale of 0–10. Examples include slow walking, bathing, or other incidental activities that do not result
in a substantial increase in heart rate or breathing rate; Moderate-intensity physical activity: on a scale relative
to an individual’s personal capacity, such as walking briskly (3 miles per hour or faster, but not race-walking),
water aerobics, and bicycling slower than 10 miles per hour; Vigorous physical activities: on a scale relative to an
individual’s personal capacity, it is usually a 5 or above on a scale of 0–10, such as jogging or race-walking or
running, swimming, jumping rope, and soccer.

Healthcare 2023,11, 3183 10 of 15
Table 4.
Prevalence of varicose vein risk scores and their variation according to occupational risk factors.
Occupational Risk Factors Low Risk Moderate/High Risk Statistical Test p-Value
Total experience as staff nurse
13.76 0.003 *
1–5 years 29 (63.0%) 17 (37.0%)
6–10 years 70 (89.7%) 8 (10.3%)
11–15 years 44 (69.8%) 19 (30.2%)
>15 years 48 (76.2%) 15 (23.8%)
Total day duty/month
0.35 F0.94
1 week 7 (87.5%) 1 (12.5%)
2 weeks 20 (76.9%) 6 (23.1%)
>2 weeks 164 (75.9%) 52 (24.1%)
Total night duty/month
0.44 0.80
None 77 (75.5%) 25 (24.5%)
2 weeks 22 (81.5%) 5 (18.5%)
>2 weeks 92 (76.0%) 29 (24.0%)
Lifting heavy objects
0.79 0.37
Yes 104 (74.3%) 36 (25.7%)
No 87 (79.1%) 23 (20.9%)
Consulted an occupational therapist
0.00 0.97
Yes 32 (76.2%) 10 (23.8%)
No 159 (76.4%) 49 (23.6%)
Wear crepe bandages stockings
0.10 0.75
Yes 26 (74.3%) 9 (25.7%)
No 165 (76.7%) 50 (23.3%)
Hours spent sitting during duty hours
1.31 0.52
<2 h 88 (73.9%) 31 (26.1%)
2–4 h 84 (80.0%) 21 (20.0%)
≥4 h 19 (73.1%) 7 (26.9%)
Hours spent standing during duty hours
3.17 F0.19
<2 h 14 (93.3%) 1 (6.7%)
2–4 h 34 (81.0%) 8 (19.0%)
≥4 h 143 (74.1%) 50 (25.9%)
Hours spent walking during duty hours
1.08 0.58
<2 h 19 (82.6%) 4 (17.4%)
2–4 h 46 (79.3%) 12 (20.7%)
≥4 h 126 (74.6%) 43 (25.4%)
F
Fisher’s exact test was used when expected counts were less than 5; * Indicates statistically significant p-values
(p< 0.05).
Table 5.
Multivariable-adjusted binary logistic regression predicting moderate/high risk of varicose veins.
Predictive Factors OR (95% CI) p-Value
Family history of varicose
veins <0.001 *
Yes 3.57 (1.82–7.00)
No Reference
Other chronic conditions
0.23
Yes 2.53 (0.55–11.67)
No Reference
Race-walking/Running
0.02 *
Yes 0.23 (0.07–0.80)
No Reference
Total experience as staff nurse
1–5 years Reference
6–10 years 0.16 (0.06–0.46) <0.001 *
11–15 years 0.77 (0.32–1.89) 0.57
>15 years 0.65 (0.26–1.62) 0.35
Regression model adjusted for age, gender, family history of varicose veins, chronic conditions, walking, and total
experience of nurses; * Indicates statistically significant p-values (p< 0.05); Other chronic conditions: polycystic
ovarian syndrome, thyroiditis, migraine, epilepsy, dyslipidemia, incompetent saphenous right and left veins,
irritable bowel syndrome, and supraventricular tachycardia.

Healthcare 2023,11, 3183 11 of 15
4. Discussion
To the best of our knowledge, this is one of the few studies in Saudi Arabia to assess
the level of risk scores of varicose veins among nurses in relation to occupational health
factors. In our study, we estimated the prevalence of varicose veins, focusing on the level of
its risk scores and its associated risk factors among nurses working at different departments
of KKUH, by using a simple random sampling technique. We studied sociodemographic
risk factors (age, gender, family history, smoking status, etc.), occupational risk factors
(longer work history, i.e., employment history), longer working hours, nature of work, and
lifestyle factors (weight, diet, and physical activity).
We found that the highest prevalence of high-risk scores for varicose veins was in
nurses working in outpatient clinics, followed by those in inpatient departments (61.5% vs.
23.1%, p= 0.03). These results were supported by a Korean study, where the prevalence
of varicose veins was significantly higher among outpatient clinic and operating room
nurses [
18
]. This could be attributed to the difference in the number of participants
recruited from each department. Our study had 74 (29.6%) participants from inpatient
departments and 90 (36.0%) participants from outpatient clinics. An Iranian study reported
the highest prevalence of varicose veins compared to other countries, where 72.4% of nurses
with ≥2 years
of service from three general hospitals had lower-limb varicose veins [
14
].
This could be attributed to the difference in workloads between Iranian hospitals and
hospitals in other countries; additionally, it was a questionnaire-based study.
A retrospective Taiwanese cohort study reported that the cumulative incidence of
varicose veins among physicians, non-physician health care providers (HCPs), and the
general population was 0.12%, 0.13%, and 0.13%, respectively, over a 5-year period. Despite
working long hours, physicians in Taiwan had no greater risk of varicose veins than non-
physician HCPs or the general population of the study. There was also no significant
difference in the varicose vein risk among the various specialist physicians. In comparison
to female non-physician HCPs, female physicians appear to have a lower risk of varicose
veins. Male physicians had a higher incidence of varicose veins than male non-physician
HCPs [
20
]. However, most of these studies have some limitations, such as selection bias [
7
]
and measurement bias [8,9].
Most of the local and international studies have some limitations, such as a selection
bias in the study conducted on females in Riyadh because of the use of a convenience
sampling technique [
7
]. All participants did not undergo a physical examination for their
varicose veins in Abha, Saudi Arabia, or in the Taiwanese hairdressers’ studies, which
could affect the accuracy of the results [
8
,
9
]. The Italian study had a small sample size and
potential recall biases [
10
]. The diagnosis of varicose veins was self-reported, which could
be a source of recall bias in the Riyadh and Dhulikhel hospitals [
12
,
15
]. Limited sample
sizes could not verify cause and effect linkages in the Egyptian and Italian studies [
10
,
13
].
Researchers in an Iranian study were unable to investigate the impact of nurses’ lifestyles
on nutrition and exercise habits, perhaps due to small sample sizes [
14
]. The Korean study
had some limitations, such as the sample population’s low average age, the short period of
service not considered in the study plan, and the number of male participants being too
low [
18
]. The other Taiwanese study weaknesses include the lack of precise information
on standing and walking hours, family history, BMI, lower-limb surgery, and parity; all
these factors could have influenced the outcomes, and their 5-year follow-up period was
too short for the development of outcomes [20].
Sociodemographic, medical, lifestyle, and occupational factors might play a part in
developing varicose veins among nurses. Our study found that working at outpatient
clinics, a positive family history for varicose veins, total years of work as a staff nurse, and
other chronic conditions are risk factors for varicose veins. Race-walking/running is a
protective factor. This finding agrees with the study conducted at Riyadh [
12
] that reported
varicose veins were associated with a positive family history (p-value = 0.001).
The sociodemographic risk factors for varicose veins that were not statistically sig-
nificant (p> 0.05) were age, gender, BMI, ethnicity, level of education, average family

Healthcare 2023,11, 3183 12 of 15
income, smoking, use of hormonal therapy, gravidity, and parity. Age, gender, BMI, use
of hormonal therapy, and the number of pregnancies were reported as risk factors for
varicose veins in most of the previous studies [
12
,
14
]. However, in our study, the majority
of nurses (n = 191, 74.4%) had low-risk scores for varicose veins, and 235 (94.0%) partic-
ipants were females. Although obesity is not considered a risk factor by itself, patients
with obesity class III showed significant limb symptoms, including recalcitrant ulcers,
prolonged healing, and frequent recurrence of leg ulceration, indicating chronic venous
insufficiency [
6
]. However, in our study, the mean BMI for all nurses was in the lower
limit of the overweight range (26.6 kg/m
2±
4.27 kg/m
2
). Chronic diseases studied and
other chronic conditions such as polycystic ovarian syndrome, thyroid diseases, and dys-
lipidemia were statistically significantly associated with varicose veins (p-value = 0.004). It
is possible that the overweight associated with these conditions increases vein pressure
and venous insufficiency, which subsequently leads to varicose vein development [
6
,
7
]. On
the other hand, among lifestyle factors, race-walking/running was a statistically significant
protective factor against developing varicose veins (p-value = 0.006), which is in agreement
with previously published studies [
14
,
18
,
19
]. Although this protective effect might be
explained by the increase in blood supply during the activity, women’s empowerment
might explain this association. The 2023 Saudi Vision seeks to empower women in Saudi
Arabia by providing them equal opportunities and enabling them to play an active role
in the country’s development. Through economic, social, and political empowerment,
the government aims to create a more inclusive and prosperous society for all its citizens.
Under Saudi Vision 2030, the government has launched several initiatives to encourage
physical activity, empower women’s sports, and promote a healthy lifestyle. Some key
measures include sports infrastructure, sports events and competitions, sports education,
and training, making it easier for individuals to access and engage in physical activity [
21
].
Our study suggests that occupational factors have a significant impact on the develop-
ment of varicose veins among nurses. Total years of experience as a staff nurse was a risk
factor for varicose veins in our study (p-value = 0.003). Similarly, in Udaipur [
17
], longer
work histories were occupational risk factors responsible for lower-limb varicose veins
among nurses. It may be explained by the fact that exposure to occupational health educa-
tion decreases with increased job experience, which might be attributed to the fact that the
longer the work experience, the less exposure there is to occupational health education. Al-
though standing during duty hours was not a significant risk factor for varicose veins in our
study, this contradicted the finding in the study in Dhulikhel hospital
(p-value < 0.001) [15]
.
Sitting during duty hours and night shifts was not statistically significant in this study
or previous studies [
11
,
15
,
23
–
26
]. Awareness about varicose vein risk factors was not
statistically significant, although in the Chinese study it was a protective factor. Therefore,
increasing nurses’ awareness is essential for raising the level of protection against varicose
veins [
19
]. Occupational health can play an important role in reducing the risk of varicose
veins by educating the nurses and/or raising awareness and maintaining the highest degree
of physical well-being among nurses. Raising awareness of occupational safety has been
considered a strategy in Australia [
27
]. In Britain, September has been designated as Vascu-
lar Disease Awareness Month [
28
]. We aspire to have educational courses for the medical
staff at KKUH on occupational health, as well as the activation of September as a Vascular
Disease Awareness Month campaign. There are three significant predictors adjusted in
the multivariable regression model. Positive family history (OR 3.57,
95% CI = 1.82–7.00
)
and total nursing experience of 6–10 years were associated with a significantly lower risk
of varicose veins compared to 1–5 years of experience after controlling other factors of
nursing experience (OR 0.16, 95% CI = 0.06–0.46), while running/race-walking showed a
protective association (OR 0.23, 95% CI = 0.07–0.80). The 2030 Saudi Vision includes plans
to improve employee safety and well-being. The government is focused on enhancing
occupational health programs in workplaces. This includes conducting regular health
assessments, providing workplace safety training, and implementing preventive measures
for occupational hazards and diseases [21,22].

Healthcare 2023,11, 3183 13 of 15
Strengths and Limitations
Most of the published epidemiological studies conducted on working nurses were
weak, with low internal and/or external validity. Several previous studies have some
limitations. The current study has a larger sample size of 250 compared to the previous
studies [
12
,
14
,
15
], and we used a different assessment tool to assess the level of varicose
vein risk scores (mild-, moderate-, and high-risk scores of varicose veins), which is a
published tool [
16
] (demographic pro-forma and varicose veins assessment tool) with a
self-administered questionnaire. Additionally, the association between the likelihood of
developing varicose veins among nurses and several predictors, including lifestyle and
occupational factors, was assessed. Moreover, implementation of standardized protocols
for data collection was ensured, which includes comprehensive training of investigators,
and can effectively mitigate inter-observer variability in the process of gathering the data.
The physical examination was undertaken by the same researcher after receiving training
on varicose vein’ examination by a consultant vascular surgeon to minimize measurement
bias (i.e., information bias).
This study has a few limitations. Exploring variations in varicose veins across time
was constrained by the use of a cross-sectional design. It provides a snapshot of the nurses’
characteristics and their likelihood of developing various veins at a specific point in time
by assessing the participants once. While one set of observations per participant in a
cross-sectional study might be one of the limitations, it does not necessarily undermine
the significance of the study. Cross-sectional studies can still yield invaluable insights,
particularly when conducted in conjunction with other research designs or when exploring
associations between variables; we examined many associations and conducted multi-
variable regression analyses. This study was restricted by the use of survey-based and
observational examinations without more diagnostic modalities such as Doppler ultra-
sonography. Although the reliability of the varicose vein risk score was tested (r = 0.99,
indicating that the tool was reliable), only the content validity of the questionnaire was
completed [
16
]. While content validity is crucial for ensuring that a questionnaire measures
what it intends to measure, reliability is another essential aspect of questionnaire valida-
tion, referring to the consistency and stability of the measurement tool [
29
]. Therefore,
it is imperative to conduct future prospective cohort studies to monitor the progress of
nurses over an extended period of time and collect multiple observations using Doppler
ultrasonography to accurately evaluate the severity of varicose veins. This approach is vital
for further scientific exploration and identification of the causal pathways.
5. Conclusions
We found that nurses who race-walked and ran for exercise had low-risk scores for
varicose veins. Therefore, we encourage nurses to do some physical activity, such as walk-
ing, on a daily basis. Nurses who know their scores may change their lifestyle and take
preventive actions to improve their condition and prevent their varicose veins from worsen-
ing. Knowing the link between nurses and varicose veins will raise public awareness about
occupational disorders in our culture, lowering the incidence or, at the very least, delaying
the onset or preventing further deterioration. It will change clinical practice by reducing
standing time during work hours and helping to focus on the groups at risk during preven-
tive and periodic visits. We recommend future studies on the association between lifestyle
factors and varicose veins, particularly diet, because there are few studies on an unhealthy
diet as a risk factor for varicose veins and a study on the association between chronic
diseases and varicose veins. Finally, we recommend focusing on occupational health by
conducting research and increasing awareness, as well as a study to establish the prevalence
of varicose veins in Saudi Arabia using a diagnostic tool like Doppler ultrasonography.

Healthcare 2023,11, 3183 14 of 15
Author Contributions:
Conceptualization, L.R.B.; data curation, G.F.A., N.I.A., H.H.R., A.M.A., J.A.A.
and M.O.A.; formal analysis, L.R.B., G.F.A., N.I.A., H.H.R., A.M.A., J.A.A. and M.O.A.; investigation,
L.R.B., G.F.A., N.I.A., H.H.R., A.M.A., J.A.A. and M.O.A.; methodology, L.R.B.; project administration,
L.R.B.; resources, L.R.B., G.F.A., N.I.A., H.H.R., A.M.A., J.A.A. and M.O.A.; supervision, L.R.B.;
validation, L.R.B.; writing—original draft, L.R.B., G.F.A., N.I.A., H.H.R., A.M.A., J.A.A. and M.O.A.;
writing—review and editing, L.R.B. All authors have read and agreed to the published version of
the manuscript.
Funding:
This research project was funded by the Research Center of the Female Scientific and
Medical Colleges, Deanship of Scientific Research, King Saud University.
Institutional Review Board Statement:
The study was conducted in accordance with the Declaration
of Helsinki and approved by the Institutional Review Board of Health Sciences Colleges Research on
Human Subjects, Ethics Committee of King Saud University-College of Medicine, Registration No. of
the study: E-22-6963; Date of Approval: 3 July 2022.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement:
The data presented in this study are available on request from the
corresponding author. The data are not publicly available due to patients’ privacy and the Institutional
Review Board’s rules and regulations.
Acknowledgments:
The authors extend their appreciation to the “Research Center of the Female
Scientific and Medical Colleges”, Deanship of Scientific Research, King Saud University, for funding
this research. We would like to thank Rony Bosco Shadap for allowing us to use her validated
questionnaire and Kaisar Iqbal, a vascular surgeon, who contributed valuable insights and expertise
that greatly aided in assessing the nurses. Finally, we would like to thank the King Saud University
Medical City (KSUMC) Nursing Affairs (NA) Research and Innovation for their assistance and time.
Conflicts of Interest: The authors declare no conflict of interest.
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