|Year : 2020 | Volume
| Issue : 3 | Page : 172-177
Lower limb varicose veins among nurses: A single center cross-sectional study in Mansoura, Egypt
Hala S Abou-ElWafa1, Aml A M. El-Metwaly2, Abdel- Hady El-Gilany3
1 Occupational Health and Industrial Medicine, Department of Public Health and Community Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
2 Medical Surgical Nursing, Department of Medical Surgical Nursing, Faculty of Nursing, Mansoura University, Mansoura, Egypt
3 Public Health and Preventive Medicine, Department of Public Health and Community Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
|Date of Submission||13-Nov-2019|
|Date of Decision||24-Nov-2019|
|Date of Acceptance||29-Apr-2020|
|Date of Web Publication||14-Dec-2020|
Dr. Hala S Abou-ElWafa
Department of Public Health and Community Medicine, Faculty of Medicine, Mansoura University, Mansoura 35516
Source of Support: None, Conflict of Interest: None
Background: Lower limb varicose veins are common among nurses due to occupational and nonoccupational risk factors. Aims: To estimate the prevalence of lower limbs varicosity and its associated risk factors. Settings and Design: A cross-sectional descriptive study was carried out among 201 nurses at Mansoura University Hospital from January 1st to May 31st, 2018. Methods: A questionnaire was used to collect sociodemographic data, risk factors for varicose veins, and occupational details. Varicose veins were diagnosed by Doppler ultrasound. Statistical Analysis: Univariate and logistic regression analyses were done. Results: The prevalence of varicose veins was 18.4%. Significant independent predictors are being ≥25 years old, working in emergency rooms and ICU/operative rooms, and using oral contraceptives with adjusted odds ratios [95% Confidence Interval (CI)] of [8.7 (2.6–28.4)], [10.8 (2.6–45.9)], [16.2 (3.9–67.4)], and [4.2 (1.3–13.2)], respectively. Conclusions: Independent predictors, other than age, are modifiable and those with highest AOR are occupationally related.
Keywords: Nurses, occupation, risk factors, standing posture, varicose veins
|How to cite this article:|
Abou-ElWafa HS, El-Metwaly AA, El-Gilany AH. Lower limb varicose veins among nurses: A single center cross-sectional study in Mansoura, Egypt. Indian J Occup Environ Med 2020;24:172-7
|How to cite this URL:|
Abou-ElWafa HS, El-Metwaly AA, El-Gilany AH. Lower limb varicose veins among nurses: A single center cross-sectional study in Mansoura, Egypt. Indian J Occup Environ Med [serial online] 2020 [cited 2021 Jan 19];24:172-7. Available from: https://www.ijoem.com/text.asp?2020/24/3/172/302821
| Introduction|| |
Lower-limb varicose veins (VVs) are relatively common, with a worldwide reported prevalence ranging between 10% and 30%., VVs are due to venous valves insufficiency, with age as an aggravating and risk factor and family history as an important risk factor. Other risk factors include female sex, number of children given birth, body weight, constipation, and history of venous thrombosis.,,, Prolonged standing or walking at work has been suggested to be a cause of VVs.,, Kind of job and body posture during work are among main risk factors for varicose veins. Nurses are at higher risk of developing varicose veins because of the nature of their job which requires prolonged standing at patient bedside and this increases their risk of getting varicose vein later. Also, the majority of nurses are female nationwide and internationally. VVs can jeopardize working output and old age health and cause other serious complications such as thrombotic problems. Among different jobs, nursing needs high mobility, long time standing, and tiring physical positions that are necessary for performing nursing duty.
Although the strong relationship between the development of lower limb varicosities and nature of work, to the best of the authors’ knowledge, no studies have investigated this vascular affection of nurses as a result of their workplace occupational exposure in Mansoura city.
This study was carried out among nurses at Mansoura University Hospital to estimate the prevalence of varicosity of the lower limbs and its possible associated risk factors among nurses in Mansoura University Hospital.
| Methods|| |
This cross-sectional descriptive study was carried out in Mansoura University Hospital during the period from January 1st to May 31st, 2018. This is a tertiary care hospital affiliated to Mansoura University, Egypt with a total bed capacity of 1512 beds.
Nurses in Mansoura University Hospital (Main Hospital) employed for one year or more.
Sample size calculation
The sample size was calculated using Medcalc 15.8 (https://www.medcalc.org/). The primary outcome of interest is the prevalence of varicose veins as detected by Doppler ultrasonography. A pilot study revealed that six out of 30 nurses (20%) have varicose veins. With alpha error = 0.05, study power = 0.80, and 5% precision then the sample size is at least 194.
The total number of nurses on duty at the time of study was 2085. A systematic random sample was selected from the list of nurses (every 10th). The selected nurses (208) were approached and requested to participate in the study and 201 (response rate of 96.6%) completed the questionnaire and Doppler examination.
The study was approved by Mansoura Faculty of Medicine Institutional Research Board “MFM-IRB”. (Registration No. of the study: R.19.04.487).
Nurses gave informed consent to participate voluntarily in the study, before the interview, with a full right to withdraw and with assurance of confidentiality and anonymity of the data.
A questionnaire was used to collect the following data: subjects’ characteristics, e.g., sex, age, smoking, exercise; past medical history and family history; risk factors for VVs, e.g., pregnancy, use of oral contraceptives, history of trauma or injury to the lower limbs; and occupational risk factors, e.g., number of daily working hours, static standing, walking, and sitting position, duration of employment, and department. Exercise was operationally defined as any bodily movement performed in order to develop or maintain physical fitness and overall health.
Weight and height were measured then body mass index (BMI) was calculated by dividing a person’s weight in kilograms by the square of height in meters (kg/m2). Obesity is defined as BMI greater than or equal to 30. All nurses were referred to Radiology Department to be investigated by Doppler ultrasonography (Toshiba, Xario 100, Japan) for the diagnosis of varicose veins according to National Institute for Health and Care Excellence (NICE) clinical guideline.
Data were analyzed using SPSS version 16. Variables were described as numbers and percentage. Chi-squared test was used for comparison between groups and crude odds ratios (COR) were calculated. Significant predictors of lower limb varicosity in bivariate analysis (age, marital status, exercise, obesity, workplace, duration of work, daily working hours, static standing, chronic constipation, OCP use, and gravidity) were entered into a multivariate logistic regression using the forward Wald method and adjusted odds ratios (AOR) were calculated. P ≤ 0.05 was considered to be statistically significant.
| Results|| |
Doppler ultrasonography revealed that 18.4% (37 out of 201) nurses have lower limb varicosities. Bilateral varicosities represented 5.5% while unilateral affection was 12.9% (26 nurses, of which 14 nurses had right limb varicosities and 12 had left limb varicosities; data are not shown in tables).
[Table 1] shows that nearly equal percentage of nurses were below and more than 25 years old, most of them (84.1%) were female, more than half (56.7%) were married, nearly two-thirds were rural residents and not practicing exercise, and only 23.4% were obese. Varicose veins are significantly more prevalent among nurses aged ≥25 years, married, not exercising, and obese.
|Table 1: Prevalence of VVs and its variation according to demographic, obesity, and exercise of nurses|
Click here to view
The prevalence of VVs is significantly higher among nurses in emergency and ICU/operative rooms, working for ≥5 years, with more than 6 daily working hours, and with static standing posture (COR = 5.4, 4.1, 5.5, 2.5, 2.6; respectively). Varicosities are significantly higher among nurses having chronic constipation, using oral contraceptives, and those with three or more pregnancies (COR = 3.4, 2.8, 7.9; respectively) [Table 2].
|Table 2: Variation of VVs prevalence according to occupational and clinical data of nurses|
Click here to view
The significant independent predictors of VVs among nurses are being ≥25 years old, working in emergency rooms and ICU/operative rooms, and using oral contraceptives with adjusted odds ratios (AOR) [95% Confidence Interval (CI)] of [8.7 (2.6–28.4)], [10.8 (2.6–45.9)], [16.2 (3.9–67.4)], and [4.2 (1.3–13.2)], respectively [Table 3].
|Table 3: Multivariate logistic regression analysis of independent predictors of VVs|
Click here to view
| Discussion|| |
Varicose vein of the lower limbs is considered as the most common vascular disorder in humans, leading to serious signs and symptoms in affected persons and sometimes leads to surgical treatments and widespread morbidity., Varicose veins are known to be more common among many professions including nurses who have to stand for a longer time during their work.
The prevalence of lower limb VVs in this study is 18.4%. A similar rate (16.2%) was observed in the Republic of Korea. A slightly higher prevalence (24.17%) was found in India; however, a much higher prevalence (72.4%), with different degrees, was reported in Iran. This difference could be due to different diagnostic approaches based on clinical finding using Clinical-Etiology-Anatomy-Pathophysiology (CEAP) standards or could be due to different durations of employment and working hours.
Studied nurses were nearly equal percentage below and more than 25 years old, most of them were female, more than half were married, nearly two-thirds were rural residents and not practicing exercise, and only 23.4% were obese.
Varicose veins in this study are more prevalent among older married female nurses, rural residents, not performing exercise, and obese with significant association except for sex and residence. Similarly, in Korea, statistically significant factors were age, pregnancy, and delivery; however, sex dependent difference was not verified. Also, in India, the prevalence was slightly higher among female nurses than male and in older age group.
In accordance with these results, in East China, nurses with advanced age (OR = 5.5, 95% CI: 4.22–7.2), married with childbearing (OR = 5.2, 95%CI: 3.97–7.04), low level of education (OR = 1.6, 95% CI: 1.22–1.99), and with family history of VVs had a greatly higher risk of varicose veins (OR = 1.8, 95% CI: 1.4–2.28). Similar results were reported from Iran where being women, older ages, higher BMI, and family history were predictors for both presence and intensity of leg varicose veins.
In the current study, VVs are significantly higher among nurses in emergency and ICU/operative rooms, more than 5 years of employment, working >6 hours daily, in static standing posture, having chronic constipation, using oral contraceptives, and those with three or more pregnancies.
These results are in agreement with a Korean study where VVs were significantly higher in the outpatient clinic and operating room, but not the emergency room and ICU which may be attributable to their high job transfer rate. Nurses with ≥4 hours of standing showed significantly higher prevalence which coincided with previous studies showing that VVs incidence is associated with working hours in a standing position.,,,,,
The biological basis for the standing hypothesis is the impeded blood flow and consecutive stasis in veins of the lower extremities because of increased intravascular hydrostatic pressure in an upright working position. Stasis in the venous system is a key mechanism in venous vascular disease.
Chronic constipation is associated with straining during defecation which could increase the intra-abdominal pressure that may lead to valvular incompetence or loaded colon could press the pelvic veins and obstruct venous return.
Similarly in Iran, long years of service, not exercising, irregular bowel movement, sitting and standing long hours, and overtime work were risk factors for the presence and intensity of leg VVs. In accordance with these results, in East China, nurses with long service time and multiple night shifts had a greatly higher risk. In India also, having ≥6 years of work experience, having >8 hours duty per day, with more hours of standing at work, positive family history, and with 3 or more childbirths appeared to be significant predictors. Nevertheless, constipation, habits of smoking and drinking alcohol, and oral contraceptive (OCP) use in female nurses did not appear to be significant risk factors.
Pregnant workers are at an increased risk of VVs due to some interaction of pregnancy-related and work-related factors as both conditions increase intravascular venous pressure (in the case of pregnancy, due to increased pressure on the abdominal veins into which the leg veins drain; in the case of standing, because of increased hydrostatic pressure).
In the present study, the significant independent predictors of VVs among nurses are being ≥25 years old, working in emergency rooms and ICU/operative rooms, and using oral contraceptives. Similarly, in East China, advancing age (AOR = 1.32, 95%CI: 1.2–1.5) and standing time (AOR = 1.7, 95%CI: 1.21–2.4) were independent predictors for VVs. Coinciding with these results, in Japan, it was confirmed that prolonged upright standing at work, greater BMI, female sex, and age were significant independent predictors. The correlation between the varicose intensity and increasing age is probably because of the enhanced pressure of surface veins resulting from leg muscle weakness and vascular wall damages following aging.
The study from Korea was in agreement where working in outpatient clinic and operating room was significantly associated with VVs prevalence after adjustment for sociodemographic factors. However, the emergency room and intensive care unit did not differ significantly which may be attributable to the high job transfer rate and the regular provision of compression stockings by the hospital to these high-risk groups.
Correspondingly, in Iran, multivariate analyses showed that standing for more than 4 hours had at least a 2 to 3 risk of developing leg VVs (with higher intensity), and per hour increase in overtime work had a 1%–2% increased risk.
The etiology of varicose veins is multifactorial and may include: increased intravenous pressure caused by prolonged standing; increased intra-abdominal pressure arising from tumor, pregnancy, obesity, or chronic constipation; familial and congenital factors. The intensity of varicosity increases with advancing age or long years of employment which is probably due to enhanced pressure of surface veins resulting from leg muscle weakness and vascular wall damages following aging.
In nursing profession, nurses have to stand for a long time with both legs bearing weight, and most of them are female, so that they are at greatly increasing risk of varicose veins, whose incidence is 60% higher than the general population. In addition to nurses, VVs are known to be more common among professions such as policemen, teachers, shopkeepers, and bus conductors who have to stand for longer time during their duties.
A high response rate of participants together with the diagnosis of lower limb varicose veins using Doppler ultrasound is an important feature of this study.
This study has some limitations. This single center study is cross-sectional, hence, cannot prove cause-and-effect relationships with a relatively small sample size. No detailed study of working conditions had been investigated.
| Conclusions|| |
The prevalence of lower limb VVs is 18.4% among nurses. Advancing age, working in emergency rooms and ICU/operative rooms, and using oral contraceptives are associated with an increased risk. These independent predictors other than age are modifiable and those with highest AOR are occupationally related. Therefore, VVs might be prevented by the provision of nurses with anti-VVs measures (e.g., compression stockings and taking breaks) and scheduling job rotation, especially at high-risk departments to avoid long duration of standing work posture, and education of nurses regarding lifestyle modification, e.g., regular exercise and weight reduction, and rational use of OCPs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Callam MJ. Epidemiology of varicose veins. Br J Surg 1994;81:167-73.
Evans CJ, Fowkes FG, Ruckley CV, Lee AJ. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. J Epidemiol Community Health 1999;53:149-53.
Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol 2005;15:175-84.
Robertson L, Evans C, Fowkes FG. Epidemiology of chronic venous disease. Phlebology 2008;23:103-11.
Hirai M, Naiki K, Nakayama R. Prevalence and risk factors of varicose veins in Japanese women. Angiology 1990;41:228-32.
Jawien A. The influence of environmental factors in chronic venous insufficiency. Angiology 2003;54(Suppl 1):S19-31.
Tabatabaeifar S, Frost P, Andersen JH, Jensen LD, Thomsen JF, Svendsen SW. Varicose veins in the lower extremities in relation to occupational mechanical exposures: A longitudinal study. Occup Environ Med 2015;72:330-7.
Tüchsen F, Hannerz H, Burr H, Krause N. Prolonged standing at work and hospitalisation due to varicose veins: A 12 year prospective study of the Danish population. Occup Environ Med 2005;62:847-50.
Chen CL, Guo HR. Varicose veins in hairdressers and associated risk factors: A cross-sectional study. BMC Public Health 2014;14:885.
Nasiri-Foourg A, Kazemi T, Nakhaii N, Kazemi N. Lower limb varicose veins and their relationship with risk factors in nurses of the Birjand University of Medical Sciences Hospital. J Birjand Univ Med Sci 2005;12:9-15.
Mishra N, Solanki SL, Mishra S. Lower limb varicose veins among nurses: A cross sectional study in Udaipur. Int J Cur Res Rev 2015;7:51-5.
Sharif Nia H, Chan YH, Haghdoost AA, Soleimani MA, Beheshti Z, Bahrami N. Varicose veins of the legs among nurses: Occupational and demographic characteraistics. Int J Nurs Pract 2015;21:313-20.
Abou Elmagd M. Benefits, need and importance of daily exercise. Int J Phys Educ Sports Health 2016;3:22-7.
Laurikka JO, Sisto T, Tarkka MR, Auvinen O, Hakama M. Risk indicators for varicose veins in forty- to sixty-year-olds in the Tampere varicose vein study. World J Surg 2002;26:648-51.
Criqui M, Denenberg J, Bergan J, Langer R, Fronek A. Risk factors for chronic venous disease: The San Diego Population Study. J Vasc Surg 2007;46:1-7.
Yun MJ, Kim YK, Kang DM, Kim JE, Ha WC, Jung KY, et al
. A study on prevalence and risk factors for varicose veins in nurses at a university hospital. Saf Health Work 2018;9:79-83.
Erding L, Shuyan C, Weiwei Z, Ying Y. Influencing factors for lower extremity varicose veins in female nurses in East China. Biomed Res 2017;28:9039-45.
Tüchsen F, Krause N, Hannerz H, Burr H, Kristensen TS. Standing at work and varicose veins. Scan J Work Environ Health 2010;26:414-20.
Kohno K, Niihara H, Hamano T, Takeda M, Yamasaki M, Mizumoto K, et al
. Standing posture at work and overweight exacerbatevaricose veins: Shimane CoHRE Study. J Dermatol 2014;41:964-8.
Sadick NS. Advances in the treatment of varicose veins: Ambulatory phlebectomy, foam sclerotherapy, endovascular laser, and radiofrequency closure. Dermatol Clin 2005;23:443-55.
Dai LT, Zhang PH. The epidemiology of superficial varicosity of lower extremities. Foreign Med Sci 1990;17:323-6.
[Table 1], [Table 2], [Table 3]