Identification of ethnic and racial disparities in the presentation of varicose veins is important. The health of minority groups is a key indicator of the success of society’s efforts to eliminate health disparities. Varicose veins are not a life-threatening disease, so the presence of ethnic and racial disparities in seeking medical care for varicose vein would highlight a discrepancy in the perception of varicose veins as a disease and the impact of the perceived disease on the quality of life. Any disparities in referral to secondary care or treatment would mean a difference in access to care and the provision of care for varicose veins.
Varicose veins are a common disorder, affecting 10 to 15% of men and 20 to 25% of women. The clinical relevance of varicose veins varies. For some patients, varicose veins represent a significant cosmetic and social issue; for others, they are a painful and debilitating chronic condition. There is wide variation in the anatomical distribution and extent of varicose veins, as well as the presence and severity of symptoms. Although it is commonly perceived as a cosmetic problem, evidence from other chronic venous disorders suggests that varicose veins may be pathologically significant.
Overview of Varicose Veins
Though lower extremity venous disorders can involve abnormal findings on physical examination and special testing, the common clinical manifestations of varicose veins and chronic venous insufficiency include pain, aching, tiredness, and leg heaviness, particularly after prolonged standing or sitting. Edema, ankle hyperpigmentation, lipodermatosclerosis, and cutaneous ulceration are specific signs of more severe venous disease. Varicose veins are usually considered a mild, though prevalent, form of venous abnormality that can cause symptoms and cosmetic concerns. They are abnormally dilated and tortuous subcutaneous veins usually caused by reflux in either the saphenous or perforator vein systems and are often associated with telangiectasias. Telangiectasias are small dilated intradermal veins which may cause the skin to appear discolored.
Varicose veins are enlarged, tortuous, and superficial veins, occurring most commonly in the lower extremities. They are a common cause of pain, discomfort, fatigue, and feelings of unsightliness for large numbers of men and women. Nearly 70% of American adults develop varicose veins and/or its more severe form, chronic venous insufficiency in their lifetime. Epidemiologic and anecdotal evidence suggests that ethnic and racial variations may exist in the presentation of lower extremity venous disorders. However, the lack of standardized data collection and diagnostic criteria for such disorders has prohibited the comparison of different ethnic and racial groups within specific populations. This review was thus developed to summarize available information on varicose veins and chronic venous insufficiency with the objectives of (i) identifying risk factors for these disorders (ii) determining whether ethnic and racial differences in the prevalence of varicose veins and chronic venous insufficiency actually exist (iii) if such differences exist, identifying potential biological, socioeconomic, and lifestyle factors that may contribute to them. This section provides an overview of varicose veins and chronic venous insufficiency and addresses the methodological issues that have limited comparative research on different ethnic and racial groups in this area.
Importance of Studying Ethnic and Racial Disparities
Researchers have pointed out that one of the strongest risk factors for varicose veins is having a family history of VV. This is an interesting statement as it is known that family history of a disease or condition generally raises the risk among family members of that condition or disease occurring to them. Two community-based studies of white populations carried out in Edinburgh and Springfield, with similar methods, show the frequency of varicose veins increasing from the lowest to the highest category of deprivation. Deprivation could be used as a proxy for socioeconomic status, and these studies suggest that there are differences in the prevalence of VV between different social strata. Randomized clinical trials, the only one of IBE and the only double-blind controlled study on VV treatment (foam sclerotherapy), have generally only included white participants. With a growing Hispanic population, other growing minority populations, and the persistent pressure to include equality of gender in trial participation, it is expected that the ethnic and gender distribution of people seeking treatments for VV will change in the future. This, combined with the plentiful unspecific evidence of inequalities in the provision of varicose vein treatments, from this and other studies on differing treatment rates for various conditions among race and ethnic groups, suggests that there are differences in the diagnosis and treatment of VV between differing race and ethnic groups that could lead to adverse outcomes.
Racial and ethnic disparities in health care are known to extend across a broad range of diseases and health services. 30% of the writing in the disparities literature is concentrated on the area of cancer, with the remainder focused on a wide array of diseases, health behaviors, and health services. Of disparities articles with a cancer focus, breast (22%) and colorectal (11%) cancers are most common. Less attention has been paid to understanding the distribution and outcomes of venous disorders and interventions across race and ethnic groups. Venous disorders are estimated to affect half of the U.S. population aged 50 and older. Like the population distribution of older age groups in the U.S., chronic venous disease affects large numbers of non-Hispanic white Americans. However, people have the perception that varicose veins are not a disease but merely a cosmetic nuisance, and therefore they could assume that ethnic and racial differences in varicose vein (VV) prevalence would mirror differences in the utilization of diagnoses and treatments for VV.
Research Objectives
This research study aims to provide information about the determinants among non-white populations and their associations with varicose veins. By understanding the determinants among non-white populations, this will contribute to the exploration of the ethnic and racial disparities concerning varicose veins. There are three objectives to this study. The first objective is to compare the prevalence and severity of varicose veins between Caucasians and non-white populations in the United States. The second objective is to identify and compare risk factors for varicose veins among minority groups and Caucasians. The third objective is to assess whether differences in prevalent varicose veins and their associated risk factors explain differences in the clinical presentation of chronic venous disease between minority groups and Caucasians.
Factors Influencing Varicose Vein Presentation
Genetic Predisposition The easiest way for genes to influence the epidemiology of a disease is if they directly cause it. Two rare examples of where this has happened with varicose veins can be seen with dominant transmission of Ehlers-Danlos syndrome type IV and also Familial Varicose Veins. However, almost all common varicose veins seen in the general population are of complex cause with no clear pattern of inheritance. In these more common cases it is population variation in genes coding for factors involved in the etiology and progression of disease that will cause differing prevalence. For example, polymorphisms in the gene coding for the 5a-reductase enzyme will result in differing levels of production of testosterone and dihydrotestosterone in different populations due to varying efficiency of conversion of the hormone. Given that the Cockett’s group have recently shown that there is a male specific association of testosterone levels with great saphenous vein reflux; such variations in hormone levels between populations could result in some groups having higher prevalence of varicose veins. The genes themselves are likely to be the result of evolutionary adaptation to environmental factors and this may be a contributing factor to the differing prevalence of varicose veins between different immigrant groups and their host population.
Each patient is a composite of a host of factors that have influenced who they have become, and this is certainly true in terms of their vein health. This review will address the social and biological determinants that may affect the shape of different individuals’ presentations of varicose vein disease. Considering that the majority of studies demonstrating ethnic and racial variation have originated from the United States, we will focus predominantly on these issues within an American context. As the influential factors we are addressing are complex and myriad, any racial or ethnic differences in varicose vein presentations are likely to be due to an interplay of these various factors, rather than any singular cause.
Genetic Predisposition
Genetic predisposition refers to the inheritance of a trait from a parent’s genetic code, which makes it more likely that the individual will develop a particular condition. Evidence for a genetic component to varicose veins comes from both clinical and epidemiological studies. A family history of varicose veins is the single most significant risk factor in the development of varicose veins. A study conducted by Bauermeister in 1959 found that 97% of individuals had parents who both showed signs of venous disease. Genotyping of twins has also shown a strong concordance rate for varicose veins between monozygotic twins compared to dizygotic twins. This suggests that a large proportion of the risk of developing varicose veins can be attributable to inherited genetics rather than environmental factors. Twin studies have also implicated inherited factors in the development of conditions which predispose an individual to varicose veins. A study by Tisi et al in 1990 found a higher concordance rate for superficial venous reflux between monozygotic twins compared to dizygotic twins, which suggests a genetic component to this condition. Deep venous disease and a reduction in venous compliance are also hereditary conditions that increase the likelihood of developing varicose veins. It has been suggested that varicose veins should be viewed as a lifelong progression of the disease of the venous system, rather than an isolated condition. This progression follows the continuum of venous hypertension, whereby there is always an increase in venous pressure compared to normal, which can cause distension of the veins and/or valve incompetence. These hereditary conditions can underlie the development of varicose veins, as congenitally abnormal veins may be more susceptible to vein distension under conditions of increased venous pressure.
Lifestyle and Occupation
An interesting study on occupational physical activity and leisure time physical activity showed contrasting effects on varicose vein occurrence, with leisure time physical activity showing a preventative effect and occupational activity showing an increased risk. Increased occupational physical activity was associated with a greater risk of disease, believed to be related to the effects of increased standing and leg muscle activity on venous haemodynamics. However, the mechanisms of leisure time physical activity on prevention are still not well understood. In contrast, a study on the NHS database showing exercise frequency gave no clear association with varicose vein occurrence. Overall, job assessment in European men has shown low physical activity jobs to have a decreased risk of developing varicose veins, though no straightforward relationship has been found between physical activity at work and varicose vein occurrence due to potential confounding variables. The effects of changes in occupational activity on varicose vein presentations have been recently analysed in a cross-sectional study in 1007 men, which has shown that occupational activity has relatively minor effects on varicose vein progression, though increasing age and weight gain have a large accelerating effect on disease.
It is well accepted that occupational risk factors may play a large role in the presentation of lower extremity varicose veins. Particular occupations may increase the risk of developing lower extremity varicose veins or may hasten the progression of existing disease. In Western countries, such as the United States and the United Kingdom, jobs that involve prolonged standing, particularly those associated with the nursing profession, have been shown to increase the risk of developing varicose veins. Nurses have been shown to have a 3-5 fold increased risk of developing varicose veins in comparison to people of the same age and sex. Other professions where prolonged standing is prevalent are also at risk. Hairdressers and teachers have shown an increased risk of disease, while professions involving heavy manual labour may hasten progression of existing disease. In Finland, the Paquid cohort study showed an increase in varicose vein occurrence in farmers and related agricultural workers. Lying down or prolonged sitting has also been suggested as an occupational risk factor for varicose veins. Though it is likely prolonged sitting has a U-shaped risk curve, with sitting at one extreme increasing the risk due to an increase in venous pressure from leg elevation, and sitting at the other extreme decreasing risk, as sitting with the legs up is a suggested method of disease management. This U-shaped curve has been shown in a recent study in women in Iran, sitting and standing.
Hormonal Factors
Hormonal influences have long been acknowledged to play a pivotal role in the development of varicose veins, with gender being the strongest epidemiological correlate. As early as the 17th century, it was recognized that women were afflicted with varicose veins more often than men, with Ginig describing the disease as a “busy and troublesome affection, seldom breeding danger, often time irritating the patient, women more than men”. This observation has been consistently and objectively confirmed in epidemiological studies over the past 50 years, with all reporting an increased prevalence and incidence in women. The earlier age of presentation for women is also striking, with 30.9% of women aged 20-24 having some form of chronic venous disease compared to only 5.7% of men. Despite clear evidence that the findings are not purely due to reporting bias and increased medical consultation, the suggestion that the increased prevalence in women may simply reflect increased longevity and survival compared to men has been a topic for debate. Atinkaya et al attempted to address this issue by age matching a random population sample taken from a district registry to obliterate difference in life expectancy and found that the prevalence of varicose veins was still double in women. The study concluded that the higher rate of venous disease in women could not simply be attributed to their longer life expectancy. The confirmation of hormonal influences in venous disease in the 1980s allowed for an answer to be proposed to the gender issue, with studies on the effects of pregnancy on venous disease opening up new insights into causation.
Ethnic and Racial Disparities in Varicose Vein Presentation
Varicose vein prevalence has traditionally been estimated by clinical examination or patient self-reporting and so is prone to errors of over or under diagnosis. The Edinburgh Vein Study is the only prospective population-based study of varicose veins and found a prevalence of trunk varicose veins and saphenous reflux of 30% in the general adult population. This does suggest that the estimates of varicose vein prevalence based on clinical examination or self-reporting may themselves be significant underestimates, given that many patients are unaware of the difference between varicose veins and spider veins and would not consider that small varicose veins or reticular veins constitute ‘real’ varicose veins.
Keating and Mason (2000) have given the most recent estimate of varicose vein prevalence in the UK based on a systematic review of the literature. They found that the prevalence of trunk varicose veins in adult men and women is 19-22% and 28-35% respectively. It is important to appreciate that these figures are estimates of cosmetic trunk varicose veins and do not include estimates of the prevalence of thread veins, ankle flare veins, or other telangiectasia.
In this section, we will look at the prevalence and severity of varicose veins in different ethnic groups. We will examine the natural history of varicose veins in pregnancy and consider ethnic disparities in the use of various treatments for varicose veins.
Prevalence and Severity by Ethnicity
There is little evidence that the severity or type of varicose veins is different in ethnic groups. A study of 177 African-Americans and the same number of Caucasians found no significant difference in types of varicose veins between the two groups. Similar findings were noted in the UK study, with no great variation in the severity of varicose veins in different ethnic groups, despite the large variation in prevalence rates.
Despite the differences in prevalence rates of varicose veins between different ethnic groups, the severity of varicose veins is greater in ethnic groups of a lower socio-economic class. Data from the US study mentioned above indicated that 0.7% of African-Americans had ulceration attributable to varicose veins, and this is the same figure for Caucasians. However, the Caucasians with ulceration were from a slightly older age group. Ulceration rates in Hispanics were higher at 0.9%, and there was a significant difference noted in the UK study, where Afro-Caribbeans had an ulceration rate of 1.3% and Indians and Asians had a much higher rate of 2.6%, despite having lower prevalence rates of varicose veins. This suggests that there are other factors related to ethnicity that contribute to the development and severity of varicose veins.
Current knowledge on the presentation of varicose veins in various ethnic groups is based on singular studies, often performed in isolated communities or specific countries. Overall, it is agreed that the risk of varicose veins varies between different ethnic groups. An American study in 1997 examined 769 individuals and noted prevalence rates of 3.6% in African-Americans, 6.0% in Hispanics, and 8.0% in Caucasians. A more recent large-scale UK study of over 40,000 individuals noted a similar pattern, with prevalence in Indians and Asians at 3%, 14% in Afro-Caribbeans, and 19% in Caucasians. Although the Indian/Asian ethnic grouping did not have a high prevalence of varicose veins, they had the highest rates of skin changes and ulceration. These patterns would suggest that there is a relationship between skin type and the development of varicose veins and their sequelae.
Cultural and Societal Influences
Health beliefs and coping strategies vary between different ethnic groups, and although there is no concrete evidence regarding ethnic differences in perception of varicose vein disease, it is reasonable to assume that culture has an effect. For example, varicose vein disease is seen as a chronic condition of the elderly in Hispanic and African-American cultures, and the concept of chronic disease may conflict with the role expectations of individuals still in the workforce. In Asian cultures, varicose vein symptoms may be rationalized as a result of another illness or onset of aging, reducing the perceived need for specific treatment of the vein problem. A longitudinal study of different racial groups with varicose veins would be best suited to determine the effects of societal and cultural factors on the progression and treatment of the disease.
There are a number of cultural and societal influences that may contribute to the disparities in presentation of varicose veins between different ethnicities. Differences in clothing norms may lead to variations in willingness to divulge vein symptoms or seek help. Visible varicose or spider veins on the legs are often viewed as unsightly or unacceptable in many cultures, and individuals affected may be stigmatized. The ability to wear long clothing to cover vein signs despite discomfort or progressing symptoms may also influence willingness to seek treatment. Similarly, in warmer climates, increased desire to wear shorts or swimwear may accentuate concerns about the appearance of the legs. In a qualitative study of 35 women who declined treatment for superficial venous disease, concerns about treatment implications on their ability to fulfill current role expectations and stigmatization of veins were common reasons cited.
Access to Healthcare and Treatment Disparities
At an institutional level, there can be further disparities with the practice of safety netting, defined as the practice of serving needy populations when standard resources are not sufficient to do so. This is commonly performed by academic public hospitals and teaching facilities through the provision of medical charity care and teaching of medical students and doctors. Due to Medicare coverage, elderly and disabled patients have a wider range of treatment choices, although location and physician type are heavily determined by financial matters and may not reflect the patient’s ethnicity or wealth. Promotion of newer treatments and specialized services are often driven by financial incentives through private practice and company sponsorship at outpatient clinics and private hospitals. Development into public health system services may be limited by costs and lack of changed Medicare policies to encompass a wider range of patients at specific locations. This can have a significant impact, especially in the USA, where 25% of patients are covered by Medicare and more than 50% of varicose vein and chronic venous insufficiency patients are above the age of 50.
Privately insured patients may request specialist consultations and treatment choice, although physicians may have contractual obligations to treat only insured HMO patients with a potential for a conflict of interest. Stepwise treatment is often seen in HMO patients with referral to vascular surgeons and performance of traditional surgery. Those seen under Medicare may not be eligible for newer treatments, with the coverage and referral to specialists being heavily dependent on local and national policy, as well as individual physician choice. This effectively segregates treatment systems by socioeconomic status and insurance and has the potential to widen disparities with the development of newer treatments.
There is further impact by insurance on individuals with the restriction of physician and location of treatment. Patients with HMOs often require a referral from a general practitioner to see a specialist. Choices of specialist type can influence treatment options and include vascular surgeons, dermatologists, and interventional radiologists. Varicose vein surgery is often performed by vascular surgeons in outpatient or inpatient hospital settings. New treatments, including thermal and chemical ablation, can be offered by vascular surgeons or interventional radiologists at outpatient clinics.
There are several reasons attributed to ethnic and racial differences in access to health care and subsequent treatment of varicose veins. These revolve around individual, specialist, and institutional levels. Insurance status is a major predictor of access to healthcare in many countries where those without or on low-income insurance are less likely to receive minimally invasive, available, and new treatments than their higher-income or insured counterparts. Varicose veins and CVI are chronic conditions that occur more frequently in older age groups. In the USA, those over 65 years of age and patients with disabilities are eligible for Medicare, a largely federally funded health program. This provides insurance coverage to approximately 15% of the population. Medicare covers treatment for varicose veins when considered medically necessary, although restriction criteria to safe and effective endovenous and new treatments can vary by state, with some Medicaid programs covering a wider range of patients.
Implications and Future Directions
With the growing diversity in patient populations across the western world, it is likely that at some time in the future, there will be a greater demand for vein treatment tailored to different cultural and ethnic groups. This will require vein specialists of all ethnicities to be in a position where they are able to optimally treat individuals from backgrounds other than their own.
Developing culturally competent strategies to treat varicose veins will only become a potential future direction when more is known about disparities in presentation and diagnosis. This would require a better understanding of differences in how the disease affects different populations, as well as knowledge about the socio-economic and cultural factors influencing varicose vein treatment in different racial and ethnic groups. In particular, it would require an answer to the question as to whether treating varicose veins is a priority in certain groups who may have competing health issues.
One study examining patients at a Vascular Surgical Clinic in a university hospital in the United States found that non-white patients formed only 7% of the total patients seen during a one-year period. Similar findings have been reported from the UK, Scandinavia, and New Zealand. This gives cause for worry because if there are certain groups with a higher frequency of varicose veins, then it follows that this condition is being under-treated in those groups.
The theme of ethnic and racial disparities in findings and clinical repercussions has a wide application across varied and diverse medical conditions. However, in the context of varicose veins, there is as yet restricted information regarding disparities in its diagnosis and treatment. It is known that there are many ethnic and racial groups that are more commonly affected by certain medical conditions than others. This does not seem to be the case with varicose veins, which affect up to 60% of the population of western nations, and therefore the greater part of research and treatment has been conducted on predominantly white populations.
Addressing Disparities in Varicose Vein Diagnosis and Treatment
Dissimilarity in management can stem from several reasons, with economic factors being one of the most prevalent. As varicose veins are not regarded as a priority in medical care and do not significantly affect the health or quality of life for sufferers, decisions for treatment can be influenced by the availability of time and money. found that those without insurance were less likely to seek treatment and more likely to use self-management or a primary care physician to manage their symptoms. In an analysis of the SEERS Medicare linked database, patterns of care and survival related to colorectal cancer in the elderly found that a larger proportion of non-white patients used emergency services, lived in poor areas and neighborhoods with lower education levels, and also had lower rates of admission to the hospital. This suggests that, similar to other diseases, varicose vein patients from poorer backgrounds can be limited in terms of the availability of care, treatment, and social support.
Disparities in treatment and necessity arise from differences in the persistence of varicose veins between ethnicities. Addressing the equality of care necessarily becomes a point of consideration. identified an increased prevalence of varicose veins in Caucasians than African Americans before and after adjusting for risk factors. However, the intent to seek treatment was 34% for Caucasians, as opposed to 17% for African Americans. This was supported by , who found that in a population-based study of women, minorities were less likely to seek therapeutic treatment for chronic venous insufficiency. In a study by , it was ascertained that although the severity of insufficiency was the same for both white and black patients, there was a difference in treatment options. White patients were more likely to be referred for surgery, while black patients were referred for conservative (non-invasive) treatment.
Promoting Diversity in Research and Healthcare Settings
A final, and somewhat optimistic note, comes from the exploration of the role of globalization in influencing research to policy translation. While the impact of globalization on health status and health inequality is outside the scope of this paper, it may be a fruitful area for future investigation. It is well recognized that decisions made elsewhere in the global policy arena can have profound effects on national and local policy making. This creates a range of opportunities for researchers to influence policy, ranging from direct involvement in global health initiatives, to the tracking of global policy decisions and their implications for local policy making. An understanding of how to best exploit these opportunities may reshape the way health services research is conducted in the future.
Barriers to the utilization of research findings in clinical practice have been well documented in the literature. Often suggested is the creation of research sympathetic clinical environments and the reshaping of client expectations concerning service delivery. The lack of success in achieving these goals can be attributed to a failure to involve clinicians and consumers in the research process. The literature suggests that increased involvement of these groups in research activity can lead to accelerated dissemination and implementation of research findings. A recent review of the literature concerning the attitudes of social and behavioral scientists to health services research suggests that involvement of health service researchers in the research process may also be beneficial. While the review is limited to one discipline, it highlights a potential area for future investigation. As such, barriers and facilitators to involvement of both health service researchers in the varicose veins research process and the translation of their findings into practice and policy remain important areas for further research.
Developing Culturally Competent Care Strategies
Current healthcare access and disparities analyses show that new avenues must be found to address ethnic differences in healthcare. Although the literature suggests that race plays a role in the severity of chronic venous disorders, no studies or reports have been done to address ways in which this disparity can be rectified in a medical setting. Developing culturally competent care strategies is obviously the most sound method for addressing ethnic difference in VVs. This can be accomplished through conducting further research to better understand the needs and causes of VVs in each ethnic group. Time must be taken to understand the social, economic, and environmental contributors to the disease. Patient education aimed at prevention can be altered to suit specific ethnic groups. With an understanding of various cultural perspectives, care providers can better educate patients by using methods that are most effective and familiar to them. Minimum requirements and treatment standards to reduce the severity of the disease in minority and low SES patients may be in order. This could involve social or legislative advocacy to improve the socioeconomic causes of VVs. Finally, development of recruitment strategies and affirmative action to increase the number of care providers from ethnic minorities can be an effective long-term strategy.
