Qualitative study of knowledge, perception, behavior and barriers associated with cardiovascular disease risk among overweight and obese Hispanic taxi drivers of South Bronx, NYC

As per 2018 U.S. Bureau of Labor Statistics report, the number of taxi drivers nationwide is estimated to be 207,920, of which New York City (NYC) is home to 16,650 drivers [1]. Taxi driving is an occupation with a stressful lifestyle and work demands. Their overall income is low and requires them to work long hours, without health coverage, or paid vacations [2, 3].

Surveys conducted internationally and, in the US, have reported that taxi, truck and bus drivers are at higher risk of developing obesity, diabetes and hypertension [2, 4‐7]. Studies on taxi drivers have shown higher prevalence of smoking, physical inactivity and unhealthy eating practices [8‐15]. NYC taxi drivers have been found to have lower insurance coverage, faced discrimination, and higher prevalence of hyperglycemia and obesity [2, 15].

However, a detailed literature review shows that there are no studies focused on the health risks of Hispanic livery taxi drivers. The purpose of this study is to understand the perception, knowledge, health behaviors and barriers related to development of cardiovascular disease (CVD) risk factors in Hispanic taxi drivers in South Bronx, NYC. In partnership with NYC community-based organizations in the South Bronx, a Center for Health Evaluation, Education, Research and Engagement (CHEVERE) was launched to address the high prevalence of CVD risk factors in the predominantly minority population [16].

A cross-sectional qualitative study design was developed to recruit Hispanic NYC livery taxi drivers and conduct focus groups. The subjects were screened and recruited from taxi bases with the help of the local Federation of Taxi Drivers in the borough of The Bronx. The recruitment methods were flyers, messages through taxi-base dispatch system radios, and referrals from livery taxi drivers and on-site active taxi-base recruitment. The research team developed a structured focus group protocol of open-ended interview questions related to cardiovascular disease. Study was reviewed and approved by the local Institutional Review Board (IRB) (IRB#15–016), and additionally each participant received a gift-card incentive of $35 at the conclusion of the focus group for their participation.

Participants were recruited based on the following inclusion criteria: age older than 18 years, body mass index (BMI) of greater than 25 kg/m², working as livery taxi drivers in NYC for at least 6 months, and self-identified as Hispanic. Patients that participated in weight loss program or were on a weight loss trial, on medications for obesity, prior surgical history of weight loss surgery, history of current severe comorbidities leading to unintentional weight loss, diagnosis of severe disease or terminal illness, or driving outside of the five NYC Boroughs were excluded. These selection criteria’s were chosen to reduce confounders and facilitate a focused understanding of the perception, knowledge, behaviors, and barriers of at-risk taxi driver population.

Focus groups were planned to collect, transcribe, code, and analyze the themes through information gathering from a purposive sample of participants from the taxi driver organizations in the hospital catchment area of the South Bronx. A cross sectional random sampling technique was utilized. Multiple in person meetings were conducted at the taxi bases to provide study information to all taxi drivers in the base. Interested taxi drivers were randomly enrolled in the study. Four different researchers would analyze the recordings independently and inductively, adopting a thematic analysis approach to obtain different codes, categories, and themes until thematic saturation was achieved.

The participants were enrolled after being screened for eligibility into the study and informed consent obtained from each participant in their primary language by bilingual research staff trained in the study protocol and informed consent process. During recruitment, participants completed a baseline demographic, social, personal (tobacco use) and clinical history questionnaire, adapted from CDC’s BRFSS survey [17]. The BMI was calculated by measuring the weight and height of the participant (Weighing scale by Elite-My Weigh; Measuring tape by Telstar) during the screening process. Subjects selected a date to participate from a pre-scheduled set of dates and locations for attending the focus groups. The focus groups were held at the recruitment taxi bases or at the hospital site in a conference room with door(s) closed for privacy. The participants were given number tags that were used as a reference for each other and eventual coding. The groups were moderated by trained research team members in both English and Spanish according to the primary language spoken by participant. The research team that conducted focus groups were trained (Clinical Research Physicians) and coached to work on groups, utilize open-ended questions and avoid focus on personal risks of participants.

The main categories of questions were organized based on perception, knowledge, behavior, and barriers. Participants were questioned on topics of etiology, risk perception, possible prevention and interventions related to CVD risks such as smoking, stress, obesity, diabetes, hypertension, and hyperlipidemia. Participants were queried with open ended questions to begin the discussion, and if participants did not elaborate on the initial question, a follow-up question was asked to clarify their response. Each focus groups lasted approximately for an hour and 30 minutes. Responses were recorded using audiotapes and transcribed verbatim. The conversations transcript was translated from Spanish to English by trained bilingual staff and analyzed using standard qualitative techniques with open code method. Four research investigators read the transcript separately and formulated concepts, which were then categorized and deduced into dominant themes. These themes were then compared and analyzed with a group consensus to ensure representative data was captured. Once recurring themes emerged and the saturation point was reached, study enrollment was stopped. In order to provide a conceptual framework and understand the complex interaction between knowledge, perception, health behaviors and the predisposition to CVD risk factors in our study population, the Health Belief Model (HBM) was employed. The HBM is one of the most utilized and easy to understand health models [18‐20]. HBM is a widely recognized psycho-social model that has been used to understand, predict and modify health behavior. HBM helps to identify perception of risks of unhealthy behavior, barriers against healthy behavior, actions taken by patients to stay healthy, and commitment to their goals [21]. The HBM consist of six posits: 1) risk susceptibility, 2) risk severity, 3) benefits of action, 4) barriers to action, 5) self-efficacy, and 6) cues to action [22] (Fig. 1). According to the HBM, people’s beliefs about their risk and their perception of the benefits of taking action to avoid it, in turn influences their readiness to take those actions [20‐25]. Study was conducted according to the COREQ guidelines for qualitative studies [26].

A total of 96 potential participants were approached. Of these, 34 did not meet the screening criteria (12 were new to the driving profession; 8 had BMI less than 25 kg/m²; 7 were not of Hispanic background; 5 worked only part-time as drivers; 2 were on a prescribed diet-plan to lose weight [with medications]) and the other 37 of the participants who were eligible, gave the following reasons to not participate: 12 were not interested; 7 did not have time; 5 not available to participate in focus groups session; 5 were no-shows to the scheduled focus group sessions; 4 stated they did not understand the purpose of the study; 2 stated the study was not a priority at this time; and 2 did not give a reason for refusal. Successive focus groups were held until thematic saturation was achieved and this point of saturation was reached after 3 focus group sessions including a total sample size of 25 subjects; there were 9 participants in Group-1; 8 in Group-2; and 8 in Group-3.

This is the first qualitative study to evaluate cardiovascular disease risk among overweight and obese Hispanic taxi drivers in NYC. The study findings, utilizing HBM conceptual framework, shows us that Hispanic taxi drivers perceive several barriers to healthy lifestyle, such as a lack of education and knowledge about healthy food choices, places where they can buy healthy affordable snacks, information about physical activities, stress management skills, poor support systems, and organizational skills.

All taxi driver participants of our study self-reported their ethnicity as Hispanic with mixed racial profile, and all but two participants were males. This finding concurs with data in literature, which shows that an overwhelming number of taxi drivers in NYC are minority men, with 84% being immigrants and 98% identify as male [2].

Even though the median household income in the Bronx borough is $35,302 [27], 68% of our group of taxi driver participants reported income below this income range. Majority of the Hispanic taxi drivers had lower than high school education, and worked long hours every week to make ends meet. Many taxi drivers reported pre-existing cardiovascular co-morbidities such as hypertension and diabetes in addition to overweight or obesity. Our finding corroborates other studies that have reported that taxi, truck and bus drivers are at a higher risk of developing diabetes and hypertension [2, 4‐7]. Interestingly, smoking rate was much lower in our study participants than published rates, the specific reason being unclear, but could be related to the impact of public health messaging in this community.

The results of our focus group sessions demonstrate that the perceptions, knowledge, beliefs and barriers noted among NYC Hispanic Taxi drivers in accordance to the following six constructs or posits of the HBM may be associated with a lower likelihood of adopting health promoting behaviors.

Thus, through the application of the HBM posits, our study shows that NYC Hispanic taxi drivers, even though perceived their risk susceptibility, lack self-efficacy, lack perceiving benefits of action, lack an understanding of cues to action, and understanding the risk of disease severity placing them at greater risk for factors that lead to CVD. They acknowledge that poor diet, stressful work environment, lack of organizational skills, increased competition from ridesharing services [28], and working extended hours are some of the barriers that contribute to their susceptibility of CVD. Furthermore, participants related that in their leisure time, consumption of alcohol, smoking cigarettes, sedentary lifestyle rather than engaging in physical activity were other factors that made them prone to being overweight and obese as elicited during the focus groups.

Our findings utilizing the HBM conceptual framework shows where opportunity for intervention lies and how we can intervene and modify the health behavior of the at-risk NYC Hispanic taxi driver population. Any future interventions will have to encompass strategies to address the above listed barriers.

Our study’s limitations include a small sample size, but we reached a saturation point within this sample. Excluded non-participants could have been healthier than participants and choose not to participate because they saw little benefit. Alternatively, non-participants could have been less healthy and felt embarrassed to participate, leading to an underestimation of CVD risk. In addition, the majority of participants in the current study were 40 years or older; responses among younger drivers may have been different. The list of themes presented is not an exhaustive list and further research is required on other themes that could potentially impact health behavior and outcomes. Differences in occupational demands reported by yellow taxi and livery car service drivers suggests that focus groups’ specific to each group could yield different views.

By obtaining a better understanding of the link between behaviors of this population, perception, knowledge, and barriers utilizing a health behavior model framework, our study highlights the predisposition for CVD risk in overweight and obese Hispanic NYC taxi drivers. Taxi drivers perceive risk factors and possess knowledge about the consequences of those health risks. Utilizing the HBM constructs, taxi drivers are found to have low self-efficacy, lack of perceived benefits of the value of engaging in a health-promoting behavior to decrease risk or have limited understanding of cues to action and greater number of perceived barriers. Barriers to improving their health include unhealthy lifestyle due to stressful and high demand work environment, for which they require support and programs targeted to improve this risk for CVD.