Step On It! Impact of a Workplace New York City Taxi Driver Health Intervention to Increase Necessary Health Care Access

Objectives. We describe the impact of the Step On It! intervention to link taxi drivers, particularly South Asians, to health insurance enrollment and navigate them into care when necessary.Methods. Step On It! was a worksite initiative held for 5 consecutive days from September 28 to October 2, 2011, at John F. Kennedy International Airport in New York City. Data collected included sociodemographics, employment, health care access and use, height, weight, blood pressure, and random plasma glucose. Participants were given their results, counseled by a medical professional, and invited to participate in free workshops provided by partner organizations.Results. Of the 466 drivers participated, 52% were uninsured, and 49% did not have a primary care provider. Of 384 drivers who had blood pressure, glucose, or both measured, 242 (63%) required urgent or regular follow-up. Of the 77 (32%) requiring urgent follow-up, 50 (65%) sought medical care at least once, of whom 13 (26%) received a new diagnosis. Of the 165 (68%) requiring regular follow-up, 68 (41%) sought medical care at least once, of whom 5 (7%) received a new diagnosis.Conclusions. This study provides encouraging results about the potential impact of an easy-to-deliver, easily scalable workplace intervention with a large, vulnerable population.New York City alone has more than 50 000 yellow taxi drivers and a similar number of livery drivers.1 A large majority, 94%, are immigrants, mainly originating from India, Bangladesh, Pakistan, Haiti, and West African countries.1 Taxi drivers are often at greater risk for cardiovascular disease (CVD) and associated risk factors than the general population.2,3 Studies looking exclusively at taxi drivers have found a correlation between the occupation and myocardial infarctions, multivessel disease, obesity, insulin resistance, high blood pressure, high triglycerides, and high low-density lipoproteins.3 By nature of their occupation, drivers have a sedentary lifestyle.4,5 Sedentariness in the general population has been linked to a higher CVD mortality rate, secondary to coronary heart disease, sudden heart failure, hypertension, and diabetes.6–11 Environmental exposures are also to blame for high CVD and lung cancer risk for taxi drivers. Exposure to particulate matter, which is often found at high levels in closed vehicles, has been linked to lower heart rate variability, a predictor of CVD, and to lung cancer.12–14Other factors, such as high stress, poor working conditions, long hours, unstable income, unhealthy diet, significant concern about personal safety on the job, and institutional and organizational barriers further contribute to poorer health among taxi drivers.5,15–17 Several reports and studies on the working and living conditions of taxi drivers have been released in California; Chicago, Illinois; and New York City and described similar health profiles for this population.5,15,16 In New York City, drivers typically work 10- to 12-hour shifts 6 days a week.4,16,18 Studies have also shown that a major systems-level obstacle for taxi drivers is lack of adequate health care; 60% of taxi drivers were found to be uninsured in a Chicago study19 and 52% in a New York City study.20 The occupation-related barriers to care experienced by this largely immigrant community are further exacerbated by literacy and language barriers, financial pressures, family obligations, and cultural values.4,19,21 South Asian taxi drivers, the largest group of yellow taxi drivers in New York City, potentially face a double burden for CVD because of both the nature of their occupation and the increased CVD risk associated with South Asian ethnicity.22–27Several studies have demonstrated the successful use of occupation-based interventions to effect lifestyle changes.17,28–31 A literature review of dietary promotion programs in the workplace demonstrated that, with industry cooperation and use of a social–ecological model of intervention, worksite interventions can have gradual and favorable results.17 In one social–ecological study, changes to workplace cafeteria food service in conjunction with behavioral interventions for workers resulted in a significant increase in fruit and vegetable consumption among participants.17 Support from workplace management was crucial for the success of this program.17 Although a paucity of data exist on interventions specifically for US taxi drivers, a number of European studies have had good results for exercise and diet interventions for taxi and other drivers.29–31 A British pilot study used a peer video to encourage drivers to make healthy lifestyle changes over a 1-year study period, resulting in 73% of participating drivers reporting a significant lifestyle change, with greater physical activity, positive diet changes, and more time spent on family activities.29 Another British study used a peer education model for CVD risk education. Peer “health champions” disseminated information about free screenings and medical referrals; more than 66% of those who received medical appointments at screenings subsequently attended them.30 In Sweden, a healthy eating workplace intervention conducted at rest stops resulted in improved nutritional balance in meal choices among truck drivers.31 The results of these studies suggest that the workplace can be an effective setting for taxi driver health interventions in the United States.28The Immigrant Health and Cancer Disparities Service (IHCD) at Memorial Sloan-Kettering Cancer Center designed and implemented a taxi driver workplace health intervention, Step On It!, in 2011 at the John F. Kennedy (JFK) International Airport yellow cab holding lot in New York City. The Step On It! intervention incorporates specific components addressing drivers’ barriers to care, including

1. health insurance enrollment education and enrollment assistance to address lack of health insurance;
2. referrals to low-cost or free health clinics and hospitals to address financial barriers to obtaining health insurance;
3. referrals to culturally and linguistically appropriate care to address language and cultural barriers;
4. events held during work hours, providing a window of opportunity, and assistance with finding clinics with flexible hours, to address drivers’ long work hours; and
5. onsite health screening and counseling with triage to urgent or regular follow-up to address lack of knowledge related to current health status and need for care.

After drivers were assessed for health care access and utilization, medical history, and CVD risk factors; screened for hypertension and elevated random plasma glucose; and measured for body mass index (BMI), Step On It! used a health care access navigation and case management intervention to link drivers to health insurance enrollment and navigate them into care when necessary. We describe the impact of this intervention on the primary outcome of interest, drivers’ engagement in needed medical care.