Work environment adversity and non-communicable Disease risk among drivers working for application-based-cab-aggregators in an Indian metropolis | BMC Public Health

This study is one of the few studies exploring associations between work environment adversity and NCD risk factors among ABCA drivers in India. The data collection started in March 2020 and was discontinued due to COVID-19-related cab service disruptions and was later resumed in the 3rd week of July 2020. The duration of sample collection was limited as the pandemic had drastically reduced the number of cabs available and was permitted only to cater to the needs of primary health care services and emergencies at different times. Despite the pandemic, we were able to complete data collection with a high response rate, which is the strength of the study. Owing to the COVID-19 appropriate behavior mandates, we deferred from measuring blood pressure and anthropometric measurements.

Our sample included drivers from both transportation and leisure zones of the city, working during day and night. All the respondents were males since we were unable to trace any female taxi drivers. Though the average reported income of the drivers was 40,000/-, nearly similar to the average per capita income of Indian citizens for the year 2020 (USD 6728, Rs 452,376 per year i.e. 37,698 per month) [10], most drivers are expected to have recurrent expenditures related to loan repayment, commercial taxes, fuel, and maintenance of vehicles. Hence their affordability for health security, insurance, and compliance with health promotion interventions is compromised. Despite this, it can be presumed that there is expendable income to indulge in tobacco and alcohol use, due to the high prevalence observed.

Karnataka State Youth Policy 2012 defines Youth as “young people in the age group of 16–30.” In our study, 30.3% of the drivers belonged to this age category compared to a study done among taxi drivers by Rathi et al., where 17.4% of the drivers were aged less than 30 years [11]. With one-third of ABCA drivers being youth, there is scope for implementing a youth-focused NCD prevention program for cab drivers or referring them to ongoing youth health promotion programs like Yuva Spandana and Life Skills in Bengaluru [12].

We observed that 36.8% of the drivers were not Bengaluru residents and hence were staying away from their families and living and working from the car. This unique attribute makes them vulnerable to regularly consuming unhealthy diets, indulging in substance use, and physical inactivity. These drivers are likely to be deprived of the care and personal psychosocial support mechanisms expected from their families.

Regular consumption of high-salt foodstuffs, fried food items, and carbonated beverages was used to define unhealthy dietary practices in this study. According to our study, around 75% of cab drivers reported unhealthy diet patterns, in contrast to the literature, which indicates the prevalence of junk food consumption to be around 18.66% [11]. Differences exist due to different operational definitions of unhealthy diets. A Study conducted in South Africa among taxi drivers revealed that regular consumption of fried snacks increased the risk of developing metabolic syndrome by 3.7 times[13].

Inadequate physical activity is a well-established risk factor for premature mortality due to NCDs such as coronary heart diseases, stroke contributing to 8% of non-communicable diseases and deaths globally [14]. Drivers who work long shifts and long work hours find it challenging to engage in physical activity. Extended periods of sitting have been linked to increased risk of diabetes, obesity cardiovascular disease, and all-cause mortality. Physical inactivity coupled with consumption of energy dense food, high in sugar and fat often lead to higher BMI, resulting in higher incidence of hypertension and blood glucose [15]. In short, this group is a ticking time bomb for cardiovascular problems in the future, with over 78% of the cab drivers reporting to be physically inactive, 46% being overweight and 75% consuming unhealthy diet.

Tobacco is used by 1.33 billion people globally, with 28.6% of the population in India using tobacco in some form (GATS-2), and 28.2% in Karnataka (GATS-2) [16] According to a survey, Bengaluru cab drivers consumed tobacco at a very high rate of 70.9%, which was higher than the national average of 42.4% for all men. Smokeless tobacco products such as gutka, khaini, and zarda, were consumed by almost 55% of Bengaluru’s taxi drivers [17]. Another study by Gany et al. found that around 30% of the drivers consumed tobacco in some form [18]. However, in our study, we observed that only 22.1% of the cab drivers consumed tobacco, which is much lesser compared to both the studies. Underreporting of substance use owing to social desirability could have been the reason for the low figures in our study.

Alarmingly, among drivers who reported alcohol use (16.8%), more than 90% were identified to be dependent users and are more vulnerable to the onset and progression of NCDs. Such high levels of dependent use warrant regular and random alcohol breath testing strategies for drivers as they pose a risk not only to themselves but also to other vehicle users, pedestrians, and the general public. Functional collaboration with the district mental health program and ABCA operators needs to be strengthened to provide brief interventions and de-addiction services.

We observed a higher risk for NCD risk factors among drivers working > 5 days a week, 7 + hours a day, staying away from family, and working night shifts. This is in line with a web of causation of NCDs wherein higher stressful work and longer working hours are associated with NCDs. Hence, results indicate a need for better strategies to monitor and address the issues of working hours, workdays, and family support.

With the high prevalence of NCDs, and NCD risk factors among an estimated 1.6 lakh registered cab drivers in Bengaluru, the proportion requiring NCD prevention and care would be significant. If we consider the entire country, the figures represent a sizeable group. It certainly calls for a concerted effort to address the issue of NCDs among drivers. The study has limitations in that it is not a representative sample of all cab drivers of Bengaluru. The work environment adversity score has scope for validity assessment across a bigger sample size.

A report released by IFAT elaborated the stressful work environment of ABCA drivers in India. 89.8% of the respondents claimed they get less than 6 h of sleep, 39.8% of the respondents spent close to 20 h in work and the lack of health insurance caused them to ignore their ailments. A significant number of respondents felt that the isolated nature of their work has affected their consumption habits of alcohol and tobacco which has incrementally increased over time [19].

In India, the existing occupational health programs do not cater to ABCA drivers, who are employed on a contract basis and are not subject to any specific laws or regulations. There are no explicitly mentioned frameworks or strategies in existing health programs to address ABCA drivers nor there is NCD risk factor surveillance in this population.

The study highlights the association between work environment adversity and NCD risk factors and indicates a dire need for Basic Occupational Health Services and social security legislation/provisions for this working population. It implies a need for government, company and individual related interventions to reduce NCD risk among ABCA drivers. The intervention will focus on setting up systems for measuring and monitoring the work environment adversity of ABCA drivers, regular screening for NCDs by periodical health examination, providing specific health promotion interventions, and establishing linkages with ongoing health programmes for management of NCDs and mental disorders. We also recommend conduction of a larger representative sample survey in more cities across the country to arrive at more precise estimates. Periodical screening for NCDs and risk factors is recommended on an annual basis. As a short-term measure, there is a need for outreach strategies in national programs and NCDs & mental health (NP-NCD and NMHP) to ensure access to health promotion, screening, and treatment services for ABCA drivers in Bengaluru. Stakeholders’ meetings (ABCA companies, cab drivers, unions, health department, and labor department) are recommended to debate and discuss strategies to reduce NCDs in ABCA drivers. An innovative way of monitoring working hours and driving time without affecting the revenues of drivers, using a technology approach is recommended.