Abstract
Background:
This study examined differences in colorectal cancer screening across sociodemographic, migration, occupational, and health-related factors in a sample of male taxi drivers.
Methods:
Male drivers eligible for colorectal cancer screening (CRCS) (≥ 50 years old) were recruited in 55 community-based health fairs conducted during November 2015 to February 2017 in 16 taxi garages or community locations located in Queens, Brooklyn, Manhattan and Bronx. Participants completed a survey that included sociodemographic, migration, occupational, health-related, and cancer screening practices. For this study 33 questions were analyzed.
Results:
The sample consisted of 137 male drivers, 27% of them had undergone CRCS. Occupation-related factors, including night shifts and driving high numbers of weekly hours, were associated with lower CRCS rates; having a family history of cancer, health insurance, a regular source of primary care, and a routine check-up in the last year, were associated with higher CRCS rates.
Discussion:
The findings suggest that drivers with health insurance and better access to primary care are more likely to be up-to-date with CRCS. The results provide important information that can inform occupation-based public health interventions.
Keywords: Colonoscopy, Adherence, Cancer Screening, Immigrant Health
Introduction
Urban taxi drivers are a large, marginalized, growing, mostly minority population with multiple health risks [1–4]. The vast majority of drivers in New York City (NYC) are immigrants (94%), mainly originating from South Asian, West African, and Caribbean countries [5]. Taxi drivers have tremendous unmet preventive and cancer screening needs, despite their increased risk (i.e., physical inactivity, high BMI, and poor diet) [1–3]. Drivers potentially face specific work-related, financial, linguistic, cultural, and logistical barriers that prevent them from seeking preventive and cancer screening services [1,3]. In a survey of taxi drivers, Apantaku-Onayemi and colleagues found that only a third of those aged 50 and over had had any cancer screening test, 26% had had a sigmoidoscopy/colonoscopy, and 32% had had a fecal occult blood exam [6]. Occupation-related barriers to colorectal cancer screening (CRCS) have rarely been examined in the literature, although a systematic review cited the need to take time off work to have a colonoscopy as a major barrier to CRCS.[7] In two other studies, with African American and Latino populations, participants felt that they could not take time off work to obtain cancer screening tests [8,9].
Although there have been improvements in CRCS rates nationwide, only 59% of the US population aged 50 and older is up-to-date with recommended CRCS guidelines [10]. Furthermore, CRCS rates are lower among those who have fewer years of education, lack health insurance coverage, are non-white, are limited English proficient, and are recent immigrants. CRCS rates by race/ethnicity and immigration status for adults aged 50 to 75 years are: 62% for non-Hispanic Whites, 56% for Blacks or African Americans, 46% for Asians, 47% for Latinos, 61% for US-born individuals, and 25% for immigrants who have resided in the US for less than 10 years [10]. In a study comparing US-born individuals, naturalized citizens, and non-citizens, only 67% of US-born citizens, 61% of naturalized citizens, and 46% of non-citizens had completed CRCS [11]. Among immigrants, those who lived in rural areas, lacked insurance, or were not English proficient, were less likely to have received CRCS [11]. Older immigrants, males, those with higher incomes, nonsmokers, married individuals, and those who visited their physicians frequently were more likely to have received CRCS [11]. Moreover, Gany and colleagues found that lack of awareness and misinformation are frequent barriers to optimal cancer screening in immigrant communities [12].
Key factors associated with CRCS in the literature are provider recommendation and awareness of the need for CRCS [13]. In immigrant populations, having a regular source of care is also significantly associated with being up-to-date on recommended cancer screening schedules [14]. Other key factors described in the literature are doctor–patient communication and relationship quality, language barriers, concern about cost and access, lack of health insurance, and lack of flexible operating hours at health care facilities [7,15–18].
The NYC Department of Health and the NYC-wide Colon Cancer Control Coalition make the following recommendations for average risk individuals: (1) colonoscopy every 10 years for individuals 50 years and older or (2) stool blood tests every year for those who are unable to or choose not to have a colonoscopy (and a recommendation for colonoscopy if the test is positive) [19]. Little is known about CRCS behavior in the large, at-risk taxi-driving community, including key facilitators of and barriers to CRCS. The purpose of the current study was to examine whether the following factors are associated with CRCS completion in male taxi drivers in NYC: medical history, such as a personal history of cancer, a family history of cancer, and comorbidities; health care access factors, including having insurance, having a source of primary medical care, time since most recent medical visit, having problems accessing medical care, and having problems understanding medical providers; migration-related factors, such as birthplace region, English proficiency, and years living in the US; and occupation-related factors, such as type of driving shift and weekly driving hours.
Methods
Participants
A cross-sectional analysis of CRCS utilization in the past ten years among taxi drivers in New York was performed using the baseline intake data from a health promotion program that consists of a community-based health fair intervention with patient navigation. Health fairs were carried out in NYC at 16 taxi garages or community locations that taxi drivers were known to frequent. Most navigators were bilingual, with fluency in the languages most frequently spoken in the study population: English, Bengali, or French. The health fair program consists of a health screening survey assessment (which elicits sociodemographic and various other aspects of health information, including CRCS history) and biometric assessments, including, height, weight, blood pressure, cholesterol, and glucose levels.
The study was conducted from November 2015 to February 2017, during which 55 health fairs in four of the five NYC boroughs took place: 42% in Queens, 25% in Brooklyn, 25% in Manhattan, and 8% in the Bronx. To be eligible for the project, participants needed to be: 1) male, 2) a licensed driver for at least six months, 3) over 21 years old, and 4) leasing a taxi from a taxi garage. The total sample of health fair drivers approached for screening was 615; 468 (76%) completed the assessment. Only participants who were eligible for CRCS (participants aged 50 and over) were included in this analysis, and 137 were considered to be evaluable cases. Our analysis of this program was approved by Memorial Sloan Kettering Cancer Center’s Institutional Review Board/Privacy Board. Voluntary informed consent was obtained from all participants.
Measures and Data Collection
Participant data, including socio-demographic measures, were collected via surveys during the health fairs. Demographic questions included age, marital status, education, and income level. Migration-related factors included country of origin, years lived in the US, language preference, and English proficiency. English proficiency was assessed with the US Census questions assessing ability to speak English (How well do you speak English? Responses: very well, well, not well, or not at all) and its recommendation that less than “very well” should be considered limited English proficiency [20]. Thus, level of English proficiency was collapsed into two categories: English proficient (English spoken very well) and limited English proficient (English spoken less than very well) [20]. All the potential participants selected at least one of the study languages (English, Bengali, or French). To ensure an adequate number of respondents in each category to conduct the analyses, countries of birth were grouped into three categories, South Asian, West African, and Other.
Occupation-related factors recorded included average time spent driving per day, average number of days working per week, number of years driving, and type of shift. To get an estimate of average number of hours worked per week, the average time spent driving per day was multiplied by the average number of days worked per week. Type of shift refers to day, night, or variable shifts.
Uptake of CRCS was identified by responses to survey questions asking about the participant’s history of CRCS and date of the screening. The questions were: 1) have you ever been screened for colorectal cancer; 2) have you ever been screened with colonoscopy, stool test for blood, sigmoidoscopy, or other; and 3) If Yes, when the most recent screening for colorectal cancer was? Other medical-related factors recorded included a history of cancer, family history of cancer, and medical comorbidities. Medical comorbidities included up to 18 health conditions (i.e., cardiovascular disease/stroke, cancer, hypertension, high cholesterol, etc.). The medical conditions questions were adopted from the Behavioral Risk Factor Surveillance System Questionnaire [21], which includes questions about diagnosis and treatment history for a wide range of conditions. Healthcare access questions recorded the participant’s insurance status, whether they had a regular source of healthcare, their provider location, and length of time since the most recent routine check-up.
An index of access to healthcare was created with five questions that had a yes/no response format. These questions about access to healthcare services were adopted from the National Health Interview Survey [22,23]. An index of communication problems was created with three questions adopted from the Survey on Disparities in Quality of Healthcare [24] and a questionnaire about the patient-physician relationship [25]. To ensure an adequate number of respondents in each category to conduct the analyses, questions were aggregated and then converted to a binomial variable indicating no communication problems or the presence of communication problems.
Analyses
Statistical analyses were executed using the SPSS 20 software package. Descriptive analyses were performed to examine socio-demographic characteristics. Binary logistic regression analyses were run to determine the relationship between the demographic, migration-related, occupational, medical, and healthcare access variables and prior CRCS completion. A p value less than .05 was considered statistically significant. Then, 14 independent adjusted hierarchical logistic regression models were conducted, controlling for age, race/ethnicity, marital status, income, and education; this allowed for the examination of associations between history of CRCS and factors that included migration history (place of birth, years of residence in the US, English proficiency), occupation (hours per week driving and type of shift), medical history (participant’s cancer history, their family history of cancer, and comorbidity index results), and healthcare access information (health insurance, regular source of healthcare, location of healthcare source, time since most recent check-up, index of access to healthcare, communication problems with provider).
Results
One hundred thirty-seven drivers were included in analyses. The mean age of participants was 58 years old and two-thirds of the sample were married or partnered (64%). In terms of education, 42% had a college degree or postgraduate degree, and about half (44%) of the sample had a monthly income of $2,000 to $3,000. The sociodemographic, migration-related, occupational, medical, and healthcare access-related characteristics by CRCS status are shown in Table 1. Twenty-seven percent (37/137) of the taxi drivers eligible for CRCS had completed screening, of whom all reported having had a colonoscopy in the past and none reported any other type of screening. All the participants who reported having had a colonoscopy had had the procedure within the past ten years. Hence, all participants who reported having had a colonoscopy were up-to-date with the recommendations for CRCS.
Table 1.
Characteristics of the sample by colorectal cancer screening status, New York, New York, 2015-2017
| Never Had Colorectal Cancer Screeninga | Ever Had Colorectal Cancer Screening | |
|---|---|---|
| Variable | % (n) | % (n) |
| SOCIODEMOGRAPHIC | ||
| Ageb | 51 (6) | 59 (7) |
| 50-59 years old | 63 (63) | 54 (20) |
| Age 60 and above | 37 (37) | 46 (17) |
| Marital status | ||
| Married or partnered | 64 (63) | 64 (23) |
| Divorced, separated or widowed | 25 (25) | 31 (11) |
| Never married | 11 (11) | 6 (2) |
| Race/ethnicity | ||
| White or Caucasian | 5 (5) | 24 (9) |
| Black or African American | 72 (71) | 57 (21) |
| Hispanic or Latino | 3 (3) | 8 (3) |
| Other | 19 (19) | 11 (4) |
| Educational attainment | ||
| Less than high-school | 8 (8) | 5 (2) |
| High-school graduate to some college | 52 (50) | 49 (18) |
| College graduate or post college | 40 (39) | 46 (17) |
| Federal poverty threshold of annual combined income | ||
| 0-99% | 25(19) | 23(7) |
| 100-199% | 44(33) | 40(12) |
| ≥ 200% | 31(23) | 37(11) |
| MIGRATION | ||
| Birth region | ||
| South Asia | 12 (12) | 11 (4) |
| West Africa | 43 (43) | 24 (9) |
| Caribbeanc | 25 (25) | 32 (12) |
| Otherd | 20 (20) | 32 (12) |
| Years in US | ||
| 1-20 years | 17 (17) | 16 (6) |
| 21-35 years | 58 (57) | 51 (19) |
| More than 35 years | 21 (21) | 22 (8) |
| US born | 4 (4) | 11 (4) |
| English proficiency | ||
| LEPe | 65 (65) | 54 (20) |
| Proficient | 35 (35) | 46 (17) |
| OCCUPATIONAL | ||
| Years driving | ||
| 1-10 years | 28 (27) | 32 (12) |
| 11-20 years | 35 (34) | 38 (14) |
| 21 or more | 38 (37) | 30 (11) |
| Hours driving per week | ||
| 16-44 hours | 19 (19) | 32 (12) |
| 45-60 | 34 (34) | 38 (14) |
| 61 or more | 47 (47) | 30 (11) |
| Type of shift | ||
| Day | 41 (41) | 65 (24) |
| Night | 46 (46) | 22 (8) |
| Variable | 13 (13) | 14 (5) |
| MEDICAL | ||
| History of cancer diagnosis | ||
| No | 97 (92) | 87 (32) |
| Yes | 3 (3) | 14 (5) |
| Family history of cancer diagnosisf | ||
| No | 87 (82) | 65 (24) |
| Yes | 13 (12) | 35 (13) |
| Comorbidities | ||
| None | 46 (46) | 32 (12) |
| 1 condition | 28 (28) | 30 (11) |
| 2 or more | 26 (26) | 38 (14) |
| HEALTHCARE ACCESS | ||
| Health insurance | ||
| None | 55 (47) | 27 (8) |
| Medicaid | 40 (34) | 53 (16) |
| Otherg | 5 (4) | 20 (6) |
| Regular source of healthcare | ||
| No | 49 (49) | 16 (6) |
| Yes | 51 (51) | 84 (31) |
| Location of healthcare source | ||
| Hospital clinic or outpatient clinic | 35 (16) | 50 (15) |
| Doctors office | 65 (30) | 50 (15) |
| Time interval since last check-up | ||
| more than a year | 54 (53) | 24 (9) |
| Within past year | 47 (46) | 76 (28) |
| Index of access to health careh | ||
| None | 74 (72) | 70 (26) |
| 1 barrier | 12 (12) | 24 (9) |
| 2 or more barriers | 13 (13) | 5 (2) |
| Communication with provideri | 13 (13) | 5 (2) |
| No communication problem | 74 (66) | 67 (24) |
| Problem understanding or being understood | 26 (23) | 33 (12) |
Note.
All the options of CRCS were presented but only colonoscopy was endorsed by the participants who have had CRCS in the past
Mean and standard deviation of participants’ age. Age range 50 to 76 years old
Caribbean countries include non-Hispanic Caribbean islands with predominantly English and French speakers
Other includes drivers born in US and countries in Latin America, Africa, Arab region, East Asia, and Western Europe
LEP: Limited English proficiency
Family history of cancer includes cancers of breast, prostate, colorectal, lung, blood, esophageal, cervical, brain, pancreatic, and stomach
Other insurances included Medicare and private PPO
Includes barriers related to cost, being accepted as a new patient and insurance coverage
Communication problems of understanding or being understood by provider
Thirty-eight percent of the sample was born in a Western African country (predominantly Ghana and Guinea), 27% in Caribbean-region countries (predominantly Haiti), 12% in South Asian countries (predominantly Bangladesh and Pakistan), and 23% were born in other countries, including eight people born in the U.S. Only 21% of the drivers had been residing in the US for more than 35 years and 56% for 21 to 35 years. Two-thirds of the sample had low English proficiency (62%). Approximately a third of the sample (29%) had been driving for ten years or less; slightly more than a third drove for 45 to 60 hours per week (35%), 42% drove for 61 hours or more per week, and almost half of the sample had a diurnal shift (47%).
Six percent of the sample had a history of cancer, predominantly prostate cancer (n=6); none had ever been diagnosed with colorectal cancer. Nineteen percent had a family history of cancer (predominantly prostate and breast cancers). About half of the sample had no insurance (48%) and 44% had Medicaid. Almost two-thirds of the sample had a regular source of healthcare (60%), and two-thirds visited their providers in their private offices. Slightly over half of the sample (54%) had seen their primary care provider within the past year.
As shown in Table 2, unadjusted logistic regression analyses revealed differences in CRCS uptake based on participants’ hours spent driving per week, driving the night shift, lacking health insurance, having no regular source of healthcare, having a longer time since most recent routine check-up, and having a personal and a family history of cancer. After adjusting for sociodemographic characteristics, all the factors remained significant, except personal history of cancer. Drivers who spent 61 or more hours/week driving were less likely to have had CRCS in the past than those working fewer than 45 hours/week (OR = 0.29; CI = 0.10-0.86), and drivers who primarily worked the night shift were less likely to have completed CRCS than those who worked the day shift (OR = 0.27; CI = 0.10-0.73).
Table 2.
Bivariable and multivariable analyses of factors associated with colorectal cancer screening in New York City taxi drivers, 2015-2017
| Variable | Unadjusted | Adjusteda | ||
|---|---|---|---|---|
| Odds Ratio | (95% CI) | Odds Ratio | (95% CI) | |
| OCCUPATION | ||||
| Hours Driving per Week | ||||
| 16-44 hours | Referent | Referent | ||
| 45-60 | 0.65 | (0.25-1.69) | 0.59 | (0.19-1.77) |
| 61 | 0.37 | (0.14-0.98) | 0.29 | (0.10-0.86) |
| Type of Shift | ||||
| Day | Referent | Referent | ||
| Night | 0.30 | (0.12-0.73) | 0.27 | (0.10-0.73) |
| Variable | 0.66 | (0.21-2.07) | 0.61 | (0.17-2.19) |
| MEDICAL | ||||
| History or current cancer diagnosis | 4.79 | (1.08-21.19) | 4.67 | (0.95-22.97) |
| Family history of cancer diagnosisb | 3.70 | (1.49-9.17) | 3.51 | (1.28-9.62) |
| HEALTH CARE ACCESS | ||||
| Health Insurance | ||||
| Otherc | Referent | |||
| None | 0.11 | (0.03-0.49) | 0.13 | (0.03-.61) |
| Medicaid | 0.31 | (0.08-1.27) | 0.34 | (0.07-1.67) |
| Regular source of health care | 0.20 | (0.08-0.53) | 0.15 | (0.05-.44) |
| Time since last check-up | ||||
| Within past year | Referent | Referent | ||
| more than a year | 0.28 | (0.12-0.65) | 0.22 | (0.09-.55) |
Multivariable models adjusted for age, race/ethnicity, marital status, income, and Educational attainment.
First degree family members, all types of cancer diagnoses
Other insurance categories included Medicare and private PPO
Drivers with no medical insurance (OR = 0.13; CI = 0.03-0.61) and those without a source of primary care (OR = 0.15; CI = 0.05-0.44) were less likely to have ever had screening than their counterparts. Drivers who had not had a medical check-up in the past year were also less likely to have ever had CRCS (OR = 0.22; CI = 0.09-0.55). Drivers with a family history of cancer were 3.5 times more likely to have had CRCS in the past than those without a family history of cancer (OR = 3.51; CI = 1.28-9.62). However, history of cancer was not significantly associated with screening (OR = 4.67; CI = 0.95-22.97).
Discussion
The study findings revealed that driving for 61 hours or more weekly, working night shifts, lacking health insurance, having no regular source of healthcare, going more than one year without a check-up, and having no family history of cancer were associated with significantly lower odds of CRCS among NYC taxi drivers. Drivers working 61 hours or more per week and those working a night shift were about 70% less likely to have had CRCS in the past than their counterparts. Many drivers routinely worked long hours (42% of the sample worked more than 60 hours/week) with frequent shift changes and irregular driving times, which may have prevented them from tending to their health and seeking preventive healthcare. It is possible that drivers working longer hours and those who work night shifts prioritize sleeping or other pressing needs over their health needs. Gany and colleagues [1], in their study of taxi drivers, found that the demanding work schedule of drivers contributes to poor health, poor sleep, stress, and less access to healthcare services. Furthermore, drivers who work long hours and night shift schedules might face additional barriers to CRCS, such as lack of time to schedule the appointment, conflict with the time of appointments and work shift, and lack of time to conduct proper preparation for the screening test due to their work schedule, among many other barriers. Finally, access to primary care and preventive services, such as CRCS, could be further inhibited by the lack of employer-sponsored health insurance for professional drivers.
Drivers who had insurance, access to primary care providers, and visited their provider for a routine checkup within the past year were more likely to have been screened for colorectal cancer than their counterparts. Not surprisingly, drivers with more access to primary care are more likely to be up-to-date with screening recommendations. A physician recommendation for CRCS has been identified as one of the main factors associated with CRCS in the general population and in racial/ethnic minority groups [13,26–28]. Finally, consistent with prior research, having a family history of cancer was a key factor associated with prior colonoscopy screening uptake [26].
Occupation-related barriers to CRCS have not been extensively examined in the literature, although a few studies with racial/ethnic minority participants found that participants reported that they could not take time off work to obtain cancer screening tests [8,9]. Furthermore, in a US national survey, individuals who reported working alternative shifts were more likely to be non-adherent with CRCS compared with workers on daytime shifts [29]. Three systematic reviews have summarized the evidence about facilitators of and barriers to CRCS [7,26,30]. The need to take time off work to have a colonoscopy was cited as a barrier in only one of the systematic reviews. The other systematic reviews did not note any occupation-related barriers. This is the first study, to our knowledge, to identify specific occupational factors associated with CRCS.
Limitations and Strengths
Certain study limitations should be noted. The current data consist of retrospective selfreports, and thus may be subject to recall bias. Although other studies have used a similar approach to studying cancer screening in community populations [26], a more robust and objective measure of screening is needed for future studies, but abstracting data from medical records of hundreds of community members from a multitude of health centers and private practices presents logistical and resource-related challenges. Future studies can use prospective longitudinal designs to study colorectal cancer screening uptake in the taxi driver population using a controlled number of health care centers. Given that this was a cross-sectional study, only associations could be examined, and no causal inferences could be made. Future studies with longitudinal designs, focusing on changes in access to health care and occupational factors and screening completion could address this issue. In addition, the study sample consisted of NYC immigrant taxi drivers of predominantly West African origin; thus, the results may not be generalizable to immigrant taxi drivers in other regions of the US or to non-immigrant drivers.
Conclusions
The results suggest that, in a sample of male taxi drivers eligible for CRCS, poor access to primary care services (lack of insurance, not having a primary care provider and not visiting the provider within the past year) and occupation-related factors, such as working long hours (61 or more), and working a night shift, are key factors associated with reduced access to CRCS. There is a need to examine the impact of occupation-related factors on access to preventive and cancer screening services among taxi drivers and other occupational groups and on interventions to overcome these barriers. A growing number of people work in nonstandard work arrangements, defined as work that is performed part-time, on temporary contracts, on an on-call basis, as third-party contracting, or remotely [31]. Such work is frequently performed by immigrants who work as maids, janitors, home health aides, drivers, maintenance workers, construction laborers, agricultural workers, and restaurant workers. These occupations are primarily, although not exclusively, low-wage jobs that require long hours and variable or night shifts. A few occupation-based interventions have been developed to promote cancer screening at work sites [27,32–34], but little is known about the factors that need to be modified or the accommodations that need to be made to promote cancer screening in occupational contexts. Occupation-based CRCS interventions are warranted. These could include free occupation-based CRCS programs, a widespread campaign about CRCS options (colonoscopy and stool-blood tests), and, for taxi drivers, taxi garage- and app-based navigation into CRCS.
Supplementary Material
Acknowledgments & Funding Sources
This research was supported by the National Institutes of Health grants: NIMHD (National Institute on Minority Health and Health Disparities) U01MD010648 Taxi STEP (Social networks, Technology, and Exercise through Pedometers), NIMHD R24MD008058 The Taxi Network, NINR (National Institute of Nursing Research) R01NR015265 Taxi HAILL (Health Access Interventions for Linkages an Lifestyle), NCI (National Cancer Institute) U54CA132378 Taxi Particulate matter Study (TIPS), and the Memorial Sloan Kettering Cancer Center grant NCI P30CA008748. The contents of this article are solely the responsibility of the authors and do not necessarily represent the views of the awarding agencies.
Footnotes
Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.
Conflict of Interest
All the authors indicated no potential conflicts of interest and no financial disclosures.
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