Abstract
Age-related cognitive and somatic motor skills changes have been linked to impaired driving abilities. Taxi drivers play an important role in providing public transportation services and security. This study aimed to examine the level of fitness-to-drive (FTD) and identify the predictors of self-reported traffic injury among the older taxi drivers. Taxi drivers 60 years and older in Bangkok and the metropolitan area were enrolled. Hierarchical regression models were carried out to examine the effects of demographics, FTD, and metacognition towards self-reported road traffic injury. Totally, 46.1% of the respondents were classified as at-risk drivers. Drivers with alcohol consumption and low risk perception toward road safety were more likely to experience road traffic injury. Regular assessment of physical and psychometric capacity among older taxi drivers could provide another empirical basis to improve public safety transport.
• Older taxi drivers with poor metacognition were more likely to be at-risk drivers. • Nearly one-half of older taxi drivers could be classified as at-risk drivers. • Driving under the influence of alcohol and low level of risk perceptions toward road safety are key contributors to traffic injury among old taxi drivers.
• Monitoring and evaluating fitness-to-drive could be considered for renewing driving licenses for older commercial drivers. • Conducting a regular assessment of relevant psychometric measures among the older drivers is important. • Innovative motivation should be imitated to enhance safety risk perceptions among public drivers.What this paper adds
Applications of study findings
Introduction
Road traffic injuries are one of the leading causes of death globally with an estimated fatality rate of 18 per 100,000 population and ranked as the eighth leading cause of death for people of all ages. It has been estimated that every year the lives of approximately 1.3 million people are cut short as a result of a road traffic accidents (World Health Organization, 2018). Modern societies are experiencing an extraordinary growth in the percentage of older adults in relation to the total population, primarily due to increasing longevity and falling birth rates (World Health Organization, 2021). The new generation of elderly differs from previous generations and is more likely to maintain their driving licenses, possess a car, and travel more kilometers than previous generations (Wallis et al., 2020). According to research studies, the fatal crash rate for older drivers per vehicle-mile traveled rose at age 65 and was likely due to loss of capabilities (Cicchino & McCartt, 2015; Gomes-Franco et al., 2020). Even though older drivers adhere to safe driving practices, their age-related decline in cognitive, motor, visual, and sensory functions impact their ability to drive safely (Balzarotti et al., 2021; Kandasamy et al., 2019). Evidence has shown they are overrepresented in crashes per distance traveled, particularly regarding serious injury or death as a consequence of crash involvement (Koppel et al., 2019). Therefore, age-related cognitive, motor, and somatic skill changes could lead to impaired driving skills.
Prior Studies on Older Drivers
Globally, many countries are facing a key challenge in rapidly aging society. Thailand is one of the fastest-aging countries in the world and will become a super-aged society by the year 2031 indicating the need to ensure services and support for elderly communities now and in the future. The literature review identified that sensory, motor, and cognitive abilities are the most important components of elderly safe driving. As age increases, chronic disease, multiple drug use, and subsequent problems increase. This can affect the ability to drive safely and can cause traffic injuries (Bahrampouri et al., 2021). Several studies have revealed various factors as predictors of traffic injuries among older adult drivers included physical functions and cognitive status factors playing a crucial role in injury (Anstey et al., 2005; Noh et al., 2020; Sandlin et al., 2014; Thorslund et al., 2014; Vance, Ball, et al., 2006; Vance, Roenker, et al., 2006). Thailand is no exception to this trend as the proportion of elderly in the population has significantly increased during the last decade, indicating the need to ensure services and support elderly communities now and in the future.
Work Related to Traffic Injuries concerning Professional Drivers
An increasing trend of registering new passenger taxis either in company or private cars has been ongoing during the past decades in Thailand. Statistics reports by the Department of Land Transport indicated that taxis contributed to a high proportion of the road traffic injury rate compared with other public vehicles (Department of Land Transport, 2022). A comparative study among professional drivers revealed that taxi drivers were more likely than truck drivers to commit errors as well as ordinary and aggressive violations (Mehdizadeh et al., 2019). Related literature indicated that adverse working conditions such as picking up potential passengers on the road, tending to rush to the waiting passengers, cruising the streets at a constant lower speed, waiting at forbidden areas and stopping frequently while driving have been identified as predictors of safety performance (Shams et al., 2011; Shi et al., 2014; Tseng, 2013). Moreover, with long periods of continuous driving and heavy workloads, taxi drivers are always faced by severe sleep problems and are particularly susceptible to fatigue (Peng et al., 2020; Zhang et al., 2018). Fatigue can result in reduced alertness and poor psychometric conditions for drivers creating a dangerous state for a long time. Moreover, it impairs the overall health of drivers and has been associated with traffic injury involvement as consequences (Husain et al., 2019; Li et al., 2019).
Taxis as Part of Public Transport in Bangkok
Bangkok has been classified as one of the most traffic-congested cities in the world. The metropolis has promoted several public transportation systems to provide accessibility for its urban population such as buses, taxis, and high-speed trains; however, facilities could not meet the demand. Public transport use and out-of-home activity engagement were associated with active well-being especially among the elderly in Thailand (Thaithatkul et al., 2022). Generally, a taxi is accepted as the easiest modes of transportation while mass transit systems in Bangkok are becoming increasingly crowded and unpleasant. The starting taxi fare is at US$1.01 and the meter increases relatively slowly to the distance traveled and considered very cheap relative to western countries. Thai law requires taxis to always run on meters and not to decline any customer that hails them when they are available. The government opened a hotline (1584) to call in relation to customer complaints against uncooperative taxi drivers. Furthermore, several mobile applications are available to request a taxi that offers a range of transportation services to users. Passengers can choose from suitable apps based on their preferences and travel needs.
Assessment of Fitness-To-Drive (FTD)
Evidences has shown that evaluating FTD consisted of risk perception, technical driving skills, and safety consciousness with physical measurements providing a faster and more efficient way to identify at-risk older drivers (Medhizadah et al., 2018; Morrow et al., 2018; Unsworth et al., 2019; Zhang et al., 2018). A study clearly indicated that psychological FTD could be able to identify personality and cognitive patterns especially of at-risk drivers (Tinella et al., 2021). Therefore, several research studies among older drivers have proved that assessing medical FTD could be useful using standardized tools for assessment (Classen et al., 2018; Medhizadah et al., 2018, Tinella et al., 2021; Urlings et al., 2018).
In Thailand, a medical fitness approval certification is required when applying for a professional driving license and for every renewal cycle; however, no age limit has been set. Taxi drivers need to evaluate their existing problems and driving fitness including some behavioral characteristics (Zhang et al., 2018). Along with older age and driver roles, they are more likely to be the most vulnerable group on the road. This study examined level of FTD in a group of older taxi drivers and determined factors associated with road traffic injury.
Methods
Sample and Procedure
Sample size was estimated using a 95% confidence interval a 26% proportion (Chan et al., 2019) and 5% marginal error. By adding 10% nonresponse rate, the minimum sample size was 301. A total of 305 Thai taxi drivers, aged 60 years and older, holding a valid driver’s license were enrolled in this study. Subjects were recruited during their resting period at hot spot parking areas in Bangkok employing three trained research assistants from May to June 2021. Approximately 20–25 minutes was spent during the paper self-administered questionnaire.
Measures
All measurements in this study were forward and backward translated by two professional staff at a university research institute for languages to ensure the accuracy and validity of the original content under local context. Pretesting was conducted using 30 older taxi drivers to assess their understanding with Cronbach’s alpha scores ranging from 0.96 (FTD) to 0.95 (metacognition). The contents and structure of the questionnaire were reviewed and revised for greater clarity to enhance comprehension after pretesting. The questionnaire consisted of four main parts described below.
Part I Fitness-To Drive
FTD was measured based on the existing literature to detect at-risk older drivers (Classen et al., 2018; Medhizadah et al., 2018, 2019). It consisted of 17 items to measure three domains: 1) technical driving skills, such as changing lanes in moderate traffic, making a left-hand turn, crossing multiple lanes, and entering traffic with no lights or stop signs (eight items), 2) risk perceptions such as altering driving patterns in response to changes in health or conditions, driving at night, fog or unfamiliar areas (five items), and 3) safety consciousness such as maintaining distance between cars and others and avoiding dangerous situations (four items). The participants rated their ability regarding all the items on four levels, ranging from 4 (very difficult) to 1 (not difficult). The classification of driver was based on the FTD score; ranking from accomplished driver to at-risk driver ranked from 1 (at-risk -) to 3 (accomplished -).
Part II Metacognition
Metacognition was defined as a person’s self-perceptions of his or her memory and concentration skills in everyday life. The seven statements asked the participants to compare their present memory with that of the past three years. Three questions were designed to estimate functional changes and four questions assessed cognitive changes occurring within the past three years (Klusmann et al., 2011). The participants rated all items based on their ability to rate five levels of change, ranging from 1 (a bit improved) to 5 (much worse).
Part III Road Traffic Injury Experiences
The participants were asked to respond to a question on traffic injuries sustained in the 12 months before collecting data. The participants responded on the experienced as “no” (0) and “yes” (1).
Part IV Socio-Demographic Information and Health Behavior
The participant’s age, education level, self-reported height and weight, years driving a taxi, and medical history were recorded. In addition, alcohol consumption was assessed during the prior three months.
Data Analysis
Differences between respondent characteristics and level of FTD (at risk, routine, accomplished driver) were examined using chi-square tests. Hierarchical regression models were applied to determine the effects of FTD and metacognition to self-reported road traffic injury. The first model (Model I) contains six demographic variables, whereas the second model (Model II) was added three dimensions of FTD. The third model (Model III) demographic, FTD, and metacognition were considered in the analysis simultaneously.
Ethics Approval
Ethics approval for the study was granted by an ethics review board of a university (COA: 2021/028.903). Participants were provided oral and written information about autonomy, compensation, and withdrawal before enrollment. The consents were obtained to ensure voluntary participation before completing the survey form. All procedures performed in the studies involving human participants agreed with ethical standards.
Results
Sample Profile
Characteristics of the Respondents by Fitness-To-Drive (n = 299).
*Diabetes, Hypertension, Cardiovascular diseases, etc.
Differences of the Risk Perception, Technical Driving Skill, and Safety Consciousness
The mean score of risk perception, technical driving skill, and safety consciousness among those with poor and good metacognition are presented. The statistical analysis indicated that a group with poor metacognition reported a higher risk perception (p value <.05) (Figure 1), while no differences were found regarding technical driving skill and safety consciousness among those with poor and good metacognition (Figures 2-3). Risk perception by metacognition. Technical driving skill score by metacognition. Safety consciousness by metacognition.
Effects on Risky Driving Behaviors
A hierarchical linear regression with three steps were performed; demographic characteristics were included in block 1 of the hierarchical model, FTD variables were added in block 2 and cognitive function was added in block 3 to predict road traffic injury. Six variables of the characteristics were entered in the first step, and were able to explain 2% of the variance of road traffic injury (F (6,292) = 1.17, p > .05).
Hierarchical Linear Regression Results of Road Traffic Injury.
Note. The first line in each cell is the raw regression coefficient, and the second line is the standard error value.
*p value <.05.
Discussion
The present study examined the role of FTD and metacognition toward road traffic injury among older taxi drivers to highlight the important of safety concerns among public professional drivers. The findings showed taxi drivers aged 60 years and older to possess good technical driving skills with few medical conditions. An eight-year study in Seoul indicated that age was the most prominent factor for the injury and taxi drivers were considered at-fault (Noh et al., 2020). In addition, diabetes and hypertension were the common medical conditions with vision disorder significantly related to age in this group. Similar results were reported in driving fitness of older Singaporean taxi drivers revealing that the drivers passed their medical fitness screening and exhibited generally competent driving skills with 31% of medical conditions (Chan et al., 2019).
This study identified approximately one-third (31.1%) of older taxi driver experienced traffic injury in the last 12 months. Aging was associated with increasing cognitive motor and sensory impairments. Related studies discovered cognitive impairment may affect driving skills (Hotta et al., 2018; Ichikawa et al., 2020; Kosuge et al., 2017; Noh et al., 2020). A prospective study of Japanese older drivers demonstrated that older drivers with high mileage were likely to be involved in a crash (Kosuge et al., 2017). To reduce the incident of traffic injuries among older drivers, preventive measures were recommended, for example, licensing policies for older drivers, screening of cognitive, emotional, neuropsychiatric symptoms, and FTD can be determined before licensing (Ichikawa et al., 2020; Jamson & Filtness, 2018). Those preventive measures could be considered especially among older taxi drivers performing their daily duty.
The result confirms driving under the influence of alcohol as a key risk factor of road traffic injuries. A study highlighted the role cognition and personality in different group of drinker drivers which investigated different psychological cognitive skills and personality among male drinker drivers matched to nondrinkers controls was conducted. This study clearly indicated that those drinker drivers showed lower reaction speed and mental rotation ability posing a high risk of traffic injury (Tinella et al., 2021). Similarly, a study conducted in Thailand revealed that current drinking and binge drinking were associated with harm from road traffic injuries due to others’ drink-driving behavior, and a person’s drink-driving behavior increased their risk for road traffic injuries due to others’ drink-driving behaviors (Nasueb et al., 2022).
In addition, this study reported that reducing alcohol consumption could prevent self-harm and harm to other people sharing the road. Alcohol affects the ability to safely manage a vehicle, to stay in the correct lane and to maintain a constant speed, also impairing the driver’s concentration and all aspects of driving safety as, for example, the tendency towards risks. Notably, even though Thailand implemented a national drink-driving law, the country still needs to commit more effort to address drinking and driving. More importantly, an integrative approach to intervention involves combined publicity and high visibility police enforcement and fitting alcolocks in commercial and public transport vehicles (World Health Organization, 2018) could be considered at the national level. A study by Tinella et al. discovered integrating different driving-related psychological dimensions in evaluating FTD showed the usefulness of standardized tools to re-assess drinker drivers. Therefore, with this evidence, the measurement of FTD could be considered a key element of the driving performance including evaluation of FTD among drinker drivers (Tinella et al., 2021). Taxi drivers are an important group in relation to drink-driving due to the greater size and mass of many commercial vehicles, notably those operated by public transport companies. As recommended by the World Health Organization, strong enforcement supported by public awareness of complaints would make potential offenders feel more likely they will be caught, leading to a swift fall in the number of offenders (World Health Organization, 2018). On a regular basis, random breath testing and police sobriety checkpoints could be part of the enforcement mechanisms that have been shown to lead to significantly reduced alcohol-related accidents.
Perception of risk as part of FTD has been identified as one key predictor of traffic injury. Risk perception in this study, for example, altering driving in response to changes in health or road conditions, driving in difficult situations (at night, high density fog unfamiliar area, etc.) were reported as traffic injury risk. Several studies confirmed the positive effect of bad weather on accidents, for instance, vehicle–pedestrian accidents (Clifton et al., 2009) and for accidents resulting in injury or fatalities (Fridstrøm & Ingebrigtsen, 1991). Notably, having lengthy experience among the participants in this study could help drivers to be able to perceive several conditions of high risk and difficulty driving. One study of a logit model identifying age and road conditions revealed that drivers often inadequately compensate for such difficult conditions, perhaps because these conditions are not always recognizable, because compensation is not feasible or because of a lack of experience with these conditions (Lee et al., 2023). With the characteristics of the job in this study, it could be inferred that greater exposure to transportation was also associated with an increased likelihood of any type of injury (Luo et al., 2023). The effects of these variables should be explored further to create a more precise and case-specific promotion in traffic environment. This difference has not been explored in depth in related works and might make a difference in designing more precise preventive strategies.
The present study discovered about one-third (73.9%) of older taxi drivers have been classified as overweight and obese while over 40% reported they had at least one medical condition requiring regular treatment. A study of a national database in Singapore on the medical and driving fitness of older taxi drivers revealed that the common medical conditions reported were hypertension, diabetes, and vision and hearing impairments which were significantly associated with age (Chan et al., 2019).
Practical implications to address road safety are critical issues in Thailand. The behavioral and safety awareness control program for older taxi drivers having more driving experiences should be implemented to increase safety outcomes. The strategy could focus on the interventions of behavioral change issues such as road traffic legislation, increasing the number of stop points for blood checking alcohol concentration and enhancing safety perception as well as social norms. In addition, maintaining effective prevention strategies and modifying lifestyle interventions for those presenting chronic conditions and sensory impairments are recommended among older drivers. Moreover, a mandatory retirement age policy by licensing authorities for older taxi drivers could be reviewed to be replaced by a functional-based retirement policy instead.
Future research efforts should offer a deeper understanding of cognitive functions and driving habits including safety concern across varied public drivers across all ages. The current study encountered limitations that may restrict generalizability of the results. For example, our sample of male drivers may have limited the ability to generalize the study findings to other population groups. In addition, the use of self-reported FTD measurement may have been susceptible to reporting or recall bias.
Conclusion
The present study provided evidence to reduce alcohol consumption and support safety awareness among the older taxi drivers. The comprehensive monitoring and evaluation of all dimensions influencing FTD and assessing relevant psychometric measures could be considered one part of the issues for renewing the driving license for commercial drivers especially those at an older age.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Mitsui Sumitomo Insurance Welfare Foundation Research Grant 2021.
Ethics Approval
All methods were performed in accordance with the ethical standards as stated in the Declaration of Helsinki and its later amendments or comparable ethical standards. Ethics approval for the study was granted by the Committee for Research Ethics (Social Sciences), Mahidol University (COA: 2021/028.903).
