key: cord-0867032-gqal42pr authors: Beckman, Kerry L.; Monsey, Lily M.; Archer, Megan M.; Errett, Nicole A.; Bostrom, Ann; Baker, Marissa G. title: Health and safety risk perceptions and needs of app‐based drivers during COVID‐19 date: 2021-09-14 journal: Am J Ind Med DOI: 10.1002/ajim.23295 sha: 52e9a9ada26cb635a584bf51ba45a4ee4778070e doc_id: 867032 cord_uid: gqal42pr BACKGROUND: App‐based drivers face work disruptions and infection risk during a pandemic due to the nature of their work, interactions with the public, and lack of workplace protections. Limited occupational health research has focused on their experiences. METHODS: We surveyed 100 app‐based drivers in Seattle, WA to assess risk perceptions, supports, and controls received from the company that employs them, sources of trust, stress, job satisfaction, COVID‐19 infection status, and how the pandemic had changed their work hours. Data were summarized descriptively and with simple regression models. We complemented this with qualitative interviews to better understand controls and policies enacted during COVID‐19, and barriers and facilitators to their implementation. RESULTS: Drivers expressed very high levels of concern for exposure and infection (86%–97% were “very concerned” for all scenarios). Only 31% of drivers reported receiving an appropriate mask from the company for which they drive. Stress (assessed via PSS‐4) was significantly higher in drivers who reported having had COVID‐19, and also significantly higher in respondents with lower reported job satisfaction. Informants frequently identified supports such as unemployment benefits and peer outreach among the driver community as ways to ensure that drivers could access available benefits during COVID‐19. CONCLUSIONS: App‐based drivers received few protections from the company that employed them, and had high fear of exposure and infection at work. There is increased need for health‐supportive policies and protections for app‐based drivers. The most effective occupational and public health regulations would cover employees who may not have a traditional employer–employee relationship. how many app-based drivers are active drivers in the United States and how this might have changed during the pandemic. Estimates from the two primary companies (Uber and Lyft) put the total number between 1 and 2 million at the end of 2020. 8 In Seattle, Washington, app-based drivers are represented by a worker organization affiliated with Teamsters Local 117. As such, these drivers have had access to additional resources through this union to help them navigate the pandemic, and the union has helped to secure additional protections for app-based drivers operating in Seattle, including minimum pay mandates (ensuring they earn the city's minimum wage of $16.69/h), pay for time spent between rides, access to an independent Driver Resolution Center, and other worker-protective actions such as hazard pay for food delivery drivers. 9, 10 During the COVID-19 pandemic, both Uber and Lyft enacted paid sick leave for drivers infected with COVID-19 but the amount drivers received and the ease drivers had in accessing it varied between drivers, and was influenced on hours driven, documentation, and municipal-specific regulations. 11 Companies also had other COVID-19 specific protections such as providing training or information on mitigating COVID-19 hazards, and getting personal protective equipment (PPE) to drivers (either for free or at cost). Before the pandemic, the independent contractor classification of drivers meant drivers would not be eligible for paid sick or vacation leave, employer-subsidized health care, or a guaranteed minimum hourly wage from the company they drive for, unless municipal-specific regulations had been established, as in Seattle. In result, the experiences of union-affiliated drivers in the greater Seattle area may represent a best-case scenario relative to drivers in many other parts of the country, where they lack union supports and municipal-specific protective policies. Here, we utilized a mixed-methods study design to descriptively characterize the experience of Seattle app-based drivers during the COVID-19 pandemic, and to explore existing and potential opportunities to reduce SARS-CoV-2 exposure. We characterized the primary outcomes of perceived stress, job satisfaction, and self-reported COVID-19 status in 100 app-based drivers affiliated with Teamsters Local 117 (Seattle, WA) using a telephone survey. Additional questions explored what their exposure and health risk perceptions were, health protective behaviors they had taken while driving, supports they had received from the company they work for, who they trusted to make decisions and recommendations. This survey was complemented with semistructured interviews with Teamster 117 leadership and drivers to better understand what types of controls were implemented and needed by drivers to protect them and their communities from exposure to SARS-CoV-2, which was hypothesized to have a positive impact on stress and feelings of job satisfaction. This study is important for understanding the experiences faced by an underserved yet essential occupational population, particularly as jurisdictions look to pass policies and regulations that either increase or decrease job-related protections for app-based drivers, such as California's Proposition 22, which by state vote classified app-based drivers as independent contractors (rather than employees of ride share companies), absolving rideshare companies of providing any state mandated benefits. 12 Moreover, this study further explores the experiences of workers during this public health emergency, which has brought to light many ways in which worker health and public health are integrated 2 | METHODS Researchers collaborated with Teamsters Local 117 who represent thousands of app-based drivers in Seattle, WA, on this mixedmethods study featuring a cross-sectional survey and qualitative interviews. The mixed-methods design allowed us to assess our primary outcomes using a cross-sectional survey, and collecting more in-depth information about how to improve outcomes for this population utilizing the qualitative interviews. The University of Washington Human Subjects Division determined this project to be exempt from review as no identifying information was being collected by researchers. Working with union and driver representatives, we developed a survey that adapted questions from previously validated scales and included new questions developed specifically for this population and the COVID-19 pandemic. The wording of many questions was adapted to increase clarity for app-based drivers, and at the advice of our community partners, responses for most measures were simplified from a five-or six-point Likert scale (e.g., scored 1, 2, 3, 4, 5) to a three-point Likert scale (e.g., scored 1, 3, 5) to streamline data collection and increase comprehension during the telephone-based survey. The survey was pilot-tested with four app-based drivers and two union representatives, and the survey was revised based on their feedback. The full survey took about 10 min to administer over the phone. Four community liaisons (active app-based drivers who liaise between the union and other drivers) administered the survey over the phone to a total of 100 active app-based drivers identified by the union utilizing a convenience sampling approach. Before administering the survey, the community liaisons met with the research team to talk through all questions on the survey and receive training on how to consistently administer the survey. The survey was administered between August 11, 2020 and September 7, 2020. Three primary outcomes were collected from the survey: perceived stress, job satisfaction, and self-reported COVID-19 infection status. Perceived stress was measured using the four-point perceived stress scale (PSS-4) 13 but instead using the 5-point response scale of Never, Almost Never, Sometimes, Fairly Often, Very Often, we used a 3-point response scale of Rarely, Sometimes, and Often. After scoring each measure based on established PSS-4 scoring guidance, the four scores were summed, with higher scores indicating more stress. In a review of six studies utilizing a PSS-4, Cronbach's ɑ ranged from .60 to .82. We calculated ɑ = .65 in our sample indicating a lower test reliability. 14 The five job satisfaction questions on our survey were inspired by the 36 question Spector Job Satisfaction Scale (JSS). 15 Respondents were asked whether or not they agree with a statement about their job using a three-point agreement scale (Agree, Neither Agree or Disagree, and Disagree). The five scores were averaged to create a composite job satisfaction score, with higher scores indicating more job satisfaction across the metrics. Recognizing the reduced access to COVID-19 testing early in the pandemic and among our community of interest, to assess COVID-19 infection we asked respondents if at any time since March 1, 2020 they thought they had COVID-19 which we used as our primary measure for COVID-19 infection. The survey also included two scales assessing psychometric judgments of how concerned drivers were about five scenarios related to COVID-19 exposures in their vehicles and six scenarios related to infection with COVID-19, including physical health and economic health outcomes. For both sets of questions, respondents answered as "very concerned," "somewhat concerned," or "not at all concerned." Both scales were averaged separately to create two composite scores related to exposure and health outcomes, with higher scores indicating greater concern about exposure to COVID-19 when driving their vehicle, or the effects related to infection with COVID-19. A third set of questions asked drivers to either agree or disagree with six statements, to assess which individuals and entities they trust to provide accurate and truthful information during the COVID-19 pandemic to keep them safe at work. Drivers also indicated how frequently they undertook six healthprotective behaviors that at the time of the survey were believed to reduce exposure to SARS-CoV-2 while driving their vehicle, and indicated which exposure controls the company they work for provided them during the pandemic. The full survey instrument can be found in Supporting Information Material 1. Demographic measures (age, race, ethnicity, and gender) were also collected, along with measures asking about their current work (driving passengers or for delivery, both, or none), current hours worked, hours worked before the pandemic, and the number of years they have worked as a driver. Raw survey data were downloaded from REDCap. We first conducted descriptive analyses on the 100 respondents who completed the survey. Linear regression analyses were used to assess associations between our primary outcomes of job satisfaction, self-reported COVID-19 status, and stress controlling for age, current hours driving, change in hours driving, and years working as a driver. These covariates were selected based on a review of the literature that indicated these items were associated with stress or job satisfaction in other occupational studies. [16] [17] [18] [19] [20] Plots of means and confidence intervals were used to illustrate notable bivariate results. All analysis was conducted in Stata 16, plots were generated using R Studio 1.2.5. We conducted six semistructured interviews with eight Teamster 117 organizers and community liaisons who fit our a priori defined inclusion criteria 1 : Knowledge of relationships between app-based drivers and the companies that employ them 2 ; Knowledge of driver safety measures implemented before and during COVID-19 3 ; Insight into app-based driver concerns and risk-related behaviors. Our first informants were recruited from our union contacts, and subsequent informants were recruited using a snowball sampling approach, with new informants identified by prior informants. Informants were asked to identify administrative controls, engineering controls, and PPE used to promote health and safety of app-based drivers, as well as BECKMAN ET AL. | 943 the public they serve, during the COVID-19 pandemic. Additionally, interviews explored barriers and facilitators to implementing these workplace controls. The study team worked with Teamsters 117 organizers to identify prospective interviewees. Interviews were conducted over video conferencing using a Zoom Video Communications product, and with participant consent, recorded and professionally transcribed. The study team employed a combination of deductive and inductive approaches to analysis. First, we developed codes inspired by the National Institute for Occupational Safety and Health's (NIOSH) hierarchy of controls 21 focusing on engineering controls, administrative controls, and PPE, as well as barriers and facilitators to their implementation. Following a data familiarization process where two members of the study team (LM and MA) each read and reread all interview transcripts, subcodes were developed to capture emergent themes within these codes. Codes and their definitions, along with examples of when to apply, were memorialized into a codebook. The same two members of the study team each independently applied the codebook to two interview transcripts using NVivo qualitative data analysis software. They then met to compare code application, adjudicate any discrepancies, and clarify code definitions. Following resultant codebook updates, they each independently coded the remainder of the transcripts, and met to compare code application and adjudicate discrepancies. Coded text was then reread and synthesized to summarize key themes, with supporting rich description and counterpoints, within each of the codes. To assess qualitative confirmability, memos were cross-referenced against the original transcripts to ensure interpretation was supported by the original data. 22 Demographics and background information from the survey respondents are presented in Table 1 . Respondents were predominantly male (97%), identified as Black or African (84%), and were under the age of 55 (87%). A total of 30% of respondents believed they had been infected with COVID-19 at some point before taking the survey. The pandemic brought changes in hours worked, with only two respondents reporting an increase in hours driven during the pandemic, 25 drivers reporting no change in hours, and 73 drivers reporting a decrease in hours driven due to the pandemic, including 42 respondents who reported they were no longer working as a driver due to the pandemic. Findings from the psychometric judgment scales are presented in Table 2 . Overall, drivers expressed very high levels of concern about all five exposure scenarios (89%-90% were "very concerned," for all scenarios) and all six infection scenarios (86%-97% were "very concerned," for all scenarios). Table 2 also presents the COVID-19 protections and controls that drivers reported receiving from the company that employs them, and their sources of knowledge and trust. Only 31% of drivers reported receiving any mask (cloth, surgical, or more protective) from the company that employs them, and a similar percentage reported receiving hand sanitizer from their company. Those who had received a mask or hand sanitizer indicated that the amount supplied was insufficient. Despite this, most drivers responded that they always wore masks and sanitized their hands when working. The majority of respondents reported receiving health-related information (82%) or exposure-related information Figure 1 ). We conducted a total of six interviews with eight key informants, Informants discussed the added financial burden of procuring adequate PPE and an overall lack of income due to reduced ridership in the pandemic, which were compounded by challenges in accessing unemployment. An informant noted difficulties obtaining partitions for vehicles due to high costs and lack of compensation. As one informant shared, "And then every person in your vehicle, you have to sanitize your vehicle. And then we buy all those equipment. So that's the thing and my issue personally… But for now, I just continue buying from my own pocket." Informants also emphasized the difficulty full time drivers face in making ends meet, paying bills, and supporting family at home. One informant described how drivers already exist on a financial "knife's edge" and how the uncertainty and depleted ridership in the pandemic have created an even more untenable financial situation for drivers. Informants discussed insufficiencies of, or skepticism around, government, employer, and union support. For instance, informants discussed a lack of information being provided by apps and the government about financial support, training, and access to PPE. Two informants talked extensively about inadequacies in the unemployment process, with one noting that drivers had to wait up to 6 months to receive unemployment benefits at the level they applied for. Additionally, two informants discussed skepticism around union support, with one informant mentioning that union distrust was influenced by company scare tactics. Informants also discussed particular challenges in accessing data Control type COVID-19 controls implemented • Union support to drivers to access unemployment benefits and other government resources, including the development of a stepby-step guide for drivers to provide one-on-one technical assistance in different languages.°U se of driver outreach field workers to provide one-on-one technical assistance in different languages, and phone-based outreach to provide public health guidance regarding the pandemic.°S haring information through online meetings and while distributing cleaning supplies. • Union-led policy advocacy or organizing in support of worker protections like sick leave, higher wages, and protection from unfair deactivation • Information and resources shared through driver leaders, with cascading effects through the driver network Engineering • Installation of dash cams in vehicles to protect drivers against potential deactivation from false claims by passengers • Mask enforcement programs implemented by apps to make it easier for passengers and drivers to prove they are wearing masks, involving passengers taking "selfies" wearing a mask before getting into the vehicle and confirming that drivers are wearing masks PPE • Driver purchasing of PPE and cleaning supplies, including face masks, gloves, and sanitizing products, out of pocket Findings indicate that this is a worker population with high levels of concerns around exposure to COVID-19, and the health and economic effects associated with the virus. As they indicated in interviews, workers experienced untenable financial situations early in the pandemic due to decreases in ridership, out-of-pocket PPE and sanitation costs, and difficulties accessing unemployment. These concerns may have been exacerbated by the lack of protective controls provided by the company that employed them, changes in hours or the ability to work during the pandemic, and self-reported pay, which did not keep up with the cost of living. The lack of power these drivers had at work due to their low pay, minority status, and lack of a traditional employee-employer relationship (a relationship that may carry benefits and be subject to state and federal occupational safety and health regulations) may also have increased feelings of concern and fear around COVID-19, and influenced the distrust drivers tended to express in the company they drove for. Despite the above, drivers tended to take pride in their work, like their job, and recognize the importance of their work in society. Thirty-percent of respondents reported they thought they had COVID-19 at some point, though we were not able to confirm infection or assess whether or not the probable COVID-19 cases originated in their vehicle. This is similar to the percent of app-based drivers in New York City that reported that they or a family member had been infected with COVID-19 (38%). 23 It is important to understand the burden of COVID-19 infection in app-based drivers because as a working population without a traditional employer-employee relationship, this could mean that these drivers had decreased access to paid sick leave, medical benefits, and the worker's compensation system, as compared to those with traditional employer-employee relationships. The lack of these safety nets and benefits may have increased the likelihood that a driver, if they were driving at all, may have practiced "presenteeism" by going to work even when they were ill, as staying home could have come at economic cost. As app-based drivers share air with members of the public in indoor close quarters, often for sustained periods of time, the health of app-based drivers is linked to the health of the community, and reducing the burden of infectious disease in these essential workers would help to decrease community transmission, and therefore should be an important priority for public health. 26 However, our qualitative findings indicate that few controls were implemented by the company's drivers work for, underscoring the relative lower priority of driver health and safety among employers. Understanding which exposure controls were available to drivers, and the barriers and facilitators to enacting more protective controls is very important to decreasing SARS-CoV-2 in this population, leading to a decreased risk of COVID-19 infection while driving, which can positively influence feelings of perceived stress and job satisfaction, as supported by our regression analyses. These qualitative findings help enable us to act on the findings from the survey, and prioritize potential interventions. Based on our modified perceived stress scale, drivers indicated they were experiencing stress, with more than half of respondents (58%) indicating they felt unable to control the important things in life "often," and 42% of respondents reporting that they "often" felt difficulties were piling up so high that they could not overcome them. The COVID-19 pandemic has exacerbated many stressors, including worry about one's own health and the health of family members, social isolation, financial insecurity, and resource scarcity, all which were found to be independently related to psychological distress and depressive symptoms in a survey of North Americans during the pandemic, and were increased in those with a lower income and experiencing additional stresses related to the sociocultural and socioeconomic implications of the pandemic. 27 Even outside of a pandemic, stress and work have a complex relationship, with work factors such as pay, job demands, and job control contributing to stress, 17, 18, 28, 29 but stress also influencing aspects such as job satisfaction. [19] [20] [21] [30] [31] [32] We saw a significant association between job satisfaction and PSS-4, as well as COVID-19 infection status and PSS-4. However, the cross-sectional design of our study impedes determination of the directionality of these associations. Regardless, workplaces taking steps to decrease employee stress, improve employee job satisfaction, and protect workers from infectious disease would decrease the burden of chronic disease outcomes and mental health outcomes in their employees, and decrease associated healthcare costs. 22, 23, 33, 34 As this is the first work to characterize stress in app-based drivers, were female, younger, lower income, non-White, and with lower educational attainment. 37 Updated PSS-4 norms in the UK pre-COVID reported a mean PSS-4 score of 5.56 ± 3.04 in males. 38 In many of our measures there was a lack of variability, making it difficult to do more involved statistical analysis of these data. This could be due to the relatively homogenous nature of the survey respondents, and to three-point response scales used in this study, which inherently reduced variability compared to five-to seven-point response scales. However, the lack of variability may also be a true Our qualitative analyses are limited by a small sample size, resulting from a small sampling frame and occupational-based inclusion criteria focused on a population without workplace access to or need for offices or computers. While the themes summarized herein offer context-rich information, additional research is necessary to ensure credibility and promote transferability. Also due to the fact that most interviewees did not work in an office or on a computer, providing written summaries of interview interpretation for participant validation (i.e., member checking) was determined not to be feasible. However, two union organizers, who also participated in interviews, reviewed final analysis memos to ensure they were grounded in practical realities. Moreover, the study team crosschecked analysis memos against qualitative data to ensure confirmability of findings. Despite these limitations, the novelty and importance of this study for public health must be emphasized. This is one of few studies that has characterized the health, safety and risk perceptions of app-based drivers-a vulnerable worker population consisting of a high population of immigrant and refugee workers. This study was done in partnership with drivers and we sought input from them at all steps of study design and survey delivery to ensure it was appropriate, applicable, and accessible. The mixed methods design we utilized added depth to the quantitative data to better understand the concerns of these workers, and identify potential areas for intervention to help better support these workers. Future work will seek to characterize changes in drivers' experiences and perceptions over time, particularly as COVID-19 restrictions wane and pandemicspecific safety nets are relaxed. The COVID-19 pandemic has highlighted how the health of workers and the community are interconnected, and the need for increased health-protective policies and controls for workers during the pandemic and beyond. Work presented here amplifies the voices and needs of workers who have been heavily impacted by the COVID-19 pandemic, yet lack access to many of the workplace protections that employees in a standard employment relationship have, 24, 40 underscoring the urgent need for increased attention to app-based drivers, and the growing app-based economy, in public health research and policy. Nonrelocatable occupations at increased risk during pandemics: United States The rise of the "just-in time workforce": on demand work, crowdwork, and labor protection in the "gig economy Unemployment Insurance and Economic Impact Payments Associated with Reduced Hardship Following CARES Act. Urban Institute The CARES Act and Its Impact on Independent Contractors and Gig Workers. Accessed Airborne transmission of SARS-CoV-2 Ten scientific reasons in support of airborne transmission of SARS-CoV-2 On Demand and on the Edge: Ride Hailing And Delivery Workers In San Francisco How Many Uber Drivers Are There? Council Connection: Council Passes Premium Pay for Frontline Gig Workers During COVID Crisis Lyft pulls bait-and-switch on promised coronavirus sick pay, drivers say A global measure of perceived stress Review of the psychometric evidence of the perceived stress scale Measurement of human service staff satisfaction: development of the Job Satisfaction Survey The effects of hours of work on health: A meta-analytic review Can work make you sick? A meta-analysis of the relationships between job stressors and physical symptoms Changes at work and employee reactions: organizational elements, job insecurity, and short-term stress as predictors for employee health and safety Factors that influence nurses' job satisfaction Chronic job insecurity among automobile workers: effects on job satisfaction and health Series: practical guidance to qualitative research. Part 4: trustworthiness and publishing The gig is up: an overview of New York City's app-based gig workforce during COVID-19 COVID-19 cases by industry Occupational health surveillance as a tool for COVID-19 prevention Social encounter networks: characterizing Great Britain Psychological distress in North America during COVID-19: the role of pandemic-related stressors Job demands, job decision latitude, and mental strain: implications for job redesign Work organization, job insecurity, and occupational health disparities The impact of job stress and job satisfaction on workforce productivity in an iranian petrochemical industry Job satisfaction and mental health of temporary agency workers in Europe: a systematic review and research agenda Directive and nondirective social support in the workplace-is this social support distinction important for subjective health complaints, job satisfaction, and perception of job demands and job control? The cost of work-related stress to society: a systematic review Mental health in the workplace: a call to action proceedings from the mental health in the workplace-public health summit Factors associated with longitudinal psychological and physiological stress in health care workers during the COVID-19 pandemic: observational study using apple watch data Psychometric data on knowledge and fear of coronavirus disease 2019 and perceived stress among workers of filipino origin in Hong Kong Perceived stress in a probability sample of the United States New normative, English-sample data for the Short Form Perceived Stress Scale Uber User Experience Survey Results Evaluating employment quality as a determinant of health in a changing labor market Health and safety risk perceptions and needs of app-based drivers during COVID-19 The authors are grateful for the support of Teamsters Local 117 and the app-based drivers who made this study possible. Funding for this study was from the University of Washington Population Health Initiative, Economic Recovery Grant. John Meyer declares that he has no conflict of interest in the review and publication decision regarding this article. The data that support the findings of this study are available from the corresponding author upon reasonable request. The University of Washington Human Subjects Division reviewed the protocol for this study and determined this project to be exempt as no identifying information was being collected by researchers.