# The Effect of Educational Intervention on Safe and High-Risk Driving Behaviors in Taxi Drivers

AUTHORS

Asghar Razmara 1 , Teamur Aghamolaei 2 , * , Zahra Hosseini 1 , Abdolhossein Madani 1 , Shahram Zare 3

1 Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

2 Cardiovascular Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

3 Department of Social Medicine, Medical School, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

How to Cite: Razmara A , Aghamolaei T , Hosseini Z, Madani A , Zare S . The Effect of Educational Intervention on Safe and High-Risk Driving Behaviors in Taxi Drivers, Hormozgan Med J. Online ahead of Print ; 24(2):e99984. doi: 10.5812/hmj.99984.

ARTICLE INFORMATION

Hormozgan Medical Journal: 24 (2); e99984
Published Online: June 8, 2020
Article Type: Research Article
Revised: March 9, 2020
Accepted: March 16, 2020
Crossmark
CHECKING

### Abstract

Background: High-risk driving behaviors is one of the leading causes of death and disability.

Objectives: The aim of this study was to determine the effect of educational intervention on promoting safe-driving behaviors and reducing high risk-driving behaviors in taxi drivers based on the health belief model and planned behavior theory.

Methods: A quasi-experimental study of interventional and control drivers (n = 40) selected by a cluster sampling method was conducted. The participants were selected from taxi stations. The intervention group was divided into 4 groups, including 10 people. The contents of the training program were based on driving laws, avoiding high-risk behaviors, and advising on safe driving behaviors. The driving behaviors were measured at baseline and 3-month post-intervention. Constructs of the health belief model and theory of planned behavior were used as an interventional program framework. Independent t-test and Paired t-test were used to compare the scores between intervention and control drivers and the intervention group before and after the intervention at each of the variables, respectively.

Results: Three months post-intervention, the scores of safe driving behaviors in the intervention group were higher than the control group, and high-risk driving behaviors in the intervention group were less than the control group. After the intervention, a significant difference was observed in the mean scores of perceived barriers, self-efficacy, cues to action, attitude, subjective norms, and perceived behavioral control between two groups (P < 0.05).

Conclusions: Educational intervention within the framework of the combined constructs of the health belief model and theory of planned behavior can reduce high-risk driving behaviors and promote safe driving behaviors in taxi drivers.

Keywords

Copyright © 2020, Hormozgan Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

### 1. Background

Road traffic accidents (RTAs) are one of the most important health problems that endangers human health. The injuries caused by these accidents are so extensive that they are called road wars (1). Continuous and effective prevention of RTAs requires coordinated and comprehensive efforts (2). Statistics show that a death occurs every 5 seconds due to the road traffic accident (3). By 2020, the number of deaths and injuries caused by RATs is expected to increase by 80% in low/moderate income countries (4). According to the World Health Organization (WHO), 34.1 death-resulting RTAs occur per every 100,000 population, and Iran has the fifth and the first highest RTA-related mortality rate in the world and the Eastern Mediterranean countries, respectively (5). According to the WHO, the issue of RTA is largely behavioral and can be prevented by modifying individual and social behaviors. It is a fact that high-risk driving behavior is one of the important and effective factors in RTAs, and the human factor has been reported as the most common cause of RTA. This factor includes driving behaviors and inadequate driving skills (6). Taxi drivers, as a large group of professional drivers who spend most of their time driving on the road, play an important role in RTAs with their high-risk driving behaviors (7). Considering the growing trend of RTA in Iran, such as: high speed, not wearing seat belts, not driving between lanes, passing red lights, the need to reflect on this problem is important through an educational intervention based on an appropriate model. In this line, several studies have succeeded in improving the high-risk driving behaviors by using theory-based educational programs (8). Since the safe and high-risk driving behaviors are influenced by individual, social, and environmental factors, the constructs of health belief model and theory of planned behavior were used to increase and promote safe driving behaviors, in this study. Many studies have been using these constructs to successfully train healthy behaviors (9, 10). According to the health belief model, individuals react to health and risk preventing messages when they think they are at a serious risk. Changing high-risk behavior is beneficial for them, and they can overcome barriers. Intervention is effective in such conditions, and self-efficacy, which means one's belief in his ability to stop high-risk behavior, can lead to the adoption of health-promoting behaviors and reduction of high-risk behaviors (9). The theory of planned behavior focuses on social factors and the motivation to follow high profile individuals, so several studies have considered it as an important factor in accepting desired behaviors (11, 12).

### 2. Objectives

Therefore, due to the importance of high-risk driving behaviors for taxi drivers, and since no intervention has ever been implemented among taxi drivers of Bandar Abbas based on behavioral models or theories to essentially focus on the impact of individual factors, attitudes and social norms on the behavior, this study was carried out to determine the effect of educational program based on constructs of theory of planned behavior and health belief model on high-risk driving behaviors of taxi drivers in Bandar Abbas.

### 3. Methods

#### 3.1. Study Population and Sample Size

This study was conducted using a controlled interventional method. The study population comprised of all taxi drivers working in the city of Bandar Abbas in 2017. Inclusion criteria include: working as a taxi driver for at least one year, having the ability to read and write in Persian, being a resident of Bandar Abbas, and willing to participate in the study. Individuals who did not participate in more than one training session were excluded. The sample size, according to the below formula in each group was estimated to be 35 subjects:

$n=Z1-α2+Z1-β2(s12+s22)(μ1-μ2)2$

However, taking into account the sample drops and to facilitate a normal distribution of samples, 40 individuals were allocated in the intervention group and 40 in the control group. The samples were selected from the taxi stations where they were working in. 24 stations were first identified in different parts of the city, and four stations were selected from them (two stations for the intervention group and two stations for the control group). Sampling was done at each station randomly from the list of taxis employed at that station. The stations were selected in such a way that samples in the control group and intervention group could not contact each other during the implementation of the training program and after the end of the intervention until the data collection was completed in the second phase. The researcher attended the designated stations in the morning and afternoon shifts and conducted the sampling. At each station, the first driver to arrive in the station was asked to enter the study if he had the conditions to enter the study and was willing to participate in the study. Then, the next drivers were selected in the interval of five (first driver to enter the station, six drivers, eleventh driver, etc.). This method continued until the number of samples per station was completed.

#### 3.2. Data Collection Tool

The data collection tool was a researcher-made questionnaire that contained demographic questions about age, education level, driving history, history of working as a taxi driver, the record of fines due to driving violations, as well as the constructs of theory of planned behavior and safe and high-risk driving behaviors. To design the questionnaire, the constructs of the health belief model and the driving behavior-measuring questionnaires from previous studies as well as a pilot study were used. In the pilot study, 12 drivers were invited to participate in a focused group discussion. Their attitudes on the safe driving behaviors, the possibility of an accident while driving, RTA consequences, obstacles to safe driving behaviors, cue to action, self-efficacy in performing safe driving behaviors, benefits and barriers to safe driving behaviors, subjective norms related to the safe driving behaviors, perceived behavioral control regarding safe driving behaviors, and the intention to undertake safe driving behaviors were evaluated, and the questions were developed. Questions related to the constructs of planned behavior theory and the structures of health belief model were designed based on the five-option Likert scale including; I completely agree, I agree, no comment, I disagree, and I completely disagree, which scored from 1 (completely disagree) to 5 (completely agree). The minimum and maximum scores of the health belief model questionnaire: perceived susceptibility, perceived severity, perceived barriers and cues to action were (5 - 25), perceived benefits (6 - 30), and self-efficacy (4 - 20). The minimum and maximum score of the theory of planned behavior questionnaire: attitude (8 - 40), subjective norms (6 - 30), perceived behavioral control (5 - 25), intention (3 - 15). The minimum and maximum scores of the driving behaviors questionnaire was (0 - 96). To avoid the halo effect, some questions were designed in reverse and behavior-measuring questions (a questionnaire consisting of 32 questions) were designed based on the four-option Likert scale, including, always, most often, sometimes and never.

#### 3.3. Reliability and Validity

To determine the content validity, the questionnaire was given to 10 health promotion and health education trainers and experts of safe behaviors and traffic, as well as their comments and points were applied (13). To determine the face validity, the questionnaire was given to 15 drivers who were similar to the target population, and they were asked to comment on the clarity, simplicity and relevance of the questions with the study objectives. No item was removed from the original questionnaire, and only a few items were corrected. The reliability of the questionnaire was calculated by Cronbach's alpha coefficient, which was higher than 0.7 in all constructs. Cronbach's alpha for each construct is as follows: perceived susceptibility (0.81), Perceived severity (0.79), Perceived Barriers (0.78), cues to action (0.79), Perceived benefits (0.82), self-efficacy (0.89), Attitude (0.84), Subjective norms (0.9), Perceived behavioral control (0.84), intention (0.87) and driving behaviors (0.76).

#### 3.4. Implementation of Educational Intervention

At first, a pilot study was carried out in the intervention and control groups. Next, the intervention group was divided into 4 groups containing 10 samples. After that, 4 educational sessions were held for each group separately over a month. Each training session lasted for at least one hour. The trainings were delivered in the form of a lecture and a question and answer. At the end, three pamphlets containing the training program were given to the drivers. The contents of the training program were based on driving laws, avoiding high-risk behaviors, and advising on safe driving behaviors. Two months after the intervention, a post-test was carried out in both intervention and control groups. Since, there was a possibility that, the intervention group might have forgotten some educational materials during these two months, they were contacted monthly and reminded of the contents. The training sessions were flexible to best fit the taxi drivers’ education level, learning strength, and availability.

#### 3.5. Data Analysis

Data were analyzed by SPSS software version 22. At first, the score of each construct of planned behavior theory and the health belief model was calculated. The higher score indicated the stronger attitude, more subjective norms, higher perceived behavioral control, greater behavioral intention in doing safe driving behaviors, greater perceived sensitivity, greater perceived severity, more perceived benefits, more perceived barriers, higher self-efficacy, and more cue to action. To compare the constructs of planned behavior theory and health belief model in both intervention and control groups before and after the intervention, Independent t-test and Paired t-test were used.

#### 3.6. Ethical Considerations

The study was approved by the Ethics Committee of Hormozgan University of Medical Sciences: HUMS.REC.1396.38. Before the data collection, the aims of the study were explained to the participants, and they participated in the study willingly. All participants were also assured about the confidentiality of their information. They were also told that they are free to withdraw from the study at any time for any reason.

### 4. Results

The average age of the participants in the intervention and control group was 45.5 years and 46.4 years, respectively. The mean driving experience in the intervention group was 18.5 years, and in the control group was 21.6 years, and there was no significant difference between them according to the result of the t-test. In terms of education level in the intervention and control groups, most participants were at the diploma level. Moreover, 58.3% of the samples in the intervention group and 41.7% in the control group had the history of driving fine, which according to the result of the chi-square test, there was no significant difference between them. Other background information related to the participants is shown in Table 1. The status and variations of the mean scores of constructs of the health belief model and planned behavior theory and performance (safe and high-risk driving behaviors) before and after the intervention are presented in Table 2. As outlined in the results, there was a significant difference between the mean scores of all constructs in the intervention group before and after the educational intervention. However, in the control group, a significant difference was only observed in the contrast of perceived severity before and after the intervention and this difference was not observed in other constructs. In comparison of the mean scores of constructs between planned behavior theory and health belief model in the control and intervention groups before the intervention, there was not statistically significant differences. However, a significant difference was observed in the mean scores of constructs of perceived barriers, self-efficacy, attitude, subjective norms and perceived behavioral control after the intervention (P < 0.05). In comparison of high-risk driving behaviors and safe driving behaviors before and after the educational intervention in the intervention and control groups showed a significant difference, in a way that, safe driving behaviors in the intervention group were higher than the control group while the high-risk driving behaviors in the intervention group were less than the control group (P < 0.05, Figure 1)

Table 1. Comparison of the Underlying Variables of Participants in Both Intervention and Control Groupsa
Demographic VariablesInterventionControlSignificant Level
Age40 (45.5)41 (46.4)0.74
Driving history40 (18.8)41 (21.6)0.283
Taxi driving history40 (10.07)41 (13.07)0.113
Fining history14 (53)10 (24.4)0.337
Level of education0.221
Illiterate2 (5)0
Primary school7 (17.5)8 (19.5)
Secondary school8 (20)12 (29.3)
High school8 (20)3 (7.3)
Diploma12 (30)17 (41.5)
University3 (7.5)1 (2.4)

aValues are expressed as number (mean).

Table 2. Comparison of the Mean Scores of Constructs of the Health Belief Model and Theory of Planned Behavior in the Intervention and Control Group Before and After the Interventiona
VariablesIntervention GroupControl Groupt-Test
Perceived sensitivity
Before23.9 (1.7)23.5 (3.2)0.59
After24.8 (0.57)24.5 (1.2)0.11
Paired t-test0.0010.09
Perceived severity
Before20.9 (3.2)21.3 (2.5)0.59
After23.1 (4.6)23.8 (2.5)0.46
Paired t-test0.020.001
Perceived benefits
Before27.5 (3.8)28.6 (2.7)0.17
After29.9 (0.47)29.7 (0.7)0.15
Paired t-test0.0010.08
Perceived barriers
Before17.7 (5.5)19.6 (4.7)0.09
After13.4 (4.5)19.4 (6.5)0.001
Paired t-test0.0010.92
Cue to action
Before17.5 (5.3)5.8 (18.8)0.28
After21.3 (5.4)18.7 (5.7)0.04
Paired t-test0.0050.89
Self-efficacy
Before14.9 (2.2)15.3 (2.3)0.53
After17.6 (1.3)15.3 (2.5)0.011
Paired t-test0.0010.9
Attitude
Before27.2 (4.9)28.8 (3.7)0.09
After32.2 (2.8)28.7 (3.4)0.001
Paired t-test0.0010.92
Subjective norms
Before22.9 (1.5)21.8 (3.4)0.06
After28.1 (1.4)22.7 (3.5)0.001
Paired t-test0.0010.21
Perceived behavioral control
Before13.6 (3.7)14.1 (4.7)0.58
After19.4 (3.3)15.1 (3.600.001
Paired t-test0.0010.28
Behavioral intention
Before13.3 (2.4)13.5 (2.4)0.66
After14.9 (0.35)14.5 (1.5)0.14
Paired t-test0.0010.05

aValues are expressed as mean (SD).

Figure 1. Comparison of the amount of performing high-risk and safe driving behaviors before and after the intervention in the intervention and control groups

### 5. Discussion

#### 5.1. Conclusions

Based on the our findings, the application of Health Belief Model and Theory of Planned Behavior is useful in designing interventions to promote safe driving behaviors and reduce high-risk driving behaviors.

### References

• 1.

Roberts I, Mohan D, Abbasi K. War on the roads. BMJ. 2002;324(7346):1107-8. doi: 10.1136/bmj.324.7346.1107. [PubMed: 12003866]. [PubMed Central: PMC1123075].

• 2.

Peden M, Scur F, Sleet D, Hyder A, Jarawan E, Mathers C. World report on road traffic injury prevention. Geneva: World Health Organization; 2010.

• 3.

Pormoallem N, Qorbani M. H Z. Assessment of Mangement and Safety Engineering in Driving Safety Promotion in Iran. Traffic Mangement Studies. 2011;19(5):13.

• 4.

Peden M. World report on road traffic injury prevention. Geneva: World Health Organization; 2004.

• 5.

World Health Organization. Estimated road traffic death rate (per 100,000 population). WHO; 2010.

• 6.

Zamani AF. Design and evaluation of educational model in order to prevent harm risky driving behaviors in motorcycle drivers. J Tarbiat Modares Uni. 2009;5:98-100.

• 7.

Mock C, Quansah R, Krishnan R, Arreola-Risa C, Rivara F. Strengthening the prevention and care of injuries worldwide. The Lancet. 2004;363(9427):2172-9. doi: 10.1016/s0140-6736(04)16510-0.

• 8.

Razmara A, Aghamolaei T, Madani A, Hosseini Z, Zare S. Prediction of safe driving Behaviours based on health belief model: the case of taxi drivers in Bandar Abbas, Iran. BMC Public Health. 2018;18(1):380. doi: 10.1186/s12889-018-5300-5. [PubMed: 29558924]. [PubMed Central: PMC5859486].

• 9.

Rahimikian F, Mirmohamadali M, Mehran A, Aboozari K, Barough S. Effect of Education Designed based on Health Belief Model on Choosing Delivery Mode. Hayat. 2008;14.

• 10.

Ramezankhani A, Khalafe Nilsaz M, Dehdari T, Soori H, Tavasoli E, Khezli M. Effects of an educational intervention based on planned behavior theory in promoting safe behaviors crossing the street in students. J Health Syst Res. 2014:2000-10.

• 11.

Razmara A, Aghamolaei T, Madani A, Hosseini Z, Zare S. Prediction of taxi drivers' safe-driving behaviors based on the theory of planned behavior: The role of habit. J Educ Health Promot. 2018;7:139. doi: 10.4103/jehp.jehp_61_18. [PubMed: 30596111]. [PubMed Central: PMC6282694].

• 12.

Tavafian SS, Aghamolaei T, Madani A. Predictors of speeding behavior among a sample of Iranian commercial automobile drivers: an application of the theory of planned behavior. Traffic Inj Prev. 2011;12(3):274-8. doi: 10.1080/15389588.2011.553976. [PubMed: 21660894].

• 13.

Lawshe CH. A Quantitative Approach to Content Validity. Personnel Psychology. 1975;28(4):563-75. doi: 10.1111/j.1744-6570.1975.tb01393.x.

• 14.

Al-Hemoud AM, Al-Asfoor MM. A behavior based safety approach at a Kuwait research institution. J Safety Res. 2006;37(2):201-6. doi: 10.1016/j.jsr.2005.11.006. [PubMed: 16678206].

• 15.

Iversen H, Rundmo T, Klempe H. Risk Attitudes and Behavior Among Norwegian Adolescents. European Psychologist. 2005;10(1):25-38. doi: 10.1027/1016-9040.10.1.25.

• 16.

Shafiei L, Taymoori P, Maleki A, Sayehmiri K. Environmental interventions based on the Health Belief Model and the Ecological-social model in the continuation of consumption of rice, free from toxic metals. Electron Physician. 2018;10(1):6153-63. doi: 10.19082/6153. [PubMed: 29588814]. [PubMed Central: PMC5853988].

• 17.

Hanewinkel R, Asshauer M. Fifteen-month follow-up results of a school-based life-skills approach to smoking prevention. Health Educ Res. 2004;19(2):125-37. doi: 10.1093/her/cyg018. [PubMed: 15031272].

• 18.

Wang J, Ye L, Zheng Y, Burke LE. Impact of Perceived Barriers to Healthy Eating on Diet and Weight in a 24-Month Behavioral Weight Loss Trial. J Nutr Educ Behav. 2015;47(5):432-6 e1. doi: 10.1016/j.jneb.2015.05.004. [PubMed: 26162481]. [PubMed Central: PMC4761236].

• 19.

Zhang YP, Li XM, Wang DL, Guo XY, Guo X. Evaluation of educational program on osteoporosis awareness and prevention among nurse students in China. Nurs Health Sci. 2012;14(1):74-80. doi: 10.1111/j.1442-2018.2011.00665.x. [PubMed: 22303915].

• 20.

Thorsen AV, Lassen AD, Tetens I, Hels O, Mikkelsen BE. Long-term sustainability of a worksite canteen intervention of serving more fruit and vegetables. Public Health Nutr. 2010;13(10):1647-52. doi: 10.1017/S1368980010001242. [PubMed: 20444314].

• 21.

Boroumandfar K, Shabani F, Ghaffari M. An investigation on the effect of Health Belief Model-based education on refusal skills in high risk situations among female students. Iran J Nurs Midwifery Res. 2012;17(3):229-33. [PubMed: 23833618]. [PubMed Central: PMC3696217].

• 22.

Rezaeian M, Sharifirad G, Mostafavi F, Moodi M, Abbasi MH. The effects of breast cancer educational intervention on knowledge and health beliefs of women 40 years and older, Isfahan, Iran. J Educ Health Promot. 2014;3:43. doi: 10.4103/2277-9531.131929. [PubMed: 25013836]. [PubMed Central: PMC4089115].

• 23.

Abood DA, Black DR, Feral D. Nutrition Education Worksite Intervention for University Staff: Application of the Health Belief Model. Journal of Nutrition Education and Behavior. 2003;35(5):260-7. doi: 10.1016/s1499-4046(06)60057-2.

• 24.

Tavafian SS, Aghamolaei T, Gregory D, Madani A. Prediction of seat belt use among Iranian automobile drivers: application of the theory of planned behavior and the health belief model. Traffic Inj Prev. 2011;12(1):48-53. doi: 10.1080/15389588.2010.532523. [PubMed: 21259173].

• 25.

Aghamolaei T, Tavafian SS, Madani A. Prediction of helmet use among Iranian motorcycle drivers: an application of the health belief model and the theory of planned behavior. Traffic Inj Prev. 2011;12(3):239-43. doi: 10.1080/15389588.2011.557757. [PubMed: 21660889].

• 26.

Martin SC, Jacobsen PB, Lucas DJ, Branch KA, Ferron JM. Predicting children's sunscreen use: application of the theories of reasoned action and planned behavior. Prev Med. 1999;29(1):37-44. doi: 10.1006/pmed.1999.0500. [PubMed: 10419798].

• 27.

Mohammadi Zeidi I, Pakpour A. [Effectiveness of educational intervention based on theory of planned behavior for promoting breakfast and healthy snack eating among elementary school students]. Razi Journal of Medical Sciences. 2013;20(112):67-78. Persian.

• 28.

Parrott MW, Tennant LK, Olejnik S, Poudevigne MS. Theory of Planned Behavior: Implications for an email-based physical activity intervention. Psychology of Sport and Exercise. 2008;9(4):511-26. doi: 10.1016/j.psychsport.2007.07.002.

• 29.

Reger B, Cooper L, Booth-Butterfield S, Smith H, Bauman A, Wootan M, et al. Wheeling Walks: a community campaign using paid media to encourage walking among sedentary older adults. Prev Med. 2002;35(3):285-92. doi: 10.1006/pmed.2002.1074. [PubMed: 12202072].

• 30.

Winge ES. Effects of a smoking prevention simulation on students' smoking attitudes. American journal of health studies. 2003;18(2/3):92.

• 31.

Markl M. Effectiveness of Road Safety Educational Program for Pre-drivers about DUI: Practical Implication of the TPB in Developing New Preventive Program in Slovenia. Transportation Research Procedia. 2016;14:3829-38. doi: 10.1016/j.trpro.2016.05.468.