Positive actions to improve mental well-being among construction workers

Master’s thesis Industrial Technology Engineering Positive actions to improve mental well-being among construction workers Author: Arnau Altet i Graell Director: Juan Jesús Pérez González Co-directors: Dr. Siddharth Bhandari, Dr. Matthew Hallowell Date: 06/2022 Escola Tècnica Superior d’Enginyeria Industrial de Barcelona Page 2 Thesis report Positive actions to improve mental well-being among construction workers Page 3 Abstract Construction workers are at a higher risk for mental health issues than every other profession. According to the Centers for Disease Control and Prevention, the construction industry is the second leading suicide rate, and nearly 25% of workers reported mental health problems in their last working month. Recent studies tried to identify the actual causes of this concerning data by putting together the more common stressors and coping strategies for construction workers. Moreover, some statistically valid relationships with depression and anxiety symptoms were pinpointed. Some leading construction companies are starting to spot the economic consequences of the workers’ mental well-being decrease. Nevertheless, the actual knowledge and resources to apply effective protocols are scarce, representing an additional barrier to mental health treatment. To address these shortcomings, this thesis firstly gathers all actual relevant information and calls it into question. All knowledge about work-related risk factors, common coping methods, and the stress appraisal process of the construction workforce is brought to light, compiling the state of the science. Secondly, the stage for employers that want to participate in employees’ mental health improvement is initiated. The future of workplace mental well-being includes a common effort of both employers and employees to address together these challenges, and finish with the loneliness that workers find when mental issues are manifested. This thesis pursues the objective to involve companies and resources by presenting a stepwise protocol to increase the awareness, measurement of crew mental health status, and efficient prioritization of resources. Keys for actions’ implementation, protocol evaluation, and apprenticeship are also introduced. Resource management and return on investment results are essential to involve stakeholders. Safety risk analysis and contingent viability modeling for safety are additionally explained thoroughly to lay the foundations of future mental health risk analysis. Having the crew motivated and pleased is socially and economically beneficial. The construction industry is lagging behind others in creating new work-friendly environments, that increase productivity and work satisfaction. Page 4 Thesis report Positive actions to improve mental well-being among construction workers Page 5 Summary SUMMARY ____________________________________________________ 5 1. GLOSSARY _______________________________________________ 7 2. PREFACE _________________________________________________ 9 2.1. Origin of the project ............................................................................................ 9 2.2. Motivation ........................................................................................................... 9 2.3. Prerequisites .................................................................................................... 10 3. INTRODUCTION __________________________________________ 11 3.1. Statistics on mental health ............................................................................... 11 3.2. What has been done in the construction industry? ........................................ 12 3.3. What gap are we addressing? ........................................................................ 12 4. LITERATURE REVIEW _____________________________________ 14 4.1. Antecedents to poor mental health ................................................................. 14 4.1.1. Literature’s mental health antecedents for construction workers ....................... 16 4.1.2. Questioning the antecedents .............................................................................. 18 4.1.3. Personal antecedents .......................................................................................... 24 4.1.4. Work-related antecedents ................................................................................... 25 4.1.4.1. Job demand risk factors .......................................................................... 26 4.1.4.2. Job control risk factors ............................................................................. 27 4.1.4.3. Job satisfaction risk factors ..................................................................... 29 4.1.4.4. Work hazard risk factors .......................................................................... 29 4.1.4.5. Workplace harassment risk factors ......................................................... 30 4.1.4.6. Work environment risk factors ................................................................. 31 4.1.4.7. Work-related antecedents’ summary ...................................................... 32 4.2. The cognitive response ................................................................................... 34 4.3. Coping mechanisms ........................................................................................ 35 4.3.1. Literature’s coping strategies for construction workers....................................... 36 4.4. The strain effects. Anxiety and depression ..................................................... 37 4.4.1. Literature’s relationships between coping and strain effects .............................. 38 4.5. Social responsibility of companies .................................................................. 40 4.6. Key gaps in literature and industry .................................................................. 41 Page 6 Thesis report 5. STATE OF SCIENCE _______________________________________ 42 5.1. Educating the workforce. Steps taken by other industries ............................. 42 6. FROM INDIVIDUAL TO COLLECTIVE RESPONSIBILITY __________ 45 6.1 Foundations for future protocols ......................................................................... 45 6.1.1. Awareness ........................................................................................................... 46 6.1.2. Measurement....................................................................................................... 47 6.1.3. Prioritization ......................................................................................................... 49 6.1.4. Implementation .................................................................................................... 49 6.1.5. Evaluation & Apprenticeship ............................................................................... 50 6.2. Foundations for future cost management ....................................................... 50 6.2.1. Safety risk analysis .............................................................................................. 50 6.2.2. Contingent viability modeling .............................................................................. 53 6.2.3. Model applications to mental health evaluation .................................................. 56 7. COSTS __________________________________________________ 57 CONCLUSIONS _______________________________________________ 59 ACKNOWLEDGMENTS _________________________________________ 61 BIBLIOGRAPHY _______________________________________________ 62 Positive actions to improve mental well-being among construction workers Page 7 1. Glossary AAU: Association of American Universities CSRA: Construction Safety Research Alliance TRIR: Total Recordable Injury Rate OSHA: Occupational Safety and Health Administration CII: Construction Industry Institute ICT: Information and communications technology CI: Construction Industry PTSD: Post-traumatic stress disorder MSD: Musculoskeletal pain disorder HR: Human resources GAS: General Adaptation Syndrome CSR: Corporate Social Responsibility UK: United Kingdom USA: United States of America UAE: United Arab Emirates P: Probability F: Frequency E: Exposure S: Severity w-h: Working Hours UR: Unit Risk Page 8 Memoria CR: Cumulative Risk EV: Expected Value ROI: Return on investment DASS: Depression Anxiety Stress Scale WCQ: Ways of Coping Questionnaire Positive actions to improve mental well-being among construction workers Page 9 2. Preface 2.1. Origin of the project The University of Colorado Boulder is one of only 36 U.S public research institutions in the Association of American Universities (AAU). Founded in 1876, five months before Colorado became a state, is home to more than 33,000 students and researchers. Ranked 13th in the Graduate Public Rankings in 2022 is an excellent location to develop Graduate Engineering Research Programs in the civil engineering field. [1][2] The Construction Safety Research Alliance (CSRA) is an alliance of industry leaders and experienced scientists who are focused on transformative construction safety research in a partnership with the University of Colorado Boulder. The rate of serious injuries and fatalities has plateaued in the construction industry for nearly 20 years. The mission of the CSRA is to assemble industry leaders and academics to conduct collaborative research that eliminates these unacceptable life-changing events. [3] Different projects have been developed during these past years such as questioning the Total Recordable Injury Rate (TRIR), used in the OSH Act of 1970, and the brand-new protocol for assessing quality based on Quality Safety Leading Indicators [4]. At this time, different innovative projects are being conducted by CSRA Ph.D. students and researchers implementing virtual reality and augmented reality for training on hazard recognition and risk estimation. This thesis is the beginning of a new project for CSRA: Mental Health Collaboration with CII. Construction workers’ mental health is closely related to their safety and with an increase in workplace accidents and fatalities. The construction industry is asking for more knowledge and tools to face the concerning data about construction workers’ mental health. 2.2. Motivation The motivation of this project is in essence the generalized concern in the industry for the well-being of its workers. The CSRA, together with the University of Colorado, is accepting to lead these unprecedented studies to help companies, and especially employees, to improve work conditions by reducing their physical and mental health issues. The authors’ motivation is to do their bit to increase the awareness of workers’ mental health, Page 16 Thesis report factors that the workers are facing every day. In this article, all these studies have been put together to define the state of the science. 4.1.1. Literature’s mental health antecedents for construction workers As previously stated, many different authors have studied the possible causes of the high stress levels in the construction industry trying to identify the risk factors that the workers have to face every day. [17] reviewed in 2020 107 articles from the PubMed, Scopus, Google Scholar, and WoS databases, and found existing relations between working conditions and mental health issues. After extracting the duplicate articles and the non-relevant ones a final list of 16 articles was revised, defining the significant risk factors that workers are facing daily and affecting their mental health with stress, depression, and anxiety. The initial list of working risk factors extracted from literature and sorted by appearances in relevant articles is: 1. Hours worked 2. Work overload 3. Increased work speed / pressure 4. Little opportunity in decision making 5. Work-home conflict / life imbalance 6. Nature of work / mental demand 7. Job insecurity / uncertainty about the work 8. Physical illness due to work 9. Low income / financial insecurity 10. Poor occupational climate 11. Little social support from colleagues / superiors 12. Occupational injury/hazards 13. Fear of failure 14. Substance abuse 15. Poor physical work conditions 16. Little relationship with co-workers 17. Poor working conditions 18. No further learning 19. Posttraumatic stress (PSTD) 20. Fatigue 21. Criticism 22. Lack of feedback 23. Low socioeconomic status 24. Overpromotion concerns 25. Interpersonal conflict 26. Alcohol consumption 27. Musculoskeletal pain & injuries 28. Marital status 29. Gender discrimination 30. Lack of respect from subordinates 31. Workplace harassment / bullying 32. Age discrimination Positive actions to improve mental well-being among construction workers Page 17 The thirty-two stressors were categorized into eight groups and some relationships between groups were also defined. This project aims to tackle the root of the problem, so some risk factors that are consequences of others are going to be ignored in future chapters. In figure 3 the relationships presented in [17] can be observed. Figure 3. Relationship between risk factors and poor mental health [17] In the next chapter of this thesis, the thirty-two risk factors selected by the [17] review are going to be questioned, together with the statistical validity of the relationships between each stressor and the final psychological strain effect, that reduces the workers’ mental health quality. As previously commented, one of the targets of this thesis is to obtain a final list of the statistically significant daily work-related risk factors and define strategies that reduce their effects on people. Page 18 Thesis report 4.1.2. Questioning the antecedents The industry efforts need to be focused on those stressors that can be modified by the employers. Those stressful events need to be related to workplace situations, and the companies must have the possibility to obtain data about the mental health effects on their people. First of all, some of the stressors were found redundant or unspecific. Others were defined as a consequence of other risk factors, instead of primary stressors. All of them were not considered in this study. Additionally, other original risk factors were considered maladaptive strategies that facilitate the emergence of other stressors. These coping strategies, together with other risk factors considered chronic or life-event stressors, were not considered as well. Below are presented the initial risk factors that are not going to be considered as daily workrelated stressors (Figure 4): Figure 4. Risk factors not considered in the final daily work-related antecedents list 1. Work overload Different articles are reporting work overload as a major stressor; [17] review considered the second more relevant. Nevertheless, this stressor is reported as a risk factor that encompasses working hours [10] and work speed or pressure due to tight deadlines [19]. Despite both factors frequently have a direct relationship, the approach to deal or cope with the stressor can differ. For these reasons, in this thesis, the work overload stressor is going to be studied as working hours and work speed/pressure separately. Positive actions to improve mental well-being among construction workers Page 19 2. Work-home conflict Work-home conflict is considered a major stressor for many recognized articles, [20] [23], despite being a consequence of job demand risk factors like the worked hours or the work pressure. In this thesis, only the primary stressors are going to be considered as mental health antecedents. Data illustrate that construction workers have more home conflicts than other professionals because of their fatigue, burnout, musculoskeletal pains, and alcohol abuse which unfortunately are common for them [23]. The construction industry has always been very resistant to changes. Even though other industries are evolving so quickly and changing every day, construction is lagging behind. Fortunately, safety for construction workers is starting to improve and work-related accidents saw an important decrease in number. Nevertheless, other important things such as gender discrimination, work environment, and alternative work schedules are evolving slower. [35] suggested changes that can improve work-life balance and improve short-term workers’ health and effectiveness. Further on, gender discrimination in the construction industry is going to be analyzed. Aside from workplace harassment or uneven job opportunities that females have to face, the workhome stressor affects them strongly leading to anxiety and depression symptoms [36]. Women have full-time jobs, like men, but they are still taking primary responsibilities in childcare and housework. [22] reported that work-home conflict is the major stressor for married women that work in the industry, which is clearly a lower percentage compared to the national average. Data also suggest that immediate actions need to be taken to reduce discrimination against females in the construction industry that, as it has been said, is far behind other industries. 3. Physical illness Physical ill workers usually experience stigma, loss of seniority, and more days off work. Older construction workers are at increased risk for medical and indemnity costs from workrelated injuries and are more likely to take disability retirement [44]. This known data might generate age-related discrimination. Compared to younger blue-collars, the elders have less physical capacity but much more experience, that unfortunately frequently is not valued. Likewise, young workers are pressured to return to work before being fully recovered and might have to face long-term effects from social and physical consequences. Bad recoveries of occupational injuries are as well proved to be related to future mental health outcomes Page 20 Thesis report [45]. [10] considered work-related physical illness due to work as the first variable for depression between workers and the second variable for suicide ideation. Even though this is concerning data, the work-related physical illnesses must be considered a chronic stressor, and consequently not considered in this study. The focus needs to be put on the daily stressors that are the direct cause of the physical illnesses, for example, the working hours, the work pressure, or unsafe work conditions. 4. Occupational injuries & hazards Construction is the second leading industry in fatalities and, even though the number of accidents has been reduced drastically, the number of fatalities has not experienced any improvement in 15 years in the US [5]. Small enterprises are responsible for half of the fatalities, because of less attention and resources to regulations in safety. Helpers and laborers are the groups at more risk, as they are doing different jobs every day and usually are the less experienced [5]. [37] and [39] demonstrate a direct relationship with occupational hazards and depression symptoms with CES-D and HAM-D tests respectively. [37] reported significantly higher anxiety symptoms from the more vulnerable workers group. Occupational hazards are the principal cause of accidents at work and conduct to other work-related risk factors like PTSD, fear of failure, fatigue, or physical illness due to work. Work-related injuries and hazards must be approached differentially as the stress caused by a near miss is different than the one caused by suffering or witnessing an accident or fatality. 5. Substance abuse The psychological distress associated with substance abuse can range from mild to serious. People who suffer from mood or anxiety disorders are almost twice as likely to also suffer a substance abuse disorder, and vice versa. Consequently, substance abuse, together with alcohol abuse, is considered a maladaptive coping strategy for stressful situations, and a facilitator for the emergence of mental health issues. Substance abuse is a way that people often use to self-medicate their symptoms of mental health problems. Drugs generate changes in the brain that can lead to mental health issues such as paranoia, depression, anxiety, or aggression. [13] found a significant relationship between substance abuse and reduced anxiety symptoms. This surprising result was subsequently nuanced: even though in the short-term Positive actions to improve mental well-being among construction workers Page 21 the results were positive, in the long-term the possibility of suffering a physical or mental health illness increased, together with suicidality rates. 6. Poor working conditions [17] distinguished between poor working conditions and poor physical working conditions in their 32-articles review. After analyzing those articles and other relevant studies not considered in this initial review of the state of science, this differentiation does not make sense. Both mentioned risk factors are going to be considered as one in this thesis. 7. Post-traumatic stress disorder Post-traumatic stress disorder (PTSD) is a mental health condition triggered by a terrifying event, either experienced or witnessed. Symptoms may include severe anxiety, nightmares, and flashbacks, as well as uncontrollable thoughts about the event [46]. People who go through traumatic events may have temporary difficulty adjusting and coping, but frequently these symptoms are reduced with time, self-care, or basic treatment. When the symptoms get worse, lasting months or years, and interfere with the person’s day-to-day functioning, PTSD can be diagnosed. PTSD is considered a chronic stressor and a consequence of occupational injuries or hazards. Protocols need to be defined and proof-tested to help workers after suffering or witnessing an accident and avoid, with the help of the working environment or companies’ mechanisms, the development of PTSD in employees. 8. Fatigue Fatigue increases the risk for mental ill-health among construction supervisors and bricklayers [25] and is significantly correlated with depression [43]. The risk of workplace injuries and accidents, together with excessive work pressure, are related to sleep problems and consequently fatigue. Analyzing it as a risk factor, fatigue cannot be considered a daily workplace risk factor, but a consequence of other risk factors such as excessive working hours or work pressure, as discussed earlier. 9. Criticism Criticism is considered a risk factor for different articles but is a term that can be sometimes Page 22 Thesis report confusing. Little support from colleagues, little relationship with co-workers, and lack of respect from subordinates can carry criticism implicitly. The actions that employers can take to reduce the problem must be addressed differently for each of the previously defined situations. 10. Socioeconomic status Socioeconomic status is the class or social standing of a group or individual and it is often measured as a combination of occupation, income, and education. Examinations of socioeconomic status reveal inequities in access to resources, privilege, power, and control [51]. Socioeconomic status cannot be considered either as a daily work-related stressor for workers in the construction field, as it is undoubtedly a chronic stressor. People in construction, and particularly blue-collars, are considered low-class people and maybe because of this reason, is commonly accepted that they can stand more difficult work conditions. Lower salaries, long working hours, fewer opportunities in decision-making, and less awareness of gender discrimination. Fewer efforts from raising their level of training and less social support from superiors are work-related risk factors that are increased by the consideration of blue-collars as a low socioeconomic status group. 11. Overpromotion Career progression is important to both blue-collars and managers. It helps with career satisfaction and staff retention, as the opportunity to take on new challenges makes people to be engaged with their day-to-day work However, significant articles that studied the behavior of construction workers, referred to overpromotion concerns as a stressor for workers. This surprising finding might be caused by the strong leadership policy that many companies in the construction field still have, punishing employees when mistakes are made. Articles that analyzed overpromotion concerns did it with the same background and meaning as the fear of failure risk factor. It is conspicuous that this stressor has a significant influence on the anxiety levels of workers, but no information or studies supported to differentiate between overpromotion concerns and fear of failure. 12. Alcohol consumption Employees of the construction industry, particularly blue-collar workers, have nearly twice the Positive actions to improve mental well-being among construction workers Page 23 rate of alcohol abuse as the national average. Around 12% of all construction workers in the US have alcohol use disorder compared to 7,5% of the national population of adults [50]. The job in construction is very challenging, both physically and mentally. To cope with stress and to self-medicate physical and mental pain many workers resort to alcohol and other substances. Substance and alcohol abuse contribute to the development of mental illness, even though [13] found a reduction in anxiety in the short term. In the long term, alcohol changes brain areas that disrupt other mental disorders apart from anxiety and depression, such as schizophrenia or impulse-control disorders. Experts consider alcohol consumption a maladaptive coping strategy that facilitates the growth of mental illnesses and a risk factor that can trigger the workers if the original cause of starting drinking is off-work. For this reason, alcohol consumption cannot be considered a daily work-related risk factor, but a maladaptive coping strategy or a chronic stressor. 13. Musculoskeletal pain & injuries People working in construction industries are at risk of various occupational diseases. Musculoskeletal disorder (MSD), and in particularly low-back pain, is the largest cause of work-related illness and can be caused by fatigue, long working hours, work speed pressure, or because of demanding physical working conditions. [39] reported that not only the already mentioned stressors can directly affect the physical wellness and increase MSD, but any stressor can be a cause since MSD is a consequence of occupational distress. Musculoskeletal pain and injuries cannot be considered a daily work-related stressor itself. Must be considered as a type of occupational injuries. 14. Marital status Marital status also plays an important role in workers’ mental health. Studies focused on the construction industry have reported that marital status works as a moderator for the married workforce. Single, separated, divorced, and widowed workers show higher levels of depression and anxiety when they are exposed to work-related stressors. [22] found less mental resistance from workers to job pressure when they have children to take care of. This stressor is affecting more the females of the industry, who usually take more responsibilities in child and housecare. Further studies need to be realized on this matter and more resources need to be dedicated to helping females to deal with home-work duties. 25,5% of the women in construction are single according to [22], a much higher Page 24 Thesis report number than the national average. Despite the influence on final mental issues, marital status must be considered as an external life-event condition. 15. Lack of respect from subordinates Supervisors need to be respected by their subordinates to develop the assigned tasks and jobs. Some articles pointed out this risk factor as an important stressor, especially for female managers. Some blue-collars deny following female supervisors’ orders and behave disrespectfully because of their sexism [39]. As will be pointed out below, future protocols will be addressed to deal with poor support, poor relationships, and poor feedback separately. Lack of respect from subordinates is going to be bundled with little support from colleagues and superiors. 16. Workplace harassment Harassment is defined as unwelcome behavior and policies that are based upon an employee's race, color, creed religion, sexual orientation, gender identity, sex, national origin, age, physical or mental disability, or genetic information. To cope with this daily existing work-related stressor and define strategies to reduce it, the need to act separately for the different types of harassment appears to be inevitable. Some articles worked with workplace harassment, others with gender or age discrimination. In this thesis different strategies are going to be studied for different discrimination attitudes, separating age, gender, and racial harassment. 4.1.3. Personal antecedents The personal antecedents are the different personal situations that workers have outside the job that might facilitate the emergence of stress, anxiety, or depression symptoms. In the previous chapter, these non-work-related stressors have been pointed out and classified as chronic stressors, life-event stressors, consequences of others, and maladaptive coping (figure 4). The personal antecedents are considered as “facilitators”, while the daily work-related antecedents are known as “triggers”. The main question that is difficult to answer is, how much information can the employers have about employees’ personal situations? Employees have the right to keep private facts about themselves confidential. Additionally, if an employer discloses private facts about an employee might be held accountable for invasion of privacy. Positive actions to improve mental well-being among construction workers Page 25 Nevertheless, despite the companies cannot have and should not use some private information about their workers, it is very convenient for mental health interventions to be aware of which personal situations may influence the appraisal process in some stressful situations. As already discussed, companies cannot have personal information about their workers but have mechanisms such as questionnaires to obtain relevant data about the general situation of employees. Mental health issues reduction protocols must consider, apart from the workplace stressors, other situations where the workers might suffer stress that are not directly related to work situations. Companies’ intervention in off-work stressors is less evident, but employers should play an important role in training and in increasing the awareness of their employees. In figure 5 the different personal stressors that companies need to take into account are presented. Figure 5. Personal antecedents that facilitate mental health issues 4.1.4. Work-related antecedents After discarding some antecedents, a new list has been defined, considering only the daily work-related stressors, and avoiding personal, non-concrete, and redundant risk factors. The nineteen final significant risk factors were categorized into six groups, to facilitate possible common coping strategies. The different groups - job demand, job control, job satisfaction, work hazards, workplace harassment, and work environment – are shown in Figure 6. Page 32 Thesis report not covered [25]. Having a good relationship with co-workers can be categorized as a more basic need: love and belongingness. This basic need reflects the social needs, such as the necessity for affection and being part of a group. Previous studies reported that a poor relationship with co-workers is an important stressor for construction workers. Additionally, some support items were identified: problem-solving together, counting on people, and a fun workplace [24]. Locke exposed in his Goal Setting Theory that working toward a goal is a major source of job motivation, and feedback is a fundamental part to reach those goals as a team [27]. Construction projects are carried out by teams, as complementary skills are needed. In teamwork communication and feedback are essential [28]. In the construction industry, the communication within the team or teams involved in a project is improvable. Frequently, managers are leading different projects in different locations, not being physically present or reachable when their subordinates are doing their tasks. It is also a common practice to outsource experts to do parts of the job, making them improvise or facing imprecise or incomplete instructions. Bricklayers need constant feedback from their supervisors, usually more than other bluecollars in industries like manufacturing or agriculture. The consequences that their errors might have on the project’s and coworkers’ safety, together with the lower levels of selfesteem, make them feel more the need for feedback [40]. [24] reported it as a major stressor. 4.1.4.7. Work-related antecedents’ summary To conclude this chapter, all the information is summarized in Table 1, where all the significant relationships between antecedents and psychological strain effects from the literature are shown. Table 1. Overview table; from antecedents to depression anxiety and stress Mental illness Definition Antecedents References DEPRESSION Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depressive disorder or clinical depression, it affects how you feel, think and behave and can lead to a variety of 1. Hours worked [10] [19] 2. Work speed / pressure [25] 4. Little opportunity in decision making [33] 5. Organizational climate [37] [38] 8. Lack of growth [25] 9. Unfair compensation [10] 11. Occupational injuries [37] [39] Positive actions to improve mental well-being among construction workers Page 33 emotional and physical problems. 13. Occupational hazards [37] [39] 15. Age discrimination [32] 16. Racial discrimination [56] 17. Poor support [25] ANXIETY Intense, excessive, and persistent worry and fear about everyday situations. Fast heart rate, rapid breathing, sweating, and feeling tired may occur. 1. Hours worked [19] 2. Work speed / pressure [47] 5. Organizational climate [39] 6. Job insecurity [20] [47] 7. Fear of failure [47] 9. Unfair compensation [10] 15. Age discrimination [32] WORKPLACE STRESS Job stress can be defined as the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker. Job stress can lead to poor health and even injury. 1. Hours worked [20] [22] [24] 2. Work speed / pressure [20] [23] 3. Nature of work [22] [25] 4. Little opportunity in decision making [24] [31] [32] 5. Organizational climate [37] [38] [39] 6. Job insecurity [20] [47] 7. Fear of failure [47] [49] 8. Lack of growth [25] 9. Unfair compensation [21] [36] 10. Isolation [53] 11. Occupational injuries [37] [39] 12. Physical illness due to work [24] 13. Occupational hazards [37] [39] 14. Gender discrimination [22] 15. Age discrimination [32] 16. Racial discrimination [56] 17. Poor support [24] [25] 18. Poor relationships [24] 19. Poor feedback [24] [40] Previous studies found significant relationships between some workplace stressors and depression or anxiety. Nonetheless, some stressors have not been related to anxiety or depression. There is no empirical proof yet that the workplace stressors nature of work, isolation, physical illness due to work and gender discrimination are increasing the psychological strain outcomes in construction workers. More research needs to be done in this direction. Page 34 Thesis report 4.2. The cognitive response Stress theories can be considered from a psychological or systemic perspective. Systemic stress, known as General Adaptation Syndrome (GAS), puts the focus on the biological changes and how the cognitive appraisal is incapable of determining the significance and relevance of the threat [12]. From a psychological perspective, stress is divided into two stages: appraisal and resources; and to perceive it, a combination of results from these two appraisal stages must occur. The primary appraisal is the moment where the receiver of a stressor establishes its significance as irrelevant, benign, or stressful. The secondary appraisal focuses on the person's ability to find resources to manage the stressor. A person perceives stress when their primary appraisal is stressful, and their secondary appraisal is incapable of finding appropriate resources to cope (figure 7) [13]. In later publications, three different categories were defined when the primary appraisal results stressful: threat, challenge, and harm. This later definition had the goal to illustrate that different coping strategies must be employed based on the stressful type, using different resources obtained on the secondary appraisal. Figure 7. The appraisal stage Positive actions to improve mental well-being among construction workers Page 35 4.3. Coping mechanisms The third stage of the mental illness process is the coping strategies. Once an event or a stressor has been categorized as stressful and resources are not available in the appraisal stage, people suffer stress. The coping strategies are the actions that are taken to try to reduce, eliminate or get used to the stress. [57] identified the two main types of coping: emotion-focused coping and problem-focused coping. Emotion-focused coping seek to regulate the emotional distress and return to normal functioning, whilst problem-focused plan to resolve or manage the problem that causes stress. Either type of coping can have a favorable or unfavorable outcome, being the favorable outcome the resolution of the problem. Unfavorable outcomes do not alleviate the stress and a reappraisal or additional coping is required. Prolonged exposures to distress may lead to anxiety, depression, or suicide attempts. The early theories of coping put the focus on the negative effects and regulation of stress, studying the process always from the negative side. [57] proposed a revised model incorporating positive psychological stress after recognizing that their early theory needed to be modified (Figure 7). The new model of the cognitive theory of stress has three new pathways to define positive actions that are taken when the outcome of the coping strategy is not favorable. The first of the three additional pathways is the meaning-based coping. This new response to distress involves the activation of beliefs and values or goals that might help to find a positive meaning to the stress. This positive emotion leads to renewed or sustained coping, avoiding that people give up dealing with the stress. The second pathway is once the positive emotion loops back to the appraisal phase, allowing the individual to redefine the stressor and re-engage in new coping efforts. Finally, the third pathway results from distress caused by the non-favorable outcome, rather than the stressor itself. The process involves searching for a positive psychological state primary through emotion-focused coping [20]. Page 36 Thesis report Figure 7. The coping mechanisms Furthermore, the coping strategies can be categorized as adaptive and maladaptive coping. Adaptive coping includes cognitive and behavioral efforts to manage stressful conditions, despite a favorable or unfavorable result. On the other hand, maladaptive coping such as self-harm or substance abuse generally increases stress and anxiety. The more maladaptive behavior, the more risk a patient faces in either sustaining or increasing the severity of the disorder [13]. 4.3.1. Literature’s coping strategies for construction workers In this chapter, the common strategies adopted by managers, supervisors and blue-collars from the industry, are going to be presented. Different previous studies put the focus on the effectiveness of the coping methods that workers are using currently, but none of them investigated which coping strategies are the ones that the workers need. The type of adaptive coping strategies implemented may depend on how the individual appraises the stressful event, its effect, environmental factors, and personality differences. However, is clear that the approach for somebody whose stressor is some type of workplace harassment should not be the same as another worker that is facing work hazards. A protocol must be designed to help as many people as possible. [21] found the influence in the variance of the psychological strain effects of people in the construction industry. The results were encouraging and engaging because even though the already aforementioned differences in the stressor’s approach, the variance of the outputs relies mainly on the coping strategies: 72.8 % of the variance in depression, 57.3% in stress, Positive actions to improve mental well-being among construction workers Page 37 and 55.3 % in anxiety. As indicated above the coping strategies might be focused on the stressor (problem-focused) or on the emotions caused by the stressor (emotion-focused). Additionally, the strategies might be adaptive if the stressed person does efforts to reduce the problem, or maladaptive if the coping strategies are not well-focused and increase the problem in long term. [20], [21] and [22] studied the common coping strategies chosen by the construction workers and their relationships with mental health issues. The adaptive problem-focused strategies are active coping, planning, suppression of competing activities, restraint coping, social support (instrumental reasons), confronting, and positive reinterpretation of the stressor. No maladaptive problem-focused strategies were identified. The adaptive emotion-focused strategies are social support (emotional reasons), mental disengagement, turning to religion, acceptance of the stressor, self-controlling, venting of emotions, and humor. The maladaptive ones are alcohol and drug disengagement, behavioral disengagement, acceptance of responsibility, self-distraction, self-blame, and denial. Different articles used interviews, surveys, or known questionnaires designed to identify coping actions and patterns as the Ways of Coping Questionnaire (WAYSS). [20] reported that the workers are commonly engaging in sports or hobbies (60%), alcohol consumption (25%), time management (25%), and coffee drinking / smoking (23%). This data is concerning, as only 25% of the workers are coping with the stress with a problem-focused strategy. The other common coping strategies are emotion-focused, known to be less effective in terms of improving mental health issues. Alcohol and drug consumption are worryingly common, once again demonstrating the need to inform workers about the dangers of this maladaptive emotion-focused coping strategy. 4.4. The strain effects. Anxiety and depression Occupational stress occurs when an imbalance between work-related demands and available resources is experienced. When the exposition to stress is prolonged the workers might start suffering from psychological, physiological, or sociological symptoms (Figure 8). Psychological strain effects are those affecting or arising in the mind, operating in a cognitive, Page 38 Thesis report behavioral, or emotional way. Some examples of cognitive effects might be loss of concentration or lack of motivation; some behavioral results are substance misuse or absenteeism, and the more common emotional outcomes are anxiety or depression [32]. In Table 1 a precise definition of anxiety and depression can be found. Physiological stress is a condition that challenges the homeostasis of the organism [59]. Homeostasis, the state of steady internal, physical and chemical conditions of the body includes many variables, such as fluid balance or body temperature. Stressful situations can activate a cascade of stress hormones that produce physiological changes [58] and outcomes with physiological strain effects like sleep disturbances, headaches, gastrointestinal upsets, or musculoskeletal pain [32]. The sociological symptoms of occupational stress are those that concern the development, structure, and functioning of human society. The more common outcomes experienced by people suffering sociological strain effects are burnout, distancing (avoiding communication), or marital discord. Figure 8. The strain effects 4.4.1. Literature’s relationships between coping and strain effects After identifying the more common coping strategies among construction workers their effectiveness and regularity were also studied. Positive actions to improve mental well-being among construction workers Page 39 [21] reported the significance of different coping strategies with higher levels of anxiety and depression, sustaining their results through multiple regression analysis and the DAS-21 screening tool. Some results were counterintuitive as the effects were studied in short-term. Positive reframing and acceptance of the stressor increase the anxiety symptoms, despite being adaptive strategies. Behavioral disengagement and self-blame are significant maladaptive strategies that also increase anxiety symptoms. The only significant coping strategy that reduced the final output was substance use, surprisingly. Alcohol and drugs can create a false perception of stress reduction in the short term, but it is demonstrated that longterm consequences are terrible for physical and mental health. For depression symptoms, only non-effective coping strategies were found significant. Acceptance, humor, behavioral disengagement, and self-blame were increasing the depression levels of the workers, although acceptance and humor are considered adaptive strategies. To sum up, [21] could only find non-effective coping strategies and not a single positive coping strategy was spotted. As discussed earlier the studies put the focus on the effectiveness of the actual used coping strategies, instead of trying to find what the workers need to do. [20] found that the only relevant coping strategy that reduces the effects of anxiety and depression is active coping. Additionally, the results withstand other studies that uphold that effective adaptive coping strategies are the ones focused on the problem. In table 2, the different known coping strategies used by construction workers and the conclusions of relevant studies in terms of effectiveness in reducing depression and anxiety are shown. As can be seen, the information in the industry is scarce. These information affirms the hypothesis introduced in the 3.3 chapter. There is no significant information that sustains emotion-focused adaptive strategies as a good way to cope with stress and avoid the emergence of depression and anxiety symptoms. Table 2. Coping and strain effects significant relationship for construction workers Construction workers’ coping strategies Depression reduction Anxiety reduction Active coping  x  Suppression of competing activities Restraint coping Instrumental social support Confronting Positive reinterpretation x Emotional social support Mental disengagement Page 40 Thesis report Turning to religion Acceptance of the stressor x x Self-controlling Venting of emotions Humor x Alcohol & drugs consumption  Behavioral disengagement x x Acceptance of responsibility Self-distraction Self-blame x x Denial 4.5. Social responsibility of companies Corporate social responsibility (CSR) means that businesses, in addition to maximizing shareholder value, should act in a manner that benefits society. Companies should adopt policies to promote the well-being of society and the environment while lessening negative impacts. CSR is traditionally broken into four categories: environmental, philanthropic, ethical, and economic responsibility. Some examples of different social strategies might be reducing carbon footprint, charity work, or environmental conscious businesses. Being socially responsible bolsters the company’s image and builds its brand. These programs can boost employees’ morale in the workplace and lead to greater productivity. It is directly related to the organizational climate risk factor, previously mentioned. Prioritizing the mental health of employees is indispensable for socially responsible companies and has indisputable effects on the economic benefits of the employer. According to Health & Safety Executive, 15.4 million workdays were lost in 2018 in the UK due to work-related stress, anxiety, and depression [8]. This data confirms mental health issues as the first reason for lost workdays, reaching 44%. Employers can not undermine the mental health of their staff. If the issue is ignored, not only the health of workers is put at risk, but the wealth of employers’ businesses and the health of the economy as a whole. The actual debate is if taking care of the employees’ well-being must be an indispensable milestone for socially responsible companies. What is undeniable is that philanthropic and ethical responsibilities must have a space for employees’ mental health, and companies should not use the stigma that surrounds mental health to avoid facing the problem and Positive actions to improve mental well-being among construction workers Page 41 assume their inescapable responsibility. 4.6. Key gaps in literature and industry Once available literature has been revised it is indispensable to define the key gaps that can help experts to understand the starting point where future studies have to begin. Although it is often not considered, workers’ mental health is in all probability the biggest question that the construction industry has to address ipso facto. The key gaps that actual and future studies have to focus their efforts on are the followings: - Lack of education of employees about their mental health. - Lack of training to employers about how to attach the mental health issues of the employees. - Lack of knowledge about the negative economic implications of workers’ mental health to corporate. - Lack of validated strategies to proactively combat mental health issues. - Lack of efficient protocols to reduce workplace risk factors and how or where companies need to invest. - Lack of information about direct relationships between work risky conditions and psychological strains on employees. - Lack of information about the coping methods used by employees. - The presence of stigma and taboo about mental well-being. Page 48 Thesis report final score only informs about stressor types that the companies need to consider, but the actions need to be designed for specific risk factors. Table 5. Workplace risk factors’ groups for construction template Risk factor groups Serial of the items in each group Final group score 1. Job demand 1, 2, 3 2. Job control 4, 5, 6, 7 3. Job satisfaction 8, 9, 10 4. Work hazards 11, 12, 13 5. Workplace harassment 14, 15, 16 6. Work environment 17, 18, 19 TOTAL SCORE 2. Levels of depression, anxiety, and stress. DASS-42 Depression Anxiety Stress Scales (DASS) is a psychometric test that can be administered to measure the severity of depression, anxiety, and stress experienced by a group of people during the last week [69]. DASS has excellent psychometric properties and is adequate for evaluating mental ill-health in employees. The DASS-42 template can be found in appendix 1, together with the scoring and interpretation guides. 3. Coping strategies of construction workers Following the same methodology as the workplace risk factors template, this questionnaire gives to employers some information about the coping strategies that their employees are taking (Table 6). Table 6. Coping strategies for construction template Coping Strategies Never Rarely Sometimes Often Always 1. Active coping 1 2 3 4 5 2. Suppression of competing activities 1 2 3 4 5 3. Restraint coping 1 2 3 4 5 4. Instrumental social support 1 2 3 4 5 5. Confronting 1 2 3 4 5 6. Positive reinterpretation 1 2 3 4 5 7. Emotional social support 1 2 3 4 5 8. Mental disengagement 1 2 3 4 5 9. Turning to religion 1 2 3 4 5 10. Acceptance of the stressor 1 2 3 4 5 11. Self-controlling 1 2 3 4 5 12. Venting of emotions 1 2 3 4 5 Positive actions to improve mental well-being among construction workers Page 49 13. Humor 1 2 3 4 5 14. Alcohol consumption 1 2 3 4 5 15. Drugs consumption 1 2 3 4 5 16. Behavioral disengagement 1 2 3 4 5 17. Acceptance of responsibility 1 2 3 4 5 18. Self-distraction 1 2 3 4 5 19. Self-blame 1 2 3 4 5 20. Denial 1 2 3 4 5 Finally, some coping strategies can be unified to have a global vision of the situation if required. Data about emotion-focused coping strategies and maladaptive attitudes can be useful to justify training workers on how to cope with daily stressors (Table 7 & 8). Table 7. Problem and emotion-focused strategies template Coping strategies groups Serial of the items in each group Final group score 1. Problem-focused 1, 2, 3, 4, 5, 6 2. Emotionfocused 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 Table 8. Adaptive and maladaptive strategies template Coping strategies groups Serial of the items in each group Final group score 1. Adaptive 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 2. Maladaptive 14, 15, 16, 17, 18, 19, 20 6.1.3. Prioritization Once all the information about daily work-related risk factors, psychological outcomes, and coping strategies has been collected, employers have to decide which type of intervention want to implement. To choose which protocol is the ideal to deploy, prioritizations need to be made based on information collected in the Awareness and Measurement chapters, together with cost models. The prioritization and final design of protocols need to be justified socially and economically. The Construction Safety Research Alliance (CSRA) developed the safety risk analysis and the contingent viability models that help safety experts to quantify their safety interventions and to know precisely the ROI of these investments. In the 6.2 chapter, both cost models are explained, together with some foundation stones for future mental health cost management. 6.1.4. Implementation The fourth stage is the Implementation when the action plan to improve the mental health of employees is implemented. The protocol must offer background information to improve Page 50 Thesis report communication and feedback flow during the implementation of the phase. One of the long-term goals of the Mental Health Collaboration project is to develop different standardized and efficient protocols that companies with fewer resources can apply with guaranteed success in reducing mental health issues. 6.1.5. Evaluation & Apprenticeship The final phase is the evaluation of the process and effect of the implemented intervention through questionnaires. The goal of this final stage is to inform the improvements and parts that need to be improved. Experts can design specific questionnaires or use the same as the measurement stage and compare the results. Mental health improvement is a cyclical protocol that despite a first implementation might have successful results, the protocol needs to be started regularly as workplace conditions and workers’ approaches can change over time. 6.2. Foundations for future cost management The CSRA has designed and tested through the evaluation of hundreds of real fatalities reports in the US, different cost models, and risk factors’ reduction cost evaluations for employers. Similar cost studies are planned to be performed in the next years following the mental health collaboration with CII project. Risk factor reduction cost evaluation and contingent viability models are going to be used as a point of reference for specific mental health cost models. Comparing risk for workplace accidents and risk for workplace mental health issues is reasonable as both problems are momentous for the industry, and have similar outcomes for the companies – workdays lost, people resigning, economic losses, and fatalities. 6.2.1. Safety risk analysis The milestone of safety risk analysis is to objectivate as much as possible the investment decisions to improve the safety of workers and to reduce accidents and fatalities [61]. Assuming that with past data it is possible to predict future conditions, the final goal is to have more information to assign resources to target interventions. First, some concepts need to be defined: - Hazard: unsafe condition that may contribute to an accident. Positive actions to improve mental well-being among construction workers Page 51 - Risk: potential event that results in an outcome that is different than planned. - Accident: Actual occurrence of a potentially negative event. The risk matrix approach was built to visualize different scales of risk, representing severity (S) and probability (P) on a 1 to 5 scale. The product of both variables represents the risk approach (figure 10). Figure 10. Risk Matrix Approach The economic efforts need to be focused on when the severity and probability estimations are high (yellow and red areas). The boundary conditions fixed in [61] are: - Green area: P x S < 5 - Yellow area: 5 < P x S < 10 - Red area: P x S > 10 Estimating probability and severity is not a trivial task for humans. It is why some models and common definitions need to be unified, to homogenize the safety data and compare it with other studies. Some extra terminology is required: - Probability (P): chance of an injury over a period of time. - Frequency (F): rate of which injuries occur. - Exposure (E): time exposed to a risk. - Severity (S): seriousness of an injury. Page 52 Thesis report - Expected Value (EV): Actual value of risk defined in terms of outcome. - Unit Risk (UR): Rate of risk for a particular activity, process, or organization. - Cumulative Risk (CR): Sum of all unit risks associated with a duration in time. Probability is expressed as a percentage, frequency in [injuries/w-h], and exposure in [w-h]. Two types of severity were defined: severity as the cost to the business [$], and severity to the worker [S]. S unit represents the severity scores (figure 11), an exponential scale obtained through the analysis of hundreds of real accident reports [62]. Figure 11. Severity score for safety [62] Finally, two different types of risks can be defined: Unit Risk (UR) and Expected Value (EV), representing the impact of risk over time. Both variables can be expressed in S or $ units. Unit Risk (UR) = Frequency (F) x Severity (S) (1) Expected Value (EV) = Probability (P) x Severity (S) (2) Being Probability the product between Frequency and Exposure (Eq.3): Probability (P) = Frequency (F) x Exposure (E) (3) Finally, the different severity levels can be combined obtaining the Cumulative Risk (CR) or the total unit cost, in [$/w-h]. This valuable and quantified information, allow companies to decide how much resources want to allocate and when is the appropriate time to do it, Positive actions to improve mental well-being among construction workers Page 53 knowing always the risks that they are considering. Cumulative Risk (CR) = ∑ Expected Values (EV) (4) Total Unit Cost = ∑ (Unit Costs)i (5) Finally, plotting the risk evolution over time for a group of tasks or individual tasks is a very useful tool to detect the moments with higher risks and assign resources (Figure 12). Figure 12. Risk-time plot 6.2.2. Contingent viability modeling The contingent viability modeling is an economic model that allows companies to objectively evaluate the cost-benefit of investments. The optimal investment strategy depends on the frequency and cost of injuries, the sequence in which the specific injuries preventions techniques are applied, and the risk mitigation of each technique. The model assumes that companies know the cost and frequency of each injury type – from minor first aid to permanent disabilities or fatalities (Table 7). Additionally, some information about different safety programs is required – frequency reduction and program cost (Table 8). Table 7. Numeric example of cost and frequency for different injuries types Injury Type Injury Cost Frequency of injury (w-h / inj) Minor first aid $214 720 Major first aid $623 1.260 Medical case $68.417 51.450 Lost work time $101.480 86.400 Permanent $268.467 262.800 Page 54 Thesis report disablement Fatality $1.600.000 8.640.000 Table 8. Numeric example of frequency reduction and program cost for six safety elements Safety Program Element Frequency reduction (w-h / inj) Safety Cost Upper management support 138.165 $2.690 Subcontractor selection and mgt 87.176 $1.810 Employee involvement 138.165 $4.000 Substance abuse programs 34.705 $2.000 JHAs 138.165 $8.000 Frequent worksite inspections 69.246 $6.000 With this information – obtained from previous CSRA studies - companies can calculate the reduction of the Expected Value and the cumulative investment for the different levels of safety (Eq.6, 7 & 8). (New F)NM = (F)N + (F reduction)M (6) (New P) NM = Total w-h / (New F) NM (7) (New EV)M = ∑ [(New P) NM x (Injury Cost) N] (8) Considering N the number of injury types, and M the safety levels or number of programs applied. The expected value for different types of safety can be plotted (Figure 13). An exponential reduction in terms of monetary risk can be observed, showing the companies that at some level of safety, the risk reduction is smoother. Figure 13. Expected Value for different safety levels (m) Positive actions to improve mental well-being among construction workers Page 55 The cumulative investment for different safety levels can also be calculated easily (Eq. 9) and plotted (Figure 14) IM = ∑ costM (9) Figure 14. Cumulative investment for different safety levels (m) Finally, the total cost of safety can also be calculated (Eq. 10) and plotted (Figure 15), finding the minimum cost and optimal investment for the company. The employer will know in advance the safety level that their workers will be working with, and the cost of keeping their workers as safe as possible. LM = EVM + IM (10) Figure 15. Total cost of safety for different safety levels (m) Page 56 Thesis report 6.2.3. Model applications to mental health evaluation Companies can also apply contingent viability modeling to acquire more knowledge about their investments in mental health and have economic substantiation for their decisions. The same severity levels applied for the original model (Figure 11) can also be considered with mental health issues. Stress can affect as well the employees from a negligible or temporary discomfort to permanent disablement or fatality (committing suicide). New scores based on mental health data must be defined for the different severity levels. Some stakes must be overcome to obtain reliable data about the mental well-being issues that employees are facing. Data collection is not only not forced by OSHA law, but ethical rules and the right to privacy of employees represent an impediment to obtaining the required information. Other challenges that future researchers must break are the mixture of data and some strong relationships that safety and mental health can have. If safety and mental health investments want to be addressed separately, some objective-defined protocols must be presented to construction companies. How to assign costs to safety and mental health must be explained. Lower severity levels are being neglected in safety models, as the efforts of the industry are put into the high severity accidents. This behavior is justified by the exponential behavior of injury costs. In the design of mental health economic models, the low severity cases should not be ignored, as the exponential behavior of costs equations is not proven yet, nor is the non-relationship between the higher and low severity issues. Finally, fatalities caused by extremely poor mental health are more subjective when it is required to define who must be held accountable. A workplace accident that causes the death of an employee is easily attributed to the employer, but a suicide, in or outside the workspace, or an accident originated by employee’s mental health problems, is much more difficult to demonstrate who is the responsible. Positive actions to improve mental well-being among construction workers Page 57 7. Costs The Construction Safety Research Alliance is supported by the generosity, engagement, and vision of industry partners. Thanks to the financial and in-kind support of partner organizations, CSRA received initial funding of $ 75,000 to start developing this project. This thesis is the beginning of a long-term project that aims to change the workplace conditions of construction workers. The project started in February 2020, and the budget used in these first five months is disclosed below (Tables 9 & 10) Table 9. Staff costs Table 10. Training costs Team member Activity Institution Hours Price per hour ($/h) Total price Arnau Altet Advanced Safety Course University of Colorado Boulder 24 $ 20,79 $ 499,00 The total cost of this master’s thesis has been $ 7.999,00. The CSRA, together with the University of Colorado Boulder, assumed $ 5.249 (65,6%), and the Europe-Colorado program the remaining $ 2750 (34,3%). The Construction Safety Research Alliance assigned 7% of the initial budget to this thesis. Much more investment from the partners is expected in the following years. Team member Position Institution Hours Price per hour ($/h) Total price Arnau Altet Researcher CSRA 400 $ 13,75 $ 2.750,00 Europe - Colorado, Balsells fellowship $ 2.750,00 Siddharth Bhandari Associate Director of Research CSRA 40 $ 50,00 $ 2.000,00 $ 7.500,00 Page 64 Thesis report construction professionals: an integrated explanatory model, Construction Management and Economics, 36:3, 153-174, DOI: 10.1080/01446193.2017.1341638 [24] Love, Peter ED, David J. Edwards, and Zahir Irani. "Work stress, support, and mental health in construction." Journal of construction engineering and management 136.6 (2010): 650-658. [25] Boschman, J. S., et al. "Psychosocial work environment and mental health among construction workers." Applied ergonomics 44.5 (2013): 748-755. [26] Gawel, Joseph E. (1996) "Herzberg's Theory of Motivation and Maslow's Hierarchy of Needs," Practical Assessment, Research, and Evaluation: Vol. 5, Article 11. DOI: https://doi.org/10.7275/31qy-ea53 [27] Locke, Edwin A., and Gary P. Latham. "Goal setting theory: The current state." (2013). [28] Katzenbach, Jon R., and Douglas K. Smith. The wisdom of teams: Creating the highperformance organization. Harvard Business Review Press, 2015. [29] Pardee, Ronald L. "Motivation Theories of Maslow, Herzberg, McGregor & McClelland. A Literature Review of Selected Theories Dealing with Job Satisfaction and Motivation." (1990). [30] Rybnicek, R., Bergner, S. & Gutschelhofer, A. How individual needs influence motivation effects: a neuroscientific study on McClelland’s need theory. Rev Manag Sci 13, 443–482 (2019). https://doi.org/10.1007/s11846-017-0252-1 [31] Tsutsumi, Akizumi, et al. "Association between job stress and depression among Japanese employees threatened by job loss in a comparison between two complementary job-stress models." Scandinavian journal of work, environment & health (2001): 146-153. [32] Bowen, Paul, Rajen Govender, and Peter Edwards. "Structural equation modeling of occupational stress in the construction industry." Journal of Construction Engineering and Management 140.9 (2014): 04014042. [33] Boschman, J. S., et al. "Psychosocial work environment and mental health among construction workers." Applied ergonomics 44.5 (2013): 748-755. [34] McClelland, David C., and David H. Burnham. Power is the great motivator. Harvard Business Review Press, 2008. Positive actions to improve mental well-being among construction workers Page 65 [35] Lingard, Helen, et al. "Improving employees’ work-life balance in the construction industry: Project alliance case study." Journal of construction engineering and management 133.10 (2007): 807-815. [36] Kamardeen, Imriyas, and Riza Yosia Sunindijo. "Personal characteristics moderate work stress in construction professionals." Journal of Construction Engineering and Management 143.10 (2017): 04017072. [37] Bowen, Paul, et al. "Work-related contact, work–family conflict, psychological distress and sleep problems experienced by construction professionals: An integrated explanatory model." Construction management and economics 36.3 (2018): 153-174. [38] Hu, Bing Shuang, et al. "Posttraumatic stress disorder in co-workers following exposure to a fatal construction accident in China." International journal of occupational and environmental health 6.3 (2000): 203-207. [39] Jacobsen, Henrik Borsting, et al. "Construction workers struggle with a high prevalence of mental distress and this is associated with their pain and injuries." Journal of occupational and environmental medicine/American College of Occupational and Environmental Medicine 55.10 (2013): 1197. [40] Kuster, Farah, Ulrich Orth, and Laurenz L. Meier. "Rumination mediates the prospective effect of low self-esteem on depression: A five-wave longitudinal study." Personality and Social Psychology Bulletin 38.6 (2012): 747-759. [41] Dipboye, Robert L., and Adrienne Colella, eds. Discrimination at work: The psychological and organizational bases. Psychology Press, 2013. [42] Boatman, Laura, et al. "Creating a climate for ergonomic changes in the construction industry." American journal of industrial medicine 58.8 (2015): 858-869. [43] Sadeghniiat-Haghighi, Khosro, and Zohreh Yazdi. "Fatigue management in the workplace." Industrial psychiatry journal 24.1 (2015): 12. [44] Welch, Laura S., et al. "Impact of musculoskeletal and medical conditions on disability retirement—a longitudinal study among construction roofers." American journal of industrial medicine 53.6 (2010): 552-560. [45] Dembe, Allard E. "The social consequences of occupational injuries and illnesses." American journal of industrial medicine 40.4 (2001): 403-417. Page 66 Thesis report [46] Horn, Sarah R., and Adriana Feder. "Understanding resilience and preventing and treating PTSD." Harvard review of psychiatry 26.3 (2018): 158-174. [47] Sutherland, Valerie, and Marilyn J. Davidson. "Using a stress audit: The construction site manager experience in the UK." Work & Stress 7.3 (1993): 273-286. [48] Deci, Edward L., Anja H. Olafsen, and Richard M. Ryan. "Self-determination theory in work organizations: The state of a science." Annual review of organizational psychology and organizational behavior 4 (2017): 19-43. [49] Suárez, J. Gerald. Managing fear in the workplace. TOTAL QUALITY LEADERSHIP OFFICE ARLINGTON VA, 1993. [50] Construction Workers and Addiction: Statistics, Recovery & Treatment Options (americanaddictioncenters.org) [51] Adler, Nancy E., and Joan M. Ostrove. "Socioeconomic status and health: what we know and what we don't." Annals of the New York academy of Sciences 896.1 (1999): 3-15. [52] Kegel, Paul. "The impact of the physical work environment on organizational outcomes: a structured review of the literature." Journal of Facility Management Education and Research 1.1 (2017): 19-29. [53] Lim, Soram, et al. "Analyzing psychological conditions of field-workers in the construction industry." International journal of occupational and environmental health 23.4 (2017): 261-281. [54] Reddy, Gopireddy MM, et al. "Musculoskeletal morbidity among construction workers: A cross-sectional community-based study." Indian journal of occupational and environmental medicine 20.3 (2016): 144. [55] https://www.nrca.net/RoofingNews/construction-workers-anxiety-depression-haveworsened-amid-pandemic.2-8-2022.10254/details/story [56] Hudson, Darrell L., et al. "Racial discrimination, john henryism, and depression among African Americans." Journal of Black psychology 42.3 (2016): 221-243. [57] Lazarus, Richard S., and Susan Folkman. Stress, appraisal, and coping. Springer publishing company, 1984. [58] Chu, Brianna, et al. "Physiology, stress reaction." StatPearls [Internet]. StatPearls Positive actions to improve mental well-being among construction workers Page 67 Publishing, 2021. [59] Kagias, Konstantinos, Camilla Nehammer, and Roger Pocock. "Neuronal responses to physiological stress." Frontiers in genetics 3 (2012): 222. [60] How to Support Mental Health in the Construction Workforce (nccer.org) [61] Hallowell, Matthew R., and John A. Gambatese. "Construction safety risk mitigation." Journal of Construction Engineering and Management 135.12 (2009): 13161323. [62] Hallowell, Matthew R., and John A. Gambatese. "Activity-based safety risk quantification for concrete formwork construction." Journal of construction engineering and management 135.10 (2009): 990-998. [63] Hallowell, Matthew R. "Risk-based framework for safety investment in construction organizations." Journal of Construction Engineering and Management 137.8 (2011): 592-599. [64] Portoghese, Igor, et al. "Measuring burnout among university students: factorial validity, invariance, and latent profiles of the Italian version of the Maslach Burnout Inventory Student Survey (MBI-SS)." Frontiers in psychology (2018): 2105. [65] Ruotsalainen, Jani H., et al. "Preventing occupational stress in healthcare workers." Cochrane Database of Systematic Reviews 11 (2014). [66] Wijnen, Ben FM, et al. "Implementing interventions to reduce work-related stress among health-care workers: An investment appraisal from the employer’s perspective." International Archives of Occupational and Environmental Health 93.1 (2020): 123-132. [67] Hoek, Rianne JA, et al. "Stress Prevention@ Work: a study protocol for the evaluation of a multifaceted integral stress prevention strategy to prevent employee stress in a healthcare organization: a cluster controlled trial." BMC Public Health 18.1 (2018): 1-8. [68] Srivastava, A. K., and A. P. Singh. "Occupational stress index." Indian Journal of Clinical Psychology (1984). [69] Nieuwenhuijsen, K., et al. "The Depression Anxiety Stress Scales (DASS): detecting anxiety disorder and depression in employees absent from work because of mental health problems." Occupational and Environmental Medicine 60.suppl 1 (2003): i77-i82. Page 68 Thesis report [70] Morra Aarons-Mele, “We need to talk more about mental health at work,” Harvard Business Review, November 1, 2018, hbr.org.