Introduction

Suicide is a global problem, and in Sweden approximately 1500 individuals die by suicide every year [1]. A number of risk factors for suicide have been identified including mental health disorders [2], somatic illness [3], unemployment and low socio-economic status [4]. Occupation and work-related factors also appear to influence the risk of suicide [1, 5, 6].

Adverse working conditions can potentially lead to suicide via depression or other psychiatric disorders and accumulating evidence shows that job stressors are associated with mental health problems [7, 8]. However, not all who die by suicide suffer from psychiatric disorders, and other work-related factors that have been associated with suicide include poor social support, bullying, exposure to trauma on the job, working in isolation and access to means [9].

There is growing evidence linking psychosocial job stressors to suicide [7, 9]. Milner et al [10] conducted a meta-analysis of suicidality and a wide range of psychosocial job stressors such as high demands, low control and lack of support, and found that exposure to job stressors was associated with an elevated risk of suicidal ideation and behaviours. The authors concluded that there is some evidence that psychosocial job stressors could be related to suicidal outcomes but highlighted that most studies were cross-sectional and that there was a need for further research to assess the robustness of the findings. A systematic literature review of work and suicide [5] found a link between occupational stressors and suicidal ideation. It was suggested that workplace ostracism, being excluded or ignored at work, may have a particularly strong effect on suicidal ideation, as this may lead to extreme feelings of thwarted belonginess [5, 11]. Workplace social support was associated with a lower risk of suicide [5]. Similarly, other studies of psychosocial factors at work have found an increased risk of suicidal behaviour for passive jobs (low demands and low control), low social support, high strain (high demands and low control) and low control [8, 9, 12]. In addition, recent research has suggested that gender dominance at workplace and occupation can be associated with suicide risk among men [1].

Death by suicide is more common among men than among women worldwide [13]. Men use more lethal suicide methods, are more likely to underreport mental ill-health and less often seek help from professionals than women [5, 14, 15]. Construction workers have an increased risk of work-related ill-health [16, 17], and male construction workers have been identified as a group with elevated risk of suicide [18–22]. A recent meta-analysis found an increased risk of construction worker suicide compared to the wider population, with a relative suicide risk of 1.25 [19]. In the US the suicide rates have been reported to be four times higher in the construction industry compared to the national average, and in the UK 3.7 times higher [22]. In Sweden it has been found that specific occupations within the construction sector, laborers and rock workers, have a higher risk for suicidal behaviour compared to other occupational groups within the construction sector, with hazard ratios of 1.4 and 1.5 respectively [6]. Poor help-seeking, stigma relating to mental health issues and macho culture have been identified as reasons to why males in the construction industry have a higher risk of suicide, although the reasons are multifaceted [20, 22]. In a recent literature review of suicide in the construction industry [17] the most common suicide risk factor was job insecurity followed by alcohol and substance abuse, lack of help-seeking, physical injury and chronic pain. Other possible reasons for higher risks for suicide among construction workers is lower educational attainment. Employees in construction have a lower educational attainment compared to most other industries [23]. A large study with more than 815 000 participants found that educational attainment may causally influence suicide attempt risk [24]. In addition, social isolation, financial insecurity and homelessness have been identified as suicide risk factors for construction workers [17]. A mixed-methods study [21] found that many construction workers do not share or seek help when in distress. They also found that there was an experience of distrust towards services provided by the workplace and that alcohol or drugs were used for self-medication against distress. On the other hand, these elevated rates may be modifiable: A study investigating the suicide mortality of Australian male construction workers during the last two decades found a rapid decline among construction workers compared to other workers [18]. The (surveillance) analysis did not address why this was the case, but the authors speculated that the improved economic activity in the construction industry, lower unemployment rates, sector-specific suicide prevention initiatives, and other factors may have contributed to the decline in suicide rates.

The workplace can be an arena for suicide prevention by focusing on workplace factors that influence the risk of suicide, including promoting helping behaviours, reducing stigma, and improving working conditions [5, 9, 22]. To inform future workplace interventions it is important to increase the knowledge of mental health and suicidal behaviour in the construction industry. Qualitative studies can provide in-depth investigations of complex phenomena such as mental health and suicidal behaviour in a work context. To our knowledge there are no previous Swedish qualitative studies investigating these issues among male construction workers in Sweden. The aim of the present study was to explore perceptions of mental ill health, suicidal behaviour and working conditions among male construction workers, in order to increase the understanding of these phenomenon and to identify relevant avenues to tailor workplace interventions to the Swedish context.

Materials and methods

Participants

A purposeful sampling strategy was used to ensure that the sample consisted of male participants with relevant experience relating to the study aims. In total, 43 males participated, with 11 individual interviews and 7 focus group interviews. The participants were individuals with work experience in the construction industry including workers, managers, and union representatives. The participants were recruited via different forums including unions, large and small construction companies, and advertisement in a construction industry union magazine, and they are further described in Table 1. The recruitment took place from 01/09/2022 until 01/05/2023. Participants received no reimbursement for their participation.

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Table 1. Information regarding participants.

https://doi.org/10.1371/journal.pone.0307433.t001

Data analysis

Thematic analysis [26] was used, as this was deemed suitable to explore perceptions of mental ill health, suicidal behaviour and working conditions among male construction workers. Thematic analysis is theoretically flexible and can be applied using different ontological and epistemological approaches. In this study a realist approach was adopted, meaning that it was considered possible to explore the participants’ experiences of their reality via interviews [26]. It was assumed that the investigation of mental ill health and suicidal behaviour among male construction workers could result in a number of themes rather than being explained by one single phenomenon. Hence, we aimed to present a description of the entire dataset relating to the research topic. This is suitable when there is less knowledge and previous research on the topic, as described by Braun and Clarke [26]. An inductive, data-driven approach was chosen as it would enable the identification of patterns and unexpected themes, which would provide a rich, detailed, and multifaceted account of the underlying data, not preconceived by the researchers. However, a reflexive attitude was adopted and critical discussions attended to the context and considered our pre-existing knowledge.

The analysis was performed by one of the authors (KA) according to the six phases described by Braun and Clark [26]. The first and second steps were to get familiarized with the data by reading each transcript several times, while registering initial codes that captured interesting features of the data. The entire dataset was systematically coded. In a third step, emerging conceptual themes were identified. Themes were identified based on their “keyness”, described as capturing something important in relation to the research aim. Next, the list of main themes was reviewed and refined until a list of defined main themes and sub-themes was established, capturing coherent data to create mutually exclusive themes. In order to strengthen trustworthiness, one of the co-authors (MS) also read all the interviews and checked and then discussed the coding done by KA, until a list of themes was agreed on. Then three of the other co-authors reviewed the analysis and slight changes were performed until a final list of main themes and sub-themes was agreed on. The final themes were named and defined, and specific quotes from the interviews were selected to describe each theme. See Table 2 for an example of the analytical process.

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Table 2. An example of the process of abstraction.

https://doi.org/10.1371/journal.pone.0307433.t002

Results

The analysis of the data resulted in identification of five main themes and a number of sub-themes (Table 3).

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Table 3. Main themes and sub-themes.

https://doi.org/10.1371/journal.pone.0307433.t003

Discussion

The current study explored perceptions of mental ill health, suicidal behaviour and working conditions among male construction workers, in order to increase the understanding of these phenomenon and to identify relevant avenues for workplace interventions. Five main themes were found in the analysis: Difficult to talk about mental health, Demanding working environment affects mental health, Substance abuse in the workplace, Importance of management, and Need for routines and social support in the workplace. Below, each theme will be discussed in turn.

The first main theme, Difficult to talk about mental health, highlighted stigma related to mental health problems in the construction industry. It was perceived to be very difficult to talk about mental health problems and that it was easier to talk about somatic problems. Previous research has found that stigma, relating to mental health, acts as a barrier to help-seeking among construction workers [27]. Similarly, stigma relating to mental health issues and low levels of help-seeking have been reported to contribute to the elevated risk of suicide observed in construction workers [20]. The participants in the current study also described a macho culture that encouraged a narrow gender role for males that promotes self-reliance and does not encourage help seeking or sharing of vulnerabilities. Construction site work has been linked to traditional masculine behaviours such as stoicism, emotional restraint, risk-taking, competitiveness and toughness [28]. It has also been suggested that stigma toward mental health problems may be particularly apparent in male-dominated industries, such as construction, where traditional ideas about masculinity tend to be maintained [27]. A literature review of suicide in the construction industry suggested that the macho culture was one reason for the elevated levels of suicide in this industry [22]. A previous study [21] suggested that many workers in the construction industry do not share that they are distressed and consequently do not identify or seek help to deal with their distress. Wittenhagen and Meurk’s [21] study identified that the construction industry was in need of a shift in workplace culture in order to promote help-seeing behaviour to reduce distress. A supportive non-judgmental environment that respects individual privacy was viewed as very important. The results in the current study highlighted that suicide was viewed as something that occurred out of the blue, and that it was difficult to see any warning signs. Follmer & Jones [29] have suggested that, despite organisations’ best efforts, some employees may not disclose suicidal ideation at work because of fear of stigmatization or discrimination. In the current study the participants were feeling shocked when a suicide had occurred and described being very emotionally affected. Howard et al. [5] found that suicide deaths have negative consequences beyond the individual, affecting co-workers and organizations and suggests that employers have good reasons to attend to how the workplace can provide support after workmate suicide. A review of interventions for suicide survivors [30] found that each suicide impacts many people, and co-workers often experience negative emotional and behavioural consequences, such as social withdrawal and reduced productivity, as a result of the loss. Indeed, some suicide programs include postvention, that entails interventions following a suicide in a work group. The aims of postvention are to alleviate the distress and promote recovery of the affected group of co-workers and to reduce risk of further suicides in the workgroup [9].

The second main theme was the Demanding working environment affects mental health. According to the participants the working environment was very stressful and physically demanding and had a negative effect on workers’ wellbeing. This is in accordance with previous research that has found that stressful and physically demanding working conditions could be contributing factors to suicide [5, 7, 9, 10, 12, 31]. In the current study the participants described that long-term physical pain often caused by occupational injury or illness, caused by high physical demands, could lead to psychological pain. Previous research has found a comorbidity between physical pain and psychological disorders such as depression and anxiety [32]. Construction work is physically demanding and can be challenging and dangerous which may lead to both musculoskeletal disorders and occupational injuries [27]. These physical risks may lead to both physical and mental health problems [4]. Occupational injuries are associated with elevated rates of suicide, which can be mediated by pain, loss of work role, reduction of income, adverse experiences with disability support processes, and more [9]. In the literature review of suicide in the construction industry risk factors included physical injury and chronic pain [22]. In the current study the participants also reported a hierarchical culture in the construction industry where particularly apprentices were exposed to a lack of support and at times bullying. Similar findings have been reported in previous research. For example, one Australian study found that apprentices are faced a number of challenges while transitioning into the construction industry; they needed to learn their unique position in the social and organisational hierarchy [33].

The third main theme was Substance abuse among construction workers. Excessive use of alcohol was perceived as a strong risk factor for suicide. Alcohol and substance abuse has been identified as a risk factor for suicide in the construction industry [22]. It has been estimated that alcohol is involved in approximately 30% of all suicide attempts [34] and alcohol use is a substantive risk factor for death by suicide [35]. Previous research has found that substance abuse problems are more common among construction workers compared to members of other occupational groups [27]. In the current study overuse of painkillers was described as a way to cope with long-term pain, and as a risk factor for suicide. Previous research has found that using painkillers to alleviate work-related pain is a common problem in the construction industry [36, 37]. It has also been suggested that it is not uncommon that workers in the construction industry self-medicate with alcohol or medication instead of seeking help when feeling distressed [21].

A further main theme was the Influence of management, which highlighted that managers may play an important role in both catalysing and alleviating mental health problems. Some managers with low mental health literacy missed typical signs of mental health issues. A recent study on distress in the construction industry found that some individuals may hide their distress, thus requiring that someone else notices the signs [21]. A systematic literature review of work and suicide [4, 5] found some support for the relation between leadership constructs and suicidal ideation, but pointed out that this research is still in its infancy. Previous research has found that interventions aiming to improve leaders’ mental health awareness have been effective in increasing intentions to promote mental health at work [38, 39], and this is an explicit action recommendation in the WHO Guidelines on work and mental health [40]. The MATES programme from Australia, a multimodal workplace-based suicide intervention program for the construction industry, aims to train individuals at all levels in an organisation including managers [41]. A systematic review of the MATES program found that it was effective in improving mental health and suicide prevention literacy, and that peer support workers were the most trusted people to go to with concerns [41]. Hence, mental health support training might most beneficially be offered to workers at all occupational levels, ranging from labourers to union reps and managers.

The final main theme was Need for routines and support in the workplace. The results from this study add to existing knowledge by highlighting that many individuals did not know what to do to if they themselves, or a workmate was suffering from mental health problems. A need was expressed for clear routines and guidelines for how individuals could get help and support regarding mental health. Indeed, many have suggested that the workplace is an important arena to tackle mental health problems, regardless of whether work caused the problems or not [5, 9, 31, 42, 43]. Howard et al. [5] suggested that organisations should provide support that can be accessed independently and anonymously, and at a minimum provide information on suicide hotlines and contact information for local counsellors and therapists in order to raise employees’ awareness of available support services. The MATES programme is an example of workplace support that connects workers in the construction industry to the most suitable available help [41]. The study by Wittenhagen and Meurk [21] identified many different options for distressed construction workers to seek help, including work colleagues or supervisor, MATES in Construction, helplines, sports clubs, health professionals, Employee Assistance Programs. In the current study it was suggested that colleagues could provide good support, but that this was only the case for the workers who belonged to the collegial group. In the systematic literature review of work and suicide by Howard et al. [5] workplace social support was found to be associated with a lower risk of suicide. It was also suggested that being excluded or ignored at work, may have a particularly strong effect on suicidal ideation, as this behaviour may lead to extreme feelings of thwarted belonginess [5, 11]. A study of the French working population found associations between suicide and low social support [12]. In the current study the participants expressed that the occupational health services could play an important role in providing support in the workplace, but that this was not always the case. For example, one issue was the need for approval by the manager before the service could be accessed. In the study by Wittenhagen and Meurk, [21] it was found that some individuals may not seek help because they did not trust the services provided through the workplace. Some workplace suicide prevention programs, internationally, provide independent sources of support that are confidential and do not require management approval [40].

Conclusions

The results from this Swedish study fit well with previous international findings regarding the challenges of a macho culture and persistent stigma of mental health in the construction industry. The themes also described a demanding working environment, a link between physical and psychological pain and alcohol as a serious risk factor for suicide. The study adds to existing knowledge by highlighting that suicides that had occurred among workmates were perceived to be very unexpected, and that many individuals did now know what to do to if they themselves, or a workmate was dealing with mental health problems. Possible implications for workplace interventions include facilitation of discussions of mental health in the workplace, training at work to recognise risk factors and to talk about mental health problems and clear routines in the workplace regarding support for mental health problems.

Supporting information

Acknowledgments

We would like to thank everyone who participated in the interviews.