Stress, fear, and anxiety among construction workers: a systematic review

Objectives The aim of this review was to assess the possible risk factors arising from working conditions, that could have an impact on the stress, fear, and anxiety of construction workers. Methods A systematic review was conducted following the PRISMA format in the Pubmed, Cochrane, Web of Science, Scopus, and PsycInfo electronic databases on February 3, 2023, using the following key words: anxiety, stress, fear, and construction workers. Methodological quality was assessed using the critical appraisal tools of the Joanna Briggs Institute. Results A total of 35 studies were included. The results showed a number of conditioning factors for stress, anxiety, and fear among construction workers such as age, inappropriate safety equipment, safety culture, high workload and long working hours, physical pain, low social support from direct supervisor or co-workers, lack of organizational justice and lack of reward, financial situation, maladaptive coping strategies, and characteristics of the pandemic. Conclusions There are a number of risk factors related to working conditions, organizations, and individuals that can affect the levels of stress, anxiety, and fear among construction workers, such as age, work hardship, safety culture and, especially, the long hours that construction professionals work. This may lead to an increase in the number of occupational accidents and higher associated fatality rates. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022367724, identifier: CRD42022367724.


Introduction
The construction sector is currently one of the main productive sectors and economic engines in most countries (1). It is in constant change, evolving as techniques improve and new technological advances appear. Despite this, it is one of the sectors with the highest mortality rates worldwide (2, 3), as it involves complex and hazardous activities such as construction itself, damming, road construction, engineering activities, demolition of all types of structures, rehabilitation and maintenance of structures, among others (4). These activities may involve a certain degree of danger if appropriate protective measures are . /fpubh. . not taken as they involve working at heights and with electrical hazards, exposure to high temperatures, excessive noise, chemical handling and dusty environment, carrying heavy equipment, handling heavy loads, and using heavy machinery (5). These circumstances or factors, which are not exceptional but common in their activity, make these workers carry out their work in harsh conditions that involve constant efforts and in environmental conditions that make their work difficult. The tasks that construction workers perform may be found to be unsatisfactory for them due to the concurrence of factors related to the work itself, individual characteristics, lifestyle and concomitant health problems, and/or problems related to the professional performance itself (6,7). In fact, these are considered to be high stress environments (8) and in which mental health problems appear to be growing (9). Stress among construction workers can lead to other problems on a physical level such as musculoskeletal disorders, on a mental level such as anxiety, and it can reduce productivity through absenteeism and presenteeism (10) and lead to errors that may endanger the safety and health of workers and co-workers (7).
Stress can be considered as the body's response to frequent and/or continuous mismatches between an individual's demands and the individual's ability to cope with them (11). This has direct physiological effects on the person and also affects health when our health maintenance behaviors are altered (12). The transactional model is one of the most prestigious models of the psychosocial stress process. Lazarus calls it "transactional" because it states that stress originates neither in the person nor in the environment, but in the interaction between the two (13). On the other hand, the Job Demands-Resources (JD-R) model developed by Bakker and Demerouti (14) provides an insight into how a mismatch between work demands and resources can lead to mental health problems such as stress, anxiety, and fear. But mental diseases are not only caused by factors intrinsic to the construction site. Other studies have shown that the socio-cultural environment in which the worker lives is a key factor for the development of mental illnesses, many of which are associated with the consumption of alcohol and other substances (15).
It is well known that construction projects often have very tight deadlines. This means that the teams of people who carry out the work, whether they are craftsmen, site teams, supervisors, or technical staff, are under a lot of pressure from their companies. In addition to stress, this can cause anxiety in the worker. Anxiety, according to Spielberger (16), can be divided into state anxiety and trait anxiety. While the former is a temporary and situational state of emotion in response to a threat, the latter is part of the personality of each individual. Although there are several studies that have assessed the levels of anxiety, stress, and fear in construction workers, each of them addresses a number of specific factors that may increase the levels of these three variables, but it is uncertain which were analyzed as risk factors for each variable (anxiety, stress, and fear) and in each study. In a sector with a high number of occupational accidents, knowing the factors could be a useful tool for establishing possible effective protective and preventive measures for these workers, and could help future researchers to consider and prioritize some risk factors over others. Therefore, the aim of the study was to assess the factors influencing stress, fear, and anxiety among construction workers.

Study design
In order to assess the risk factors related to levels of anxiety, stress, and fear among construction workers in the construction industry, a systematic review was conducted following the guidelines of the PRISMA statement (Preferred Reporting Items for Systematic reviews and Meta-Analyses) (17). The protocol followed is listed in the International Prospective Register of Systematic Reviews (PROSPERO) with code CRD42022367724.

Databases and search strategy
The search was carried out in the Pubmed, Cochrane Library, Web of Science Scopus, and PsycInfo electronic databases on the basis of the keywords that the research question yielded following the PECO strategy (Table 1).
Based on these keywords, the Medical Subject Headings (MeSH) thesaurus was consulted, yielding the descriptors Anxiety, Psychological Stress, Fear, and Construction industry. In order to enlarge the scope of the search, synonymous terms were used to complete the search based on the Medical Subject Headings (MeSH) thesaurus (Table 2), linked by the Boolean operators AND and OR. Table 3 shows the search strategy used, carried out on February 3, 2023, for each of the above databases during the search process for articles published in the last 10 years.

Selection criteria
The following inclusion criteria were used for the selection of articles: (1) original articles published in English, Spanish, French, and Portuguese; (2) typology: original articles, metaanalysis, short communications, and case reports; (3) articles published in the last 10 years; and (4) articles measuring any of the following values and/or effects: level of stress, anxiety and fear, number of cases of people with stress/anxiety/fear, substance .

Data collection and extraction
For this search, a pre-established protocol was initially followed for the search and revision strategy in order to minimize the risk of bias in the selection and subsequent publication. This strategy was similar in the different databases by using the aforementioned descriptors and related keywords through the Boolean operators AND and OR. In the drafting of this work, two researchers independently carried out the bibliographic searches. As a secondary strategy, a search was carried out based on the use of references and names of the authors cited in the different records selected (reverse or snowball search) with the intention of verifying the existence of works not found in the primary search. For the screening and selection of articles, duplicate studies were eliminated and those articles that could be included were selected after reading the abstract and title according to the previously established criteria. After this initial screening, the same authors analyzed the full articles and selected those studies potentially suitable for inclusion in the review. This selection was made by consensus between the two researchers and any discrepancies that may have arisen were resolved by a third author.

Methodological quality assessment
Two reviewers independently determined the methodological quality of the selected studies using the critical appraisal tools of  These tools allow the assessment of the methodological quality of a study and the extent to which a study has excluded or minimized the possibility of bias in its design, conduct, and/or analysis. The versions for analytical cross-sectional studies ( Table S3) were used, setting the cut-off point at 6-9, respectively, for inclusion in this review. The included studies were assessed and the mean scores were obtained.

Results
A total of 35 studies were selected. The initial search strategies identified a total of 1,150 references, which were then screened according to the topic of this review. Twenty-six of the 35 studies were analytical cross-sectional studies, 2 carried out qualitative research, 6 were mixed methods, and 1 was a quasi-experimental study ( Figure 1). Table 4 shows the characteristics of each of the 35 studies included in this review. These were classified by author and year of publication, country, design and objective, participants, instrument, and main results. In addition, the results of the JBI critical appraisal tool were added.
Of the 35 selected studies, 8 articles were conducted in China; 4 in the United States, Australia and Korea; 2 studies were conducted in Singapore, Ghana, and India; and 1 study was conducted in Canada, Ethiopia, the Netherlands, Indonesia, Nigeria, the United Kingdom, Pakistan, Saudi Arabia, and Taiwan. In 26 of the 35 selected articles, the sample consisted of construction workers in general, and in 3 of them a distinction was made between workers and supervisors. In another 2, the sample consisted of foreign or migrant construction workers, and the rest had specific characteristics, making a total aggregate sample of 13,399 subjects. As for the topic of research, 31 studies were found on stress, 10 on anxiety, and 3 on fear.

Stress
The prevalence of substantial mental distress was between 16 and 50% among construction workers (20,32) [20,32]. A number of age-related stressors were identified (21,30,33,39)   The prevalence of substantial mental distress was 16% in CWs. This was supported by follow-up clinical interviews where 9 of 10 workers fulfilled the criteria for a mental disorder. Substantial mental distress was associated with both injury rate and self-reported pain.   The most frequently reported stressors were missing special events (86%), relationship problems with partners (68%), financial stress (62%), shift rosters (62%), and social isolation (60%). High psychological distress was significantly more likely in workers aged 25-34 years and workers on a 2 weeks on/1 week off roster. Workers who were very or extremely stressed by their assigned tasks or job, their current relationship, or their financial situation were significantly more likely to have high/very high K10 scores than those not stressed by these factors. Workers who reported stress related to stigmatization of mental health problems were at the greatest risk of high/very high psychological distress.

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Chakraborty et al.   Age was positively related to perceived stress. Job tenure was positively associated with both perceived stress and employee age. Skill discretion was not related to perceived stress in younger workers while it was negatively related to perceived stress in older workers. There is a negative relationship between LMX and perceived stress in older workers. However, for younger workers, LMX was not related to perceived stress. A negative relationship between procedural fairness and perceived stress was confirmed in older workers, unlike in younger workers.   Prevalence of risky drinking was higher than the national average, particularly for younger (<25 years) and mid-aged (45-54 years) workers. One in 6 CWs reported workmates being visibly affected by alcohol in the workplace. Key predictors of risky drinking were perception of alcohol-related risks to workplace safety, general health, alcohol knowledge and descriptive norms regarding workmates' alcohol use. Although job stress was positively correlated with AUDIT-C scores, it was not found to be a significant predictor of drinking in this study, indicating that stress was not a primary driver of alcohol in the sample.

Australia
To understand CWs work ability through exploring musculoskeletal bodily pain and the impact this has on construction workers' mental health.
-Musculoskeletal pain -Work ability -DASS-21 When broken down by age group, level of depression, anxiety, and stress were in the normal range for all age groups apart from participants in the 30-39 age group who experienced a mild level of anxiety. Participants whose pain had originated from work and who had upper neck and back pain, lower back pain, and pain in other joints had a significantly higher level of depression severity.  3 themes emerged from the interviews and focus groups: job demands and structure, social support and workplace relations, and job precarity. From the survey, higher psychological demands, higher work-to-family conflict, lower supervisor support, higher discrimination, and higher likelihood of losing a job were associated with higher psychological distress. When combined into a single model job, demands and work-to-family conflict remained significant.

Iremeka et al. (42) Nigeria
To ascertain the effect of a group rational emotive behavior therapy (group REBT) on stress management among skilled construction workers in Nigeria.

Quantitative cross-sectional study
Skilled CWs (n = 160) -PSS-14 -WIB-Q -Telegram group -Group REBT (8 weeks) Results show that group REBT significantly improved stress and work-related irrational beliefs scores of the skilled construction workers after they were exposed to the intervention and compared with their colleagues in the control group. The significant reduction in stress and work-related irrational beliefs scores of the treatment group were also sustained at follow-up.  Emotional stress in CWs can be positively predicted by confrontative coping, emotional discharge, and self-control, but can be negatively predicted by proactive coping. Similarly, physical stress is positively predicted by confrontative coping, self-control and avoidance, but negatively predicted by proactive coping. Non-compliance with safety rules was positively predicted by emotional stress, physical stress, and avoidance. No demographic factor was identified as a significant stress or safety factor for workers. The more working hours, the higher the working stress, so it was the highest when working more than 57 h. Job stress was significantly lower in the promotion opportunity variable, when they were unmarried and in charge of practical affairs (p < 0.05).

Frimpong et al. (45) Ghana
To analyze the influence of age and work location on young workers' work-related mental health.

Mixed methods approach
Young CWs (n = 445) Interviews, focus group discussion and quantitative survey instrument.
-Work-related physical health -Work-related mental health There was a high prevalence of the work-related substance abuse disorder, sleep problems, schizophrenia, and mania. No significant differences in the levels of work-related mental health problems were exhibited among different youth age sub-groups. Work location however accounted for significant differences in the levels of substance abuse disorder, sleep problems, anxiety disorder, and somatic symptoms exhibited. Pandemic perception was significantly related to psychological and physical stress. Emotion-focused coping was mainly triggered by pandemic fear and job insecurity, while problem-focused coping was mainly triggered by organizational pandemic response. Furthermore, the effects of pandemic fear and organizational pandemic response on job stress were mediated by problem-focused coping. Singapore To establish the prevalence of depression, anxiety and stress among foreign workers in the construction industry in Singapore.
About 29% of the study population exhibited moderate to extremely severe levels of depression; 37% showed moderate to extremely severe levels of anxiety; and 33% expressed moderate to extremely severe levels of stress. Ethnicity and lack of awareness of job scope were found to be significant predictors of all three parameters studied, namely, depression, anxiety and stress.
The results also revealed stress as a causative agent of occupational accidents (29,36,40).

Anxiety
Between 37 and 50% of construction workers showed moderate to extremely severe levels of anxiety (47,50). Among the risk factors to which construction workers may be exposed are those related to working conditions (25,37,45), working hours (28), substance use (28) and nicotine dependence (50), safety culture (37), age (39), high workload (37), lack of organizational justice and lack of reward (37), ethnicity and lack of knowledge (47), and the characteristics of the pandemic (51).

Fear
Fear among construction workers was mainly associated with the characteristics of the COVID-19 pandemic (46, 51), with possible job insecurity (46), and with fear of losing their jobs (49).

Discussion
The different studies showed multiple conditioning factors for stress, anxiety, and fear among construction workers such as age, inappropriate safety equipment, safety culture, high workload and long working hours, physical pain, low social support from direct supervisor or co-workers, lack of organizational justice and lack of reward, financial situation, maladaptive coping strategies, and characteristics of the pandemic.
The number of hours worked by employees is a determining factor for the level of stress according to the Occupational Stress Index (OSI). Several studies have found working hours of more than 12 h per day (27) or up to 47 h per week (28). This may lead to people not having enough time to spend with family/friends or to experimenting considerable fatigue, with the possible risk of injury or accidents of various kinds (22). This may require an understanding of the individual characteristics of workers in order to reduce the work-related stress generated by working hours and the associated lack of sleep that this may trigger (39).
In many cases, construction projects have to comply with a completion date, and must be finished within that timeframe with the resources that were initially planned. In this sense, many construction workers, despite being fatigued, continue to work for fear of losing their jobs, prioritizing the economic needs of their families over their physical health (27). Likewise, these long working days sharing space and tasks with other colleagues and superiors can be triggers of emotional stress related to an excessive mental workload (34) and at the physical level. The nature of construction work makes overexertion commonplace and routine, exposing the worker to frequent injuries that have a physical and mental impact on their daily life, both at work and in their social and family life (29). This could be explained by the job preservation mechanism, where people tend to work much harder when they perceive a threat of job loss (52). Similarly, financial strength can . /fpubh. . be a protective element or have a buffering effect on mental health problems in this area, as it allows individuals to meet their daily needs and have more resources to seek immediate mental health care (53). On the other hand, several of the studies in this systematic review link the age of individuals to mental health (21,30,33,39).
In the work carried out by Yaldiz et al. (33), age was positively related to perceived stress. In contrast, the study by Turner and Lingard (39) found no relationship between stress, depression, and anxiety and age, but did find that only one age group, 30-39-yearolds, experienced a mild level of anxiety. Younger workers were more likely to be concerned about the amount and complexity of work than about their own ability, as they were inexperienced at this age at which they are likely to be unable to adequately cope with the additional workload. In addition, young workers more frequently overexerted themselves for significant periods of time and in the face of higher physical burdens (54). In contrast, a study in Ghana found no significant differences in levels of work-related mental health problems among different age subgroups of young people (45).
Safety culture is another factor that has been linked to higher levels of stress and anxiety (5, 22-25, 31, 32, 34, 43). In fact, many workers who are subjected to high levels of stress are more prone to accidents at work due to non-compliance with safety measures (43); i.e., the risk of accidents in stressed workers is up to 3.47 times more frequent than in unstressed workers (36). Similarly, masons tend to have little participation in decision-making, which, coupled with high work demand, low social support, and low organizational justice (55) may cause symptomatology consistent with stress, depression, and anxiety (19), thus increasing the risk of errors.
In this line, the low social support of the direct supervisor or co-workers is a key element as a protective or risk factor, depending on the case (19, 23,30,33,34,41). According to Bowers et al. (26), the most common stressors are lack of special events (86%), relationship problems with partners (68%), financial stress (62%), shift work (62%), and social isolation (60%). This phenomenon can lead many construction workers who believe they have mental health problems to be reluctant to participate in mental health programs or to seek help or support from family members, superiors, or medical services (39).
Finally, with appropriate coping techniques, construction workers can improve their stress levels. However, maladaptive coping techniques such as substance use (alcohol and drugs), self-distraction, denial, venting, among others, lead to increased depression, anxiety, and stress (28, 43, 46).

Limitations
The present study has a number of limitations. Firstly, while the studies included in this review offered valuable contributions to knowledge about the mental health of construction workers, there are not enough studies that encompass the geographical dispersion and socio-cultural differences, types of construction work, and situations that can be encountered in the construction sector. This is why the results found in this review cannot be extended to all construction typologies, company types and sizes, and the important contextual variations that may exist in different regions of the world. Secondly, the multifactorial nature that can give rise to the different risk factors related to mental health makes it impossible to establish a precise interpretation of their cause, as many of these factors are found outside the workplace, such as education, culture, religion, family, or the personal condition of each worker, among others. In this sense, another limitation to be considered is the fact that the different working conditions established in each country at a global level and the laws and customs applied in each one of them in this area hinder the performance of a homogeneous analysis in general terms, as coping behaviors may differ considerably between one place or another, since certain working contexts that could a priori be considered susceptible to harming the health of the worker have become normalized.

Conclusions
Accidents at work can be related to the mental health of workers, and age, hardship, and especially the long hours worked by construction professionals are factors that are significantly related to stress, anxiety, and fear. However, further studies are needed in this area that also include different work contexts and variables such as culture, education, professional qualifications, work environment, support systems, among others, in order to establish an early detection of risks.
The findings of this review could help construction companies to establish policies toward improving the working conditions of their employees and to increase knowledge about mental health in this sector. In this way, researchers and professionals dedicated to occupational safety, health, and risk prevention can identify these psychosocial factors and establish strategies and proposals to minimize the possible occurrence of such risk factors.

Data availability statement
The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.