Suicide represents a substantial health and social issue for Australia, with the Department of Health and Ageing estimating that suicide comprises 3.9% of the total burden of disease in terms of years of life lost [1
]. Australian Bureau of Statistics (ABS, 2011) figures for 2009 indicate that 2,130 Australians completed suicide (9.6 per 100,000), accounting for 1.5% of total deaths recorded, 24.0% of all deaths due to injuries, and exceeding the 1,417 deaths due to transport accidents [2
The impact of gender on suicide rates has previously been acknowledged, both internationally [3
] and in Australia, where 76.6% of 2009 suicides were male [2
]. Drawing on data from the National Mortality Database, the Australian Institute of Health and Welfare reported that suicide was the leading cause of death for males aged 25–44 years in 2007. Suicide ranks second to coronary heart disease in its contribution to potential years of life lost (PYLL) by Australian males [4
An emerging area of interest in suicide research is the impact of employment status and industry on rates of suicide. While being employed is associated with reduced risk of suicide overall [5
], recent evidence suggests suicide rates are differentially distributed across industry and occupational groups. Australian males in manual occupations were more likely to have completed suicide between 1966 and 2001 than their non-manual worker counterparts [7
]. This gap may be widening, with rates of suicide for manual workers increasing over the period examined, while rates for non-manual workers remained stable.
Research in Australia and abroad has demonstrated elevated rates of suicide amongst tradesmen and construction workers compared with the general working male population [8
]. To investigate industry-specific patterns in Queensland suicides, Anderson and colleagues [5
] compared data from 7,652 suicides in the Queensland Suicide Register with population data from the ABS for 1990–2006. For individuals 15–64 years, the greatest risk of suicide was in Queensland agricultural, transport and construction industries, with all suicides by construction workers being male.
Following a Royal Commission into the Building and Construction industry report identifying that 41% of all death claims made on behalf of Queensland construction workers over a four-month period were attributed to suicide [12
], the Queensland Commercial Building and Construction Industry commissioned the Australian Institute for Suicide Prevention and Research (AISRAP) to investigate incidence and correlates of suicide within the industry. The study estimated suicide rates for construction workers at 40.3 per 100,000, significantly above the overall national rate for males (16.8 per 100,000) [13
]. In particular, the rate for 15–24 year olds (58.6 per 100,000 people) represented a three-fold increased risk of suicide compared with male Australians of that age group generally, and in Queensland. Compared with other industries, construction workers were significantly more likely to have consumed alcohol immediately prior to death, and experienced relationship problems and multiple stressful life events in the months prior to death [13
]. Construction workers aged 15–24 years who completed suicide were significantly more likely than non-construction counterparts to show evidence of untreated psychiatric conditions preceding death [13
Focus group discussions with Queensland construction industry workers and representatives identified both industry-specific and more general factors that may contribute to increased risk, including work conditions, interpersonal relationship difficulties, marital breakdown and associated issues maintaining relationships with children, along with job insecurity and associated pressures [13
]. Some studies suggest suicide rates for construction workers reduce markedly once demographic and socioeconomic variables are taken into account (gender, age and relationship status) [9
], while others find the elevations robust despite controlling for these factors [6
‘MATES in Construction’ (MIC) is a charity established in February 2008 by the Building Employees Redundancy Trust (BERT) to prevent suicide through implementing recommendations of the AISRAP study [14
]. MIC is funded from several sources; 40% funding from BERT, 25% from the Queensland Government, and 35% from a variety of industry funds including unions, employer associations and contractors. MIC is a multimodal prevention and early intervention program, consistent with the Living Is For Everyone (‘LIFE’) strategy [17
] and Mrazek and Haggerty’s [18
] spectrum of prevention and intervention, and includes the following objectives:
promote awareness amongst construction workers about mental illness and suicide in the construction industry, warning signs for suicide and the preventability of suicide
reduce stigma associated with mental illness, suicide and help-seeking
enhance symptom identification by implementing a volunteer gatekeeper program within the construction industry community
improve access and engagement with specialised services and programs for specific difficulties (e.g., drug and alcohol problems, separated fathers without custody of their children)
improve access to mental health intervention through flexible delivery of outreach and case management support for those at risk
ensure support provided is mindful of the context and needs of the construction industry population, to maximise engagement
encourage workers to access 24-hour telephone crisis support
We present preliminary evaluation of the effectiveness of MIC for the period from April 2008 to November 2010. While the primary goal of suicide prevention programs is to reduce suicidal behaviour, the low base rate of suicide and complexities associated with gathering accurate data regarding attempted suicide suggest that these outcomes are less meaningful for evaluation of a program in the short term [19
]. In line with AISRAP recommendations [14
], we examined the impact of MIC on short- and medium-term indicators of effectiveness, including knowledge of suicide prevention and support services, and help-seeking behaviour. Additionally, it has been recommended that consideration of effectiveness of an intervention should include examination of its social validity, that is, the degree to which the focus and procedures involved are viewed by the target population as acceptable and of social importance [20
]. Given evidence that male construction workers who suicide are less likely to have sought or accessed assistance for mental health difficulties, we argue that social validity is crucial when evaluating MIC.
3.1. Social Validity and Acceptability of MATES in Construction
During the period of the study, 54 of 83 building sites approached by MIC (64%) agreed to participate in the program. As at 30th November 2010, four sites were considered ‘MIC compliant’, indicating that at least 80% of workers completed GAT, together with one trained Connector per 20 workers on site. Twenty-nine sites had completed GAT and were progressing towards MIC compliance, and 21 prospective sites had indicated interest in MIC. Figures on MIC compliance are an underestimate given that worksites are time-limited, and sites may have achieved compliance, but were then closed. Participation in most aspects of MIC has grown exponentially since the beginning of the program, as depicted in Figure 1
3.2. Effectiveness of General Awareness Training
On the pre-GAT measure of suicide and prevention awareness (Cronbach α = 0.75), the majority of GAT participants disagreed
or strongly disagreed
with each of the statements (see Table 1
): “you can’t stop people who really want to suicide” (52.7%), “suicide is a private issue that should be dealt with in the home only” (81.5%), “suicide always occurs without warning signs” (62.4%), “talking about suicide can cause suicide” (59.8%), and “women are more at risk of suicide than men” (71.2%). An initial test examined baseline suicide prevention awareness, comparing test subjects (7311) with comparison subjects (355) using Mann-Whitney U
test. Comparing responses to each question in turn, no significant differences were found between test and comparison groups on the first five (pre-GAT) questions.
Responses by GAT participants on the post-GAT questionnaire (Cronbach α = 0.88) indicated that most participants agreed or strongly agreed with “people considering suicide often send out warning signs or invitations” (73.4%), “suicide is everyone’s business” (80.3%), “most people who suicide really don’t want to die” (76.5%), “poor mental health is a workplace health and safety issue” (80.9%), and “the construction industry must do something to reduce suicide rates” (87.4%).
Mann-Whitney U tests found significant intervention effects with stronger agreement from GAT participants on all five post-GAT questions than comparison group participants. The results of these analyses were: Question 6 (“people considering suicide often send out warning signs or invitations”), U = 1090887.50, z = −4.382, p = 0.00, r = 0.05; Question 7 (“suicide is everyone’s business”), U = 1033887.00, z = −6.05, p = 0.00, r = 0.07; Question 8 (“most people who suicide really don’t want to die”), U = 924475.00, z = −8.83, p = 0.00, r = 0.10; Question 9 (“poor mental health is a workplace health and safety issue”), U = 1149071.50, z = −2.68, p = 0.00, r = 0.03; and Question 10 (“the construction industry must do something to reduce suicide rates”) U = 1007089.00, z = −6.76, p = 0.00, r = 0.08.
Due to disparity of sample size between the GAT and comparison groups, the Mann-Whitney test was applied to a subsample of 355 GAT participants who completed GAT during the same period that the 355 comparison participants’ data were collected. The purpose of this was to reduce any influence of contextual factors that could threaten the external validity of findings, for example the weather or working conditions during that month, or diffusion of suicide prevention awareness through the industry since the commencement of the MIC program, with possible repeat exposure to GAT due to the itinerant nature of the population, and other contextual, societal or industry factors. In the absence of data to confirm this, it was assumed that diffusion of awareness and repeat exposure would occur randomly, with these issues affecting GAT and comparison groups equally.
Analysis of pre-GAT results from this subsample replicated the findings based on the full GAT sample, namely, an absence of significant differences between groups on the baseline questions. The post-GAT findings also replicated the large sample analyses, with GAT participants demonstrating significantly stronger agreement with items assessing suicide awareness than comparison participants on Question 6 (U =
52202.00, z =
−3.76, p =
= 0.13, N=
701), Question 7 (U =
45199.00, z =
−6.54, p =
= 0.25, N =
701), Question 8 (U =
43568.50, z =
−7.12, p =
= 0.27, N =
700), Question 9 (U =
51516.50, z =
−3.93, p =
= 0.15, N =
699), Question 10 (U =
44496.00, z =
−6.86, p =
= 0.26, N =
699). Data from these analyses are presented in Table 2
3.3. Effectiveness of Connector Training
Data were available for 696 participants (96%) who completed Connector Training between October 2008 and November 2010. Although data was not collected on referral pathways to Connector Training, many of these were likely to have been recruited through the GAT course, with 7% (n = 602) of all GAT participants indicating on their GAT forms a willingness to complete the Connector training and to perform this role on site. Data was available for a total of 424 safeTALK feedback forms and 604 Connector feedback forms. Responses to items on the Connector forms are presented in Table 3
, demonstrating strong endorsement of items reflecting the social importance and perceived effectiveness of the MIC program.
Following Connector training, 98.8% of participants agreed
or strongly agreed
that they “know where and how to get help now” (refer Table 3
). On the evaluation form for the safeTALK component of Connector Training (n = 424), 96% of participants reported feeling well prepared
or mostly prepared
to “talk directly and openly to a person about their thoughts of suicide” (Figure 2
). With regard to helpfulness of the training, 74.1% of respondents rated training as 5 (very helpful)
on a scale from 1 (not at all helpful
) to 5 (very helpful
). Ratings indicated that 98.6% (n = 418) of participants intended to tell someone about the program.
3.4. Help-Seeking Behaviour and Engagement with Intervention
The MIC emergency help-line received 1521 after-hours calls between July 2008 and November 2010, with patterns of usage over time indicated in Figure 3
. We note this excludes calls responded to by MIC staff during business hours, which is not available. Additionally, 328 (4%) GAT participants requested a follow-up phone call from a Field Officer by indicating this on the evaluation form following the training.
A total of 674 workers accessed case management from MATES in Construction between April 2008 and November 2010, which represents 7.2% of MIC participants. Of these, 44% were self-referred (n = 287), with referrals also made by unions (n = 94), Connectors (n = 74), employers (n = 67), other service providers (n = 57), family (n = 23), training organisations (n = 15) or due to a critical incident response (n = 7). Thirty of these clients were referred to case management through the apprenticeship-based resilience program, Life Skills Toolbox. A majority of clients were based in Brisbane (n = 413), whilst case management was also provided to clients living in the Gold Coast (n = 139), Sunshine Coast (n = 8), Central Queensland (n = 7), regional Queensland (n = 66) and interstate (n = 10).
As depicted in Figure 4
, case management clients sought assistance from MIC for a variety of issues, with many presenting multiple areas of concern. Active suicidal ideation was reported by 101 referred clients, with 30 clients requiring suicide intervention. Case management clients were eventually referred to any of a variety of specialist services, depending on the nature of the presenting difficulties. Forty-one percent of case management clients were referred to Converge International (n = 274), an employee-assistance counselling organisation contracted to provide services to MIC clients. Liaison or referral also occurred with unions, financial services, various Government Departments, medical services, and legal professionals.
Postvention support was provided to 10 building sites in Queensland. Eight of these involved support following a suicide, one followed a lethal workplace accident, and one following an accidental death outside work hours. Postvention following the accidental death occurred on a site that was MIC-compliant at the time, but is now closed. Four postventions occurred on sites where some workers had received GAT, and the remaining five occurred with sites not participating in MIC. None of the deceased workers had attended GAT, and it is noted that suicide postvention support was the impetus for two sites to eventually engage with MIC.
The current study found evidence to support the social validity and effectiveness of the MATES In Construction program for the Queensland Construction Industry. A positive response from construction industry employers has been critical to program implementation, with this requiring staff to “down tools” in order to participate in MIC components, but also to convey organisational support for suicide prevention and MIC. This strong commitment to the program by the industry was assisted by MIC being partially funded and indirectly overseen by both Unions and Employer Associations through BERT, as well as frequent consultation between MIC and industry representatives throughout program development and implementation. Following GAT, a majority of the 7311 participants indicated high levels of agreement that mental health and suicide prevention is a workplace health and safety issue, and should be addressed by the construction industry. The number of volunteers to become Connectors exceeded MIC compliance standards of one Connector for every 20 construction workers. A majority of Connector Training participants reported that they could see how MIC would be effective in saving lives on site and that they appreciated the importance of meeting MIC compliance objectives. Considering that at-risk male construction workers may be less likely to seek assistance for mental health difficulties [13
], the level of engagement by participants of MIC, both in terms of sheer numbers and positive ratings on questionnaires, suggests that MIC is a feasible and acceptable intervention for reducing the suicide rate within this difficult-to-engage population.
In addition to its social validity, analysis of short- and medium-term indicators provides evidence of MIC effectiveness, as per AISRAP [14
] recommendations. GAT participants demonstrated significantly increased ratings of suicide prevention awareness compared to the non-GAT comparison group. Given effect sizes were small, the main impact of GAT training may be through the social legitimisation of building industry concern about suicide prevention. Connector training participants’ ratings of the training as helpful, together with their positive evaluations of their help-seeking knowledge and preparedness to intervene with a suicidal individual following exposure to the training, also provides qualitative evidence of the potential effectiveness of this component. Furthermore, a majority of participants reported that they intended to tell others about the training, which may indicate potential diffusion effects of suicide prevention awareness throughout the wider community [28
These findings indicated positive engagement by MIC participants with support options presented by the program. An increasing number of participants accessed the MIC emergency help-line and 4% of GAT participants (n = 328) requested a follow-up call from a MIC staff member following involvement in this training. Case management support was accessed by 7.2% of workers on involved sites. This compares favourably with the rate of approximately 5% of Australian men with a mental health condition in the 12 months prior to 2007 who accessed professional support according to the Australian Bureau of Statistics [29
]. Many case management referrals were attributed to MIC initiatives, including referrals from Connectors, the Lifeskills Toolbox program for apprentices, or by indicating on GAT feedback forms. At 44%, self-referrals represented the greatest proportion of referrals to case management, which reflects positively on the mental health awareness and help-seeking behaviour by construction workers participating in MIC compared with the historically low engagement with mental health services for this population compared with non-construction worker peers [13
Despite MIC being a suicide prevention program, the majority of referrals to case management were for issues other than suicidality. This is consistent with research suggesting that individuals are more likely to seek professional assistance for an emotional or personal problem than for suicidal ideation [30
]. Accordingly, it is possible that MIC may have an impact on suicide rates longitudinally through several mechanisms: by improving awareness and reducing stigma associated with both mental health and help-seeking, whilst also facilitating access to services for early intervention targeting salient risk factors for this population, such as substance abuse and family issues [13
The current findings should be considered in the context of methodological limitations. As the GAT questionnaire is contained in the workbook accompanying training, suicide prevention awareness ratings may have been influenced by workbook content. While the impact of this on the validity of GAT effectiveness findings is reduced due to comparison participants also completing questions within the workbook, descriptive data concerning baseline attitudes and knowledge may overestimate actual community awareness, possibly through a ceiling effect. Additionally, due to the itinerant nature of the industry, some GAT participants may have already completed the program, despite efforts to minimise duplication in the database. While it is likely that repeat exposures to GAT would be randomly distributed throughout the GAT and comparison samples, any impact on findings due to non-random distribution cannot be ruled out. In terms of influence of MIC on help-seeking, data on baseline levels of engagement with professional mental health and other support services would enable impact on help-seeking behaviours to be examined. For example, it may be useful to investigate whether those who engage with case management would have accessed support elsewhere, or at all, had they not been involved in MIC. Finally, the reliability and validity of our findings can be improved in future research by using standardised questionnaires, for example, to assess suicide awareness and help-seeking intentions or behaviour [32
Comparison of GAT post-intervention ratings with a non-GAT comparison sample, to control for contextual confounding, demonstrated an intervention effect; however, in the absence of demographic data, it is impossible to conclude the equivalence of the two groups, hence findings should be interpreted with caution. It will be important to support the current preliminary findings with further evaluation employing a cluster-randomised repeated measures design. It is recommended that longitudinal follow-up examine the durability of intervention effects, to determine whether booster sessions of GAT or Connector Training are required. Investigation of the relative impact of the different program components may assist to maximise effectiveness and efficiency of MIC. Similarly, it may be helpful for future evaluations to consider how MIC may best be structured and delivered in future, as an increasing proportion of workers become GAT and Connector trained. Finally, while established risk and protective factors associated with suicide are often the best available outcome variables when evaluating suicide prevention programs in the short- and medium-term, the impact of MIC on actual rates of suicide would be important to examine once sufficient participant numbers enable this to be statistically meaningful.