This paper is in three sections. Section One presents a historical overview of international initiatives that have expanded the role of music in healthcare, from the initial formalization of music therapy to its more research-based rehabilitation focus to recent decades that have seen an increasing role for professional and community musicians, paraprofessional music services, music-oriented service organizations, and a very large increase in medical funding for music effects. “Music Care” is a particular and comprehensive concept promoted by the Room 217 Foundation in Canada, featuring an inclusive and integrated approach to optimizing the use of music in healthcare settings. It is part of an expanding landscape of global practices and policies where music is used to address specific issues of care. Section Two is provided as an illustration of the growing scope of the concept of using music in healthcare. It reports on a multi-year project that engaged 24 long-term care homes in conducting individualized action research projects using the fundamental approach of “Music Care”, empowering all caregivers, formal and informal, musicians and non-musicians, to use music to improve quality of life and care. Section Two presents only high-level results of the study focused on using music care to reduce resident isolation and loneliness. Section Three draws on the results from the study reported in Section Two to inform the potential and path to the future of music optimization in any healthcare setting. The first formalization of a role for music in modern healthcare was the establishment of music therapy (MT) as a profession. In the last 80 years, MT has gained recognition around the world  for its While the professional practice of music therapy has become well-established in many parts of the world ,3,4, theThis paper will landscape some of the ways that music has expanded beyond music therapy over the last 20 years and provide an example that illustrates an innovative approach to address significant healthcare issues in long-term care. Music therapists have delved more deeply into specialized areas, creating valuable new techniques and applications that can be used by other medical staff. For example, neurologic music therapy (NMT) is a treatment methodology developed by Drs. Michael and Corene Thaut. From its early days in 1999 at Colorado State University to today at the University of Toronto, the Academy of Neurologic Music Therapy offers NMT training that features music-based diagnostic techniques in three functional domains: sensorimotor, speech/language, and cognition. NMT is used by music therapists and allied care professionals like physiotherapists, occupational therapists, and speech language pathologists to employ focused, music-based medical interventions. In 2015, the Oxford Handbook of Neurologic Music Therapy was second overall in the British Medical Association (BMA) Book Awards for neurology (600 entries), an unprecedented achievement for a work in music therapy. In 2019, one of the NMT techniques—rhythmic auditory stimulation—was identified as a clinical best practice in the stroke rehabilitation guidelines in Canada and the US [In France, music therapist and doctor of clinical psychology, Stéphane Guétin, has developed a methodology to use music prescriptively to control pain and anxiety. His U sequence is able to synchronize music with vital signs, and can be used digitally for treatment via the MedAppCare by medical personnel .In 2011, Andy Tubman, a music therapist in California, co-founded a program called SINGFIT, which uses a technology-based app to prescribe singing for residents of senior living communities. Staff members are trained in both the technology and methods of SINGFIT to deliver the program and engage residents “in musical journeys that are great for the mind, body and spirit” .In the late 1970s, German medical doctors Roland Droh and Ralph Spingte began to explore ways of using music to address pain and anxiety, and attracted other doctors and academics to their newly formed group, the International Society for Music in Medicine . ParalleFor the last 30 years, the vibroacoustics field has situated itself in the music as medicine camp. Since 2012, the work of VIBRAC, a research and training center in Finland, has strengthened the scientific basis for vibroacoustic therapy, and serves as a point of contact for researchers and clinicians around the world. VIBRAC has established an international training model that reaches various fields and professions interested in integrating vibroacoustic therapy into regular care practice .Universities and colleges have begun to create institutes and centers to build critical evidence around aspects of music in healthcare. These academic centers include the McMaster Institute for Music and the Mind  that studies musical development of infants and children; the Sidney de Haan Research Centre  that explores participation in creative arts for well-being; the Cognitive Brain Research Unit  that researches music processes and their plasticity as they relate to neural conditions; the Cambridge Institute for Music Therapy Research  that conducts interdisciplinary research in music therapy; and the Institute of Music Physiology and Musicians’ Medicine (Hanover University in Germany) that researches conditions of performing musicians ,13,14,15Research funding is an indicator that music and health is becoming a social priority. In 2016 in the US, the Sound Health initiative was launched as a partnership between the Kennedy Center and the National Institute of Health (NIH), the largest funder of biomedical research in the world. The importance of this research examining the evidence for and mechanisms of the effects of music on health conditions and the investment cannot be overstated. In 2019, the NIH granted 20 million USD to fund the first set of projects more narrowly focused on questions emerging from neuroscientists. The second round of funding focused on exploring how music impacts normal health and development, rigorous studies of music interventions to treat disease symptoms, and promoting the understanding of basic mechanisms through which music is processed by the brain and body .As research and practice in music and health continues to expand, an increasing variety of non-music therapists and non-medical personnel are using music in care settings. Professional musicians are bringing their musical practice into healthcare contexts to engage residents and patients in aesthetic and creative experiences. Programs in the UK include Music in Hospitals and Care  and LiveIn 1999, Musique et Santé, a not-for-profit organization in France, established an apprentice program for professional healthcare musicians trained to work alongside care and medical staff in traditional healthcare spaces with cultural rather than clinical goals, engaging and interacting closely with patients at bedside. This practice has now extended into Europe and other parts of the world .Community musicians grew out of a socio-political movement in the UK in the 1960s. As a global practice, it evolved from a grassroots endeavor to a field of study in higher education. According to Higgins and Willingham, community music practice has widened its perspectives and application to various health and social care settings . For exaMusicians who are not trained music therapists but with niche music training have gained momentum in healthcare over the past 20 years. For example, harp therapy refers to several practices that use the harp as a therapeutic agent in home and clinical settings for specific outcomes, like pain reduction, end-of-life care, and sensory stimulation . In 2003While scopes of musical practices are expanding in healthcare, so grows an interest in equipping formal and informal caregivers with musical skills and resources. In 2002, Eva Göttell and her colleagues in Sweden began to report on relevant research they were doing with formal caregivers in care homes who did not necessarily have any formal training in music. By adding singing and music to formal care routines for persons living with dementia, there was an increase in mutuality of interaction. Specifically, staff noted that the patients had straightened posture, stronger movements, and increased awareness of themselves and their environment. Positive emotions were enhanced, and aggressiveness diminished ,30,31,32In 2009, the Room 217 Foundation  began inSeveral music-based programs have become mainstream in healthcare communities and communities at large. In 2014, the film Alive Inside  populariTechnology as a means of music delivery in healthcare has substantially expanded. The virtual music instrument has been developed for multiple applications e.g., children with special needs at Holland Bloorview Hospital in Toronto . An inteVirtual reality and artificial intelligence applications are being developed for delivering music into healthcare contexts. Currently, an American start-up called n*gram health has begun to use virtual reality to deliver virtual and augmented reality applications for seniors . A groupOne of the most significant growth areas is the World Health Organization’s developing agenda for arts in health. In November 2019, the World Health Organization presented the largest evidence report ever published on arts and health, which gives an overall picture of the role the arts play in supporting health globally . Dr. DaiThe findings are structured into two sections. The first focuses on prevention and promotion: how arts can affect social determinants of health, support child development, encourage health-promoting behaviors, help to prevent the development of mental and physical illness, and support caregiving. The second section focuses on how the arts can support the management and treatment of mental illness, neurodevelopmental and neurological disorders, and non-communicable diseases, as well as support the delivery of acute care and palliative care. The findings are illustrated with a selection of case studies from across the WHO European region and presented alongside a series of policy options for how to support the development practice and research internationally .A world leader in national policy around music and health, the UK formed an All-Party Parliamentary Group on Arts, Health and Wellbeing (APPGAHW) in 2014. The APPGAHW aims to improve awareness of the benefits that the arts can bring to health and well-being. This group conducted a three-year national inquiry and made recommendations to improve policy and practice to the government . A groupOne of the most recent developments in music and healthcare in Japan and the UK is the advent of social prescription ,50,51,52Most recently and without forewarning, the world has witnessed music’s powerful connection to societal health during a global pandemic. Countries have offered musical tributes to frontline care workers. On a local level, neighborhood concerts demonstrated how music mitigates isolation and keeps mental health in check. For example, Italy turned to music during COVID “to create a nationwide concert to lift our spirits and make a daily appointment to be social” .This section has shown the growing interest in music in healthcare in the past two decades. Previously, music therapy as a profession had established itself as a practice, but research to demonstrate its efficacy has in general been on the weak side . Most ofOne current concept that is gaining traction is the music care approach , which pOver the past four years, the Room 217 Foundation has facilitated action research in 27 long-term care (LTC) homes in the greater Toronto area to implement the music care approach. A pilot study was done first in 2017 in three long-term care homes using a music care action research project (MCAP) to address the experience of resident isolation and loneliness.When someone transitions into LTC, no matter their age, the move is often accompanied by isolation, loneliness, or both ,57,58,59A key output from the pilot study was the development of the integrated model of music care (IMMC)—a concept of the necessary factors to integrate music into standard healthcare. Foundational to the IMMC is training and information, understanding that music can have both beneficial and adverse effects on a person’s well-being . The goaResearch data should inform any expansion of the role of music in healthcare. Unfortunately, many of the initiatives employing music in health contexts of the past two decades have little to no research foundation. The Room 217 Foundation that has developed and promotes the music care approach expects that the implementation of music care in LTC homes will be informed by research data, so systematic data collection related both to the process of implementation and to the results of the implementation contribute to the knowledge base supporting and developing the music care approach. One of the most well-suited research methodologies for understanding the process of an implementation and the effects it has is participatory action research. This research exemplifies how the scope of music in healthcare is expanding in LTC settings to combat the prevalent challenges of resident isolation and loneliness.A study was designed to explore two things simultaneously: (1) how can an LTC facility effectively implement the Room 217 music care approach? and (2) what effect would a locally determined music care project have on residents’ experiences of loneliness and isolation? To answer these questions, essentially, 24 case studies of LTC homes were conducted. The means of the implementation was the facilitation of a locally designed action research project. Cross-case analysis was done to determine any effect from the diverse projects on loneliness or isolation.The purpose of this study was to determine the effects of a music care action project (MCAP) on the isolation and loneliness experienced by residents in LTC homes in Ontario, Canada. Research questions included:Does a situational implementation of an integrated model of music care change LTC residents’ experience, especially as it pertains to isolation and loneliness?How do LTC homes begin to integrate music on a day-to-day basis into the community culture?What are the factors that contribute to a successful MCAP?The basic methodology used was a six-step participatory action research (PAR) design see . Action The outside researcher facilitators motivated the PAR process by having five meetings with each site team, following the steps of the PAR design. Site teams are indicated as STM1–5 in The study took place in 24 LTC homes recruited from three cities in the greater Toronto area. Room 217 recruited these homes and had a memo of understanding with each participating home see . Study pA total of 265 residents were enrolled as participants in action projects in these 21 data-reporting LTC homes. Fifty-six percent of participants were female and 44% were male, with a mean age of 78.5 years. Fifty-two percent of participants were living with moderate to severe cognitive impairment (CPS score of 3+).While the COVID-19 pandemic did not impact the delivery of the action project or the subsequent continuation of music care as a regular practice within the LTC home, it did impact post-data collection at three participating sites. This is because site team members were redeployed or their roles were redefined to support urgent pandemic-related tasks and activities. Legislation implemented to protect residents prevented data collectors from entering the home to interview residents after the study was complete. Consequently, data was obtained from 21 LTC homes.The entire PAR process took between six to eight months to complete in each home. A site-specific MCAP was implemented for two months at each LTC site, and focused either on the outcome of isolation or of loneliness. Note: Each LTC home decided on their own specific action plan. The action research interventions implemented in the participating LTC homes included: 1:1 music visits, choirs or singing sessions, making music care kits, music clubs, bursts of spontaneous musicking, handbell choirs, care plan integration, intentional mealtime music, and culturally-specific music. In each case, it was the intention of staff to address the need of isolation and loneliness with music.Four projects were individually based, eight projects were group based, and 12 projects involved both individual and group elements. Individually based projects are when the majority of music care is experienced in a 1:1 context; group-based projects happen when the majority of the music care is experienced in the context of a group.Pre- and post-isolation and loneliness measures were evaluated using one of two validated tools. The Friendship Scale  measuredNoteworthy in the expanding role of music in healthcare is the shift from only certified music therapists using music in care to many healthcare workers participating in the use of music in care. There were many players involved in completing this implementation of music in care. Key roles and responsibilities for participatory action research are described in Credentialed professional music therapists were significant leaders in this study and were used in three roles: as program facilitators see , music cPre- and post-intervention Resident Assessment Instrument-Minimum Data Set (RAI-MDS) data were collected. This included five assessment domains: the Cognitive Performance Scale (CPS), the Aggressive Behavior Scale (ABS), the Index of Social Engagement (ISE), and the Depression Rating Scale (DRS); when possible, homes also provided data for the Changes in Health, End-Stage Disease, Signs, and Symptoms Scale (CHESS).Five LTC homes saw an average positive change in RAI-MDS CPS scores, indicating that the implementation of a music care initiative positively impacted the cognitive function of participating residents. Seven LTC homes experienced positive changes in ABS score. Six homes demonstrated increased ISE scores. Nine of the homes reported decreased DRS scores  experienced by program participants. Four homes were able to report on CHESS, and one home saw an average positive change in this score over the course of the action project.The majority of sites (67%) collected data on resident isolation using the Friendship Scale. The remaining 33% used the Loneliness Scale to collect data on resident loneliness. Each site determined that choice. On the validated isolation and loneliness tools, not every home documented average positive changes. Contributing factors include resident cognitive impairment, which could impact the ability to respond to a verbal questionnaire, the fit of resident participants to the project, translation of validated scales, and external events, such as outbreaks, the COVID-19 pandemic, and personal health changes. A responder on the Friendship Scale showed an increase in average post-project scores, indicating a decrease in the experience of resident isolation. A responder on the Loneliness Scale displayed a decrease in average post-project scores, indicating a decrease in experience of resident loneliness.More residents were involved in the chosen music care initiative.Additional music care initiatives were created.More LTC challenges were impacted in addition to isolation and loneliness.Additional residents may benefit from the ripple effects of music care action projects. The ripple effect occurs when music care  is expanded and spreads beyond the scope of the project and is an indicator of music care integration. The ripple effect manifested in three ways:In one LTC home, a majority of residents had a mental health diagnosis, and tended to be marginalized and disenfranchised, and were often homeless prior to living in LTC. The youngest resident was 28. These unique demographics contributed to the experience of isolation and loneliness at the home. Music at Mealtimes was the name of this site’s MCAP. Playlists using resident-requested songs were created. Speakers and MP3 players were purchased for each dining room, and music was played during all three meals each day for eight weeks. There was a 2.61 increase in average Friendship Scale scores, which means self-perceived isolation decreased for project participants during this time period. The site team decided to collect additional data of ripple effects resulting from other positive changes because of the MCAP. For example, the LTC home average RAI-MDS aggressive behavior score decreased. The number of residents with pressure ulcers, associated with undernutrition and weight loss, decreased by 50%. Fifty-six percent of participating residents gained weight. Staff explained that residents were focused on enjoying the music and eating their food rather than watching or engaging in altercations. The amount of food being returned to the kitchen after each meal decreased from 30% to 5%. It was reported that one resident participant went from eating 25% of her meal to 50–100% when the music was on.Music care training designed for staff, volunteers, and family was integral to the MCAP. Helping caregivers feel confident to use music effectively and responsibly was the objective. One family member who was a site team participant shared, “Before I began the music care training, I thought I knew a lot about the benefits of music. I had been singing to my mom for years, who has advanced Alzheimer’s disease, and have seen how beneficial the music was. I was amazed at how much I did not know and to learn how powerful a tool music is and the many ways it can be used. For example, how music and humming can have a calming effect; how ascending and descending melodies have different effects and how music can evoke memories and reduce depression and loneliness.”Several sites reported that, during the initial grim days of COVID-19, the music care training that was conducted for the MCAP had prepared their frontline workers to use music as an important connection with residents and their separated family members. At one site, care workers who had music care training in MCAP pivoted to help family members create playlists for their loved one to listen to.Limited Resources (informants repeatedly pointed to a lack of resources to expand music activities)Distinct Experiences Life Enrichment Dynamic Relationships (symbiosis between the impact of relationships and how music care was delivered)Program Flexibility (MCAPs were adaptable)Potential Continuity Enhanced Socialization (MCAPs created a space where residents felt connected to each other and to staff)A significant part of the research methodology was to conduct 5–15-min (dependent on cognitive capacity) in-person or phone interviews with some of the residents and staff at some of the homes to gain more understanding of their thoughts, feelings, and insights into the music care experience see . Thirty-The multiple data types and sources in this study give a richer understanding of numeric results, providing a more personal narrative and background about the effects of music on resident experiences of isolation and loneliness and what is needed for more successful music care integration from the staff perspective. In this way, quantitative and qualitative results are complementary.The action research project reported had two facets: (1) a study of the process of the implementation of the music care approach in 24 LTC homes and (2) a study of the effect of music care activities on loneliness and isolation among the participants. Results of the first facet are primarily reported in Section Three, and the principal limitation for a general understanding of the role of music in healthcare was the fact that the MCAPs were conducted only in LTC homes. It cannot be known from this study whether MCAPs would have similar or different results in other healthcare contexts, like hospices, or hospitals. The second facet was reliable and important at one level: it showed that the music care approach, even with diverse activities or projects, resulted in positive effects. However, at the level of determining the activity effect rather than the music care approach, it had serious limitations. If viewing this level of the study as a clinical trial, which it was not within the context of an action research study, it fell short on crucial dimensions due to the lack of standardization, control, common measures, or comparison groups.Future research needs to study the process of implementing music care in multiple healthcare settings in other locations in Canada, where healthcare systems and parameters may differ, or in other countries, which may have other parameters altogether. Future research on the effect of music care activities on isolation and loneliness needs to be done as rigorous clinical trials. Future research also needs to explore the effect of music initiatives in LTC on other outcomes.A review of section one of this paper shows that the many initiatives over the past decades fit into one or more of the 10 domains  describeThe study in section two of this paper is an illustration of a method to systematically introduce and develop the internal ownership and the sustainable commitment to music care. The study reported did not develop the full potential of all three domain categories, but introduced the crucial aspects on which such potential could be built: music training of general staff, an organizing team, an initiative to use music programming, participation in data collection for effect monitoring, and, in places, opportunities for music therapists to work alongside general staff. What follows is an examination of how the study reported in section two can inform future efforts by organizations and initiatives around the world to reach the potential of music in healthcare.First, the study is an example of how research based on the music care approach is actually reaching into a healthcare setting—LTC, one that doesn’t typically focus on research – and engaging staff, residents, family members, and volunteers to think differently about music’s possibilities as a meaningful solution to challenges. The study compels us to consider aspects of the music care approach that could be expanded into more healthcare settings beyond LTC. Engaging the stakeholders of the institution in a process of systematic inquiry develops ownership and sustainability.Second, the action plan used in the MCAP integrates all of the music care efforts. Local LTC homes synthesized and applied information about isolation and loneliness, music care delivery domains, and strategies learned in training to their specific site. Each action plan was self-designed and carried out by the representational site team, which resulted in a keen sense of shared responsibility for implementation and accountability. The plan was supported by a music care expert, such as a community musician or music therapist. At the end of one cycle of the MCAP, the pivot step in the PAR methodology allowed for the site team to repeat or adapt the action plan to meet the same outcome, or to address a different resident or community need. In some cases, the next MCAP included expanding into another music dimension i.e., hiring a music therapist or training the physical therapist on staff in NMT. The site-responsive action plan becomes a critical component of integrating, sustaining, and optimizing music in all healthcare contexts.Fourth, playlists delivered on MP3 players, tablets, or computers were only minimally used in the MCAP study illustration. In light of the innovative way music technology is being leveraged globally in healthcare (see Section One), there may be a gap in how it is being used in LTC compared to other settings. Expanding the use of technology to deliver music in LTC will need to become a priority for providers. It may be that in the case of the MCAP study, training did not provide enough technology-based project ideas, or that the staff was reticent to use technology for delivery. It may also be institutional policy matters, since in some instances, staff were not permitted to use personal devices at work, so technological applications were limited.Third, evaluation is a core component of any effort to measure the impact of music in healthcare. The MCAP study had several evaluation activities including (1) an initial assessment of what was happening around the use of music in the LTC home prior to the beginning the project; (2) pre- and post-data collection around the action plan; (3) site team collective reflection through collaborative analysis, interpretation, and judgments of site-specific results; (4) reporting results prepared by facilitators, including a customized report; and (5) follow-up with project leaders to determine the ongoing effectiveness and integration of music care at each participating site. Collecting evidence of music’s effects, analyzing, and making meaning of it is a significant part of efforts to integrate music into healthcare. When this approach extends into other health contexts, evaluation, whether by checklist or by more rigorous means, must be built in to determine whether changes occur.Fifth, while quantitative and qualitative results from MCAPs describe outcomes as they pertain to isolation and loneliness, understanding what makes the projects work from an operational perspective may be just as important if music is to be expanded into healthcare settings as an integrated approach. As part of the report to each LTC site, enablers and barriers of success were explicitly stated and explained in the context of that site. They have cumulatively been grouped into categories, named as a factor , and given a diagnostic question to help determine readiness factors of success in music care delivery .From this study, the collection of music care delivery readiness factors for success gathered during MCAP evaluation may help predict the success of future projects and address any gaps prior to starting a MCAP in order to ensure readiness. While this tool was developed within the long-term care setting, it could be applicable to other care settings where MCAPs take place.The number and range of initiatives in music and healthcare reviewed in section one and the example of an implementation effort for a comprehensive use of music in health settings in section two demonstrate the potential of an expanding role for music in healthcare. Particularly, the music care approach, with its focus on inclusion and integration, is an example of how music can be expanded for operational sustainability. Music becomes a top-of-mind response amongst a care team, whether a music therapist is present or not, to solve a community challenge. The PAR process creates the methodology for the shared response, while the MCAP becomes a tangible and accountable intentional effort towards achieving an agreed upon outcome.What can we learn from the music care approach illustrated in section two that can be expanded upon by initiatives around the world?1. The music care approach could become a best practice model for several reasons. (a) It is meant to be integrated into what already exists, specifically personal care plans, care tasks, and programming, into the ethos of the care community. (b) The standardized adapted PAR process integrates outcome measures as the motivation for community-wide adoption and practice. (c) Evaluation is adaptable according to the outcome being measured. (d) It is manualized, scalable, and suitable for widespread adoption.2. A standard of music care will be needed in order to maintain quality and scope of practice ethics. Guidelines need to be articulated, including competencies, certifications, integration, results, etc. In this standard of care, there must be room and direction for all stakeholders, including care staff, volunteers, family members, patients/residents/clients, and community groups.3. A music care certification model could be introduced into LTC and potentially other healthcare settings that accounts for various dimensions of music care delivery see . The pla4. A baseline music care training needs to be provided for students training to be formal caregivers in healthcare. Curriculum in colleges and universities, at the very least, needs to provide an evidence-based understanding of the beneficial and adverse effects of music, a landscape of music care delivery best practices and approaches and how to access them, and strategies and interventions that can be integrated and safely used.5. Music therapists are positioned for leadership in the expanding landscape, and must see the whole, not just their part of the picture. Music therapy training will need to include curriculum on teamwork, working inter-professionally, systems leadership, and survey courses on other music health delivery practices.6. Technology must become a strategic driver in music care delivery. During COVID-19, music care providers pivoted to video conferencing platforms to provide continuity of care. Frontline care workers used tablets and phones in unprecedented ways. It may be that new frontiers have opened for technology-assisted music delivery in LTC, making it more acceptable and assessible.The expanding awareness and scope of music in healthcare over the past twenty years has been exponential. While music therapy has gained global acceptance, more players and practices have emerged and pushed the boundaries of thinking, practice, experience, and interested stakeholders in music and health. The pandemic has shone light on the urgency for greater quality of life approaches in LTC in Canada: 80% of COVID-19 deaths have occurred thus far in LTC . The nee


Open defecation remains a major environmental sanitation challenge facing all areas of Ghana. This notwithstanding, the socioeconomic drivers of this phenomenon are overlooked. This study, therefore, analysed the factors that influence the choice of toilet facilities over the practice of open defecation in the country. Ghana Living Standard Survey round 7 (GLSS7) data were analysed using multinomial logit regression. From the data, a majority of households used improved toilet facilities  in Ghana and over one-fourth of households engaged in open defecation. The regression result revealed that the choice of toilet facilities over the practice of open defecation was significantly influenced by the sex of the household head, age, household size, education, marital status, locating in urban areas, regional locations, ownership of dwelling, type of dwelling, expenditure on rent, expenditure quintile, and per capita consumption expenditure of the household. Specifically, male, younger, less educated, and first income-quintile household heads have higher probability of practicing open defecation in Ghana. These variables point to specific policy directions that should be corrected or targeted to minimize, if not eliminate, the practice of open defecation in the country. The Media Coalition Campaign against Open Defecation should be intensified and directed towards the males, youths, and the less educated populace. This study also justified that calls for Ghanaians to change their attitudes or behavior towards open defecation are mere rhetoric if such calls are not defined within the socioeconomic conditions of the people of the area. There is a clear global commitment towards achieving an improved sanitation across the world. This is well captured by the world leaders' pledge under the Sustainable Development Goal 6 (SDG6). An important indicator under this goal is to “achieve access to adequate and equitable sanitation and hygiene for all and end open defecation” by the end of 2030 . Cited iThe effects of open defecation and poor sanitation continue to be a major sanitation theme being discussed among scholars and policy makers. Open defecation leads to the spread of disease, perpetuates under nutrition and poverty, and has a negative effect on personal dignity , 5–9 andGhana is classified under countries with 5–25% of the population engaging in open defecation, amidst inadequate availability of data . SpecifiThe choice of toilet facility can be determined by a number of factors. According to Appiah-Effah et al. , the staThe study was conducted in Ghana. Ghana is a tropical country located on the west coast of Africa with a 2019 population of about 30,093,201 and a 2018 economic growth rate of 5.6% .Nonetheless, Ghana's classification as a lower middle-income country in SSA, open defecation remains a major sanitation challenge for the country. For instance, in 2016/17, 5.9% and 29% of urban and rural households, respectively, had no toilet facility and therefore practice open defecation in bushes, beaches, and fields. While as high as 77.1% of households in the Upper East Region practice open defecation, as low as 4% of households in the Greater Accra Region practice open defecation . Such opGhana's sanitation management is regulated by the Environmental and Sanitation Policy whose primary goal is to develop “clear and nationally accepted vision of environmental sanitation as an essential social service and a major determinant for improving health and standard of living in Ghana” . In thisThis study relied on GLSS7 data. These are national data that seek to comprehensively assess Ghanaian households and their characteristics. The data were downloaded from the Ghana Statistical Service (GSS) website upon expression of interest by the authors to understand the sanitation conditions in the country. From the data, a total of 14,154 households were used for this study. Information on the toilet facilities used by the households was categorized from the original data for the convenience of this study. The data sorted were analysed through a multinomial logit regression in STATA 14.Multinomial logit regression is an econometric method used in analysing nominal data where there are no meanings to the values assigned to the variable labels . For instance, in this study, open defecation is assigned 0 while WC was assigned 3. However, these assigned values (0 and 3) are meaningless in their own rights but to enable the software to read the data and allow estimation. Thus, we could have assigned any positive integer, say, 100 to open defecation and 1 to WC with no effect on the result. Primarily, the multinomial logit regression assumes that if households are faced with several toilet facilities, the household uses only one alternative. Therefore, households in this study are assumed to be using solely their reported toilet facilities and this allowed the study to proceed with the formulation of a multinomial logit regression to fit the data set. In this study, open defecation is used as a reference group to all other toilet facilities . The analytical procedure of the multinomial logit is described as follows.i receives a utility from choosing a particular toilet facility j, then this can be defined asUij is the derived utility, β is a vector of parameters, X is a vector of independent variables, and ε is an error term. Assuming there are J alternatives, the probability of choosing alternative k is given asGiven that an individual Redefining the probability of choice from equation ,(3)Prij=β(1) is assigned 0, then the set of coefficients estimated in this study can be defined asTherefore, if Given this formulation, the empirical model estimated is given asGeographically, open defecation and the use of pit latrines and KVIP were common among rural households while the use of WC and public toilets were common among urban households. The high open defecation in rural areas than urban areas is consistent with earlier reports by Appiah-Effah et al. –18, 21. In addition to The variable sex had a negative effect on the choice of toilet facilities over the practice of open defecation, and this is significant for only public toilet and WC facilities. Relative to open defecation, the marginal effects show that the male heads have, respectively, 0.027 and 0.007 probabilities less of using public toilets and WC toilets than female heads. This result is conceivable since female heads and females in general often feel shy in defecating in the open than males. Studies also show that women who engage in open defecation are more vulnerable to infections and nonpartner sexual violence than men , 23–25. Age had a positive effect on the choice of toilet facilities over the practice of open defecation, and this is significant for public and WC toilet facilities. The marginal effects were all 0.001. The implication is that the higher the age of the household head, the higher the probability of using public or WC toilet over open defecation. In most Ghanaian settings, age comes with high social responsibility and the behavior of the elderly provides moral ground to advice the youths against open defecation. In order for the elderly to maintain their social status in their communities, they may not like to engage in open defecation. This result is also consistent with general observation where younger persons are mostly seen engage in open defecation. Relatedly, the elderly household heads might have accumulated enough capital over time to either invest in the construction of personal toilet facilities or pay for the use of public toilet facilities on a daily basis. Consistent with this study, Akpakli et al.  found thThe effect of education on the choice of toilet facilities by household heads is positive and significant for pit latrines/KVIP and WC. Thus, the highly educated household heads have higher probabilities of using pit latrines/KVIP and WC and do not practice open defecation. This is because, not only does education improves the understanding of a person on the health implications of open defecation but also the literate in Ghanaian societies are more under public criticism for wrongful attitudes. A common description of literates who engage in socially or morally unfit acts is “ (s)he not the one who completed school” or “I thought his/her education should make him/her better.” These are damming comments which denigrate the value of one's educational status and can be tired to Kumar and Sinha  explanatHousehold size is significant in explaining the choice of toilet facilities by Ghanaian households. While heads with larger household size have higher probability of choosing public toilets over open defecation, heads with lesser household size have higher probability of practicing open defecation over the use of pit latrines/KVIP and WC. Since almost every household member would prefer going to toilets in the morning before going out or in the evening before sleep, it requires that more toilet facilities are required at home; otherwise, some household members would go to the public toilets or in the open where there is little to zero waiting time. Osumanu et al.  also estCurrent marital status of household heads had a positive significant effect on the probability of using pit latrines/KVIP and WC over the practice of open defecation. This suggests that household heads who are currently married have higher probabilities of using the former toilet facilities over the latter. This is because couples often would want to have high level of privacy in almost every aspect of their lives. Therefore, it is expected that they would prefer private toilet facilities such as pit latrines than going to the open or public toilet. A similar result was obtained by Akpakli et al.  in GhanaTwo location variables are considered in this study: the urban or rural areas and regional locations. All these factors had significant effect on the choice or use of at least one toilet facility over the practice of open defecation. The result suggests that household heads located in urban areas have higher probability of using public toilets and WC over the practice of open defecation but a lower probability of using pit latrines/KVIP over open defecation. Generally, while WC and public toilet facilities are common in the urban areas refer to , the pitThe three housing characteristics considered under this study all had significant effect on the usage of a particular toilet facility. The result on the ownership of dwelling showed that household heads that are located in houses that are not personally owned or owned by family relative have higher probabilities of using public toilet and WC over the practice of open defecation but have higher probability of practicing open defecation over the use of pit latrines/KVIP. On WC, most government and private residents such as estates have WC provisions in the design of the houses. Also, one condition people use in accepting accommodations for rent from private entities is the availability of toilet facilities. Therefore, based on the economic or income status of a person, people always prefer where there is a WC or a nearby decent public toilet. The result also shows that household heads that resides in houses such as compound, flats, or semidetached houses have significantly higher probabilities of using pit latrines/KVIP over practicing open defecation. Similarly, those residing in flats or semidetached houses have significantly higher probabilities of using WC over open defecation. This result suggests that persons who have no decent accommodation such as perching or slums have higher probability of practicing open defecation. Consistently, the result established that the higher the rent on housing, the higher the probability of using pit latrines/KVIP and WC but the lesser the probability of using public toilets over the practice of open defecation. This is because the cost of housing is based on its characteristic such as the presence of a toilet facility. The improved the characteristics, the higher the rent. It is therefore not surprising that household heads who paid higher rents would be unwilling to go to public toilets that are often unhygienic but rather practice open defecation. Evidently, Osumanu and Kosoe  reportedWelfare quintile had significant effects in explaining the types of toilet facilities used by Ghanaian households. Overall, households located in the second, third, fourth, and fifth quintiles significantly have higher probabilities of using WC and public toilets as against the practice of open defecation. This suggests that the poor-class households (the first quintile households) often engage in open defecation than the rich- and the middle-class households. This is because the primary focus of the poor or those in the first quintile is how to provide food to their families and not how to deal with waste (a by-product from eating). Consistently, McGranahan  describeOpen defecation remains a major sanitation challenge in Ghana and over the years, it is one of the topical sanitation issues in the Ghanaian media. Therefore, this study outlined the socioeconomic factors that influenced open defecation in the country. This study was articulated on the basis that these socioeconomic factors drive the expressed behavior or attitude of people to engage in open defecation and, hence, should be considered as fundamental factors to tackle and not blame open defecation solely on “behavioural attitudes”. Evidently, this study established that open defecation is higher in the country. Specifically, more than one in every five households engaged in open defecation in the country. This observed level of open defecation in Ghana far exceeds the average in SSA, thereby raising concern for the country.The study established that several socioeconomic and housing characteristics significantly explained the choice of the toilet facility used by the households. These includes the sex of the household head, the age, household size, education, marital status, locating in urban areas, regional locations, ownership of dwelling, type of dwelling, expenditure on rent, expenditure quintile, and per capita consumption expenditure of the household. It is concluded, therefore, that open defecation is common among the male, younger, less educated, and household heads in the first income quintile. The housing characteristics also indicated that the provision of private and government residents is appropriate in addressing open defecation challenges in the country. Largely, the findings can be tired to the economic status of the households, as the poor or as it may be related to other factors have the tendency towards the practice of open defecation. It is, therefore, concluded that any call for Ghanaians to change their attitudes or behaviours towards open defecation should be rooted in the socioeconomic and housing conditions of the people of the area; otherwise, such calls may be mere rhetoric. As a consequence, government should take steps to ensure that house owners provide toilet facilities in their homes. This can be achieved through two major ways. First, to offset the positive effect of low income and housing characteristics on open defecation, affordable housing projects by successive governments have to be taken more seriously and implemented to its fullest. This is because such housing policies come along with sanitation management plans. Secondly, community-led total sanitation should be promoted among communities to help the community members pull resources together for the construction of toilet facilities either at household level or at specific community locations. This, for instance, can reduce open defecation among the males and the youths, as they would be deeply engaged in such community commitments. Government through the Ministry of Local Government must take interest in ensuring that public toilet facilities in the country are kept clean and conducive for use. This would demotivate people, especially the literates from the use of open defecation across the country.


Occupational exposure to potentially contaminated sharp instruments can result in the transmission of several pathogens and diseases. It is therefore necessary to investigate the factors that lead to these events and the interventions that can be used to address them.To assess and describe the frequency of occupational exposure to sharps injury among employees of the Instituto Nacional de Câncer José Alencar Gomes da Silva in 2017 and 2018.This was a cross-sectional, exploratory and descriptive study based on the records of occupational accidents involving exposure to biological materials and the reports made to the Institute’s Occupational Health Division.A total of 108 incidents were reported, 87 of which involved sharp instruments. Most accidents occurred in the surgical ward, and involved medical staff. The findings revealed low adherence to clinical and laboratory follow-up protocols. There were several errors in data entry and high rates of missing data for important characteristics of the accidents and victims, which prevented a more thorough description of these incidents.This study revealed several aspects of occupational accidents, victims and follow-up procedures, allowing for the discussion of strategies that could improve the reporting, prevention and management of these events. These risks are even higher in the hospital environment due to the high frequency with which invasive procedures are performed in this setting. In the context of health care work, sharps injuries are defined as events involving the accidental penetration of the skin by a sharp object. In the United States, the National Surveillance System for Health Care Workers (NaSH) reports that 80% of these injuries are caused by six types of object: disposable syringes, hypodermic needles, suture needles, winged-steel needles, intravenous catheter stylets and phlebotomy needles.2 is thought to suffer nearly 3 million sharps injuries a year. In Brazil, though studies report a high rate of occupational exposure to sharps injuries,8 there are no real estimates of the number of workers affected by these incidents. Occupational accidents with exposure to biological material are usually reported to the Information System for Notifiable Diseases (SINAN), but the section of the report form where individuals are asked to describe the circumstances of the accident is often left blank.The global population of health care workers, which is of approximately 35 million people,9 However, previous studies have found that over 50% of health care workers who experience this type of accident do not report its occurrence,1 preventing an accurate assessment of the situation and the adoption of preventive measures. According to the literature, several factors contribute to the underreporting of these incidents, including a low perception of contamination risk, unfamiliarity with reporting systems,10 the perception of the accident as irrelevant and unfamiliarity with the health care protocols for assisting victims of occupational accidents.11After an occupational accident involving a sharp instrument, a report must be filed, and the worker involved must receive adequate medical assistance, including an analysis of the accident, preventive and prophylactic measures, as well as any additional procedures required by the institution.12The scientific literature on accidents with exposure to biological material (including sharps injuries) in Brazilian hospitals consists mostly of quantitative studies that attribute the accidents to the behavior of workers themselves. The focus on individual behavior rather than working conditions and occupational processes as the causes of occupational accidents denotes a casuistic approach that is rooted in the historical study of these issues. In Brazil and several other countries, the prevailing attitude of government institutions, employers and the press is that occupational accidents are caused by the workers themselves, due to negligence, distraction or dissatisfaction with work, thereby excluding organizational issues and increasingly precarious working conditions as potential causes of accidents.13 notes that some aspects of work organization in hospitals may contribute to the occurrence of occupational accidents. These include the progressive intensification of work, the need to perform multiple simultaneous activities and the presence of frequent interruptions, in addition to other aspects of the collective management of current challenges. Factors related to sharp instruments themselves may also influence accident risk. A study conducted in an American hospital found that sharp instruments that require manipulation or disassembly after use were associated with a higher rate of accidents than syringes with disposable needles.1SilvaSeveral initiatives can be implemented to address occupational exposure to potentially contaminated sharp instruments. Workers must be made aware of the risks to which they are exposed in their daily work environment, and of the need to care for their own safety and that of their colleagues. Health care services should promote workers’ health and focus on accident prevention, ensuring that all initiatives involve workers’ knowledge and participation. In light of these observations, the aim of this study was to assess and describe the occurrence of sharps injuries in employees of the Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA) in 2017 and 2018, and discuss strategic interventions to address these accidents.This was a cross-sectional, exploratory and descriptive study on occupational accidents involving exposure to sharp instruments recorded at the INCA between January 2017 and December 2018. The INCA specializes in cancer care, and comprises four separate sites  at different addresses in the city of Rio de Janeiro, which collectively employ approximately 3,600 workers.Information on exposure incidents was collected in two stages. The first stage involved accessing a database of occupational accidents involving biological material in the institutional intranet. This database contains information on the workers, the accidents, and all relevant actions taken after the incidents. The records of these events were then retrieved from the Occupational Health Division (OHD), a service that provides assistance to health care workers. This method of data collection was chosen because gathering data from the OHD alone would exclude all accidents where victims did not report to this division to complete the recommended follow-up procedures.Institutional protocols at the INCA recommend that all workers who have occupational accidents involving exposure to biological material be immediately evaluated by the on-call doctor at the First Aid Service (FAS) in the hospital where the incident occurred. During the assessment at the FAS, the doctor records the incident in the intranet database by filling out a Report Form for Accidents Involving Biological Material, in addition to providing the necessary assistance to the worker. After the initial medical consultation, the worker is referred to an occupational physician at the OHD.The following data were collected for each incident: gender, age range, length of employment, occupation and sector of the worker; clinical site, date and time of incident, type of fluid, object, body part involved, type of exposure, circumstances, use of personal protective equipment (PPE), evolution of serological results and availability of OHD reports for the accident. These variables were selected in order to obtain a better understanding of the circumstances under which the incidents occurred. The data were stored in an electronic database and organized into tables, after which the incidents were analyzed and described. Only those involving full-time employees of the INCA were included in this study. Reports filed on behalf of outside contractors were excluded, since accidents involving these individuals are managed according to different protocols, where the INCA is only responsible for providing initial medical care. All subsequent follow-up assessments fall under the responsibility of the workers’ primary employer.The present study was approved by the Research Ethics Committee of the Escola Nacional de Saúde Pública Sérgio Arouca/Fundação Oswaldo Cruz and the INCA, under protocol numbers 2.771.058 and 2.873.753, respectively.A total of 108 incidents involving biological materials were recorded in the database. Eighty-seven of these were caused by sharp instruments. The accidents and their characteristics are described in As shown in Serological test results  showed t14 a hospital in northern Thailand,15 and a university hospital in Serbia.16 The predominance of females in the health care sector has been described by Wermelinger et al.17 as a global phenomenon. In Brazil, the author noted that census data from the year 2000 showed that the vast majority of health care workers were female, with women accounting for nearly 70% of the workforce in this sector.The present study showed that women were most affected by sharps injuries, with female workers accounting for 57.5% of cases. This may be explained by the fact that most workers in the health care sector and the institution examined are female. Similar results have been obtained in previous studies of Brazilian hospitals,18 also observed a higher frequency of accidents in workers with less time and experience in their current positions. National and international studies have also shown that medical staff members account for a higher percentage of accidents involving sharp instruments.19A significant number of incidents also affected resident physicians (26.5%) and workers who had been at the INCA for approximately 1 year (24%). These individuals may not have the necessary skills and training to perform their activities. This could be due to low-quality education, inexperience or poor working conditions. With regard to resident physicians, it is important to note that although these individuals are still in training, they tend to be on the front lines of patient care, and often perform high-complexity procedures. A study by Ottobelli et al.20When the data were classified by hospital department, findings showed that the surgery ward had the highest incidence of accidents (40.2%), possibly due to the number of patients who go through surgery and the frequency with which the surgeons must handle sharp instruments under high-risk, high-pressure conditions. Operating rooms often have large pieces of technological equipment, leaving little room for workers to move around safely during procedures. Some types of surgery also require additional equipment, the use of devices that can weigh up to 20 kg, and the presence of specialized personnel. Many procedures also require the team to remain in the operating room for over 10 hours. These features are characteristic of the work in the surgical department, which is a cause of concern, since they also increase the risk of accidents. This poses a challenge for workers’ health initiatives and interventions targeting causal pathways and risk factors for work-related accidents and injury. This may be the reason why the present findings and those of previous studies point to surgical departments as the settings with the highest number of sharps injuries.21 and Brazil.23 Blood was cited as the most common contaminant, and was involved in 69% of incidents, which is in line with previous findings in the literature.20The assessment of incidents per clinical site revealed that CH1 accounted for the highest proportion of incident reports (92%). This is indicative of underreporting in the other locations, as well as an unusually high prevalence of occupational accidents in CH1. Though this facility has the largest workforce and sees the largest number of patients, the level of activity at other units during the study period suggests that incidents there must have gone unreported. There is, as such, a need for a more detailed study of this issue in the other hospitals. Most accidents (84%) occurred in the daytime. This might be due to the faster pace of work during the day, and the increased number of procedures such as surgeries. These data corroborate the results of studies conducted in PortugalIn the first stage of data collection for the present study, some variables were found to have high levels of missing data , since the Report Form for Accidents Involving Biological Material, used to enter information into the intranet database, does not contain entry fields for additional information on the accident and the victim. The lack of information on these and other variables prevented a more thorough analysis of events, since few occupational accident victims reported to the OHD, which would have allowed for a more detailed assessment of the incidents.The OHD is located near the CH1, in the central part of the city of Rio de Janeiro and far from the other clinical centers , all of which are located in the northern part of the city. One reason why workers may not report to the OHD after their accidents to complete the clinical and laboratory follow-up may be the absence of such a department within the hospitals themselves and/or near their current jobs. This may be especially true for workers in the northern centers. This hypothesis is supported by our findings, which show that only 23% of workers reported their accidents to the OHD. These reports were used to collect additional data, which are relevant to the development of accident intervention programs.The activities performed by health care workers, many of which are invasive procedures involving sharp instruments (including hollow-bore needles), are especially conducive to accidents. Current guidelines recommend that sharp instruments be replaced with devices that offer greater protection to workers whenever possible.This may be due to the nature of the work itself, which requires the use of hands and fingers to manipulate equipment and perform health-related procedures. Recommendations such as avoiding the use of fingers for support during procedures involving sharp instruments might help prevent accidents.With regards to disposal procedures, it is important that workers avoid placing sharp instruments in overfilled disposal boxes; pushing objects into the boxes during disposal; moving sharps boxes to make room for more material; and, especially, keeping the boxes far from the place where the residue is produced. As for blood collection, the most commonly used method still involves the use of needles and syringes to draw blood and transfer it to a collection tube, without placing the hands on any surface for support. This procedure is associated with increased risk to workers and other members of the medical team. The identification and monitoring of these behaviors is crucial for the development of accident prevention strategies.21These factors and situations refer to work organization and working conditions. They might be especially frequent in precarious contexts, where workers are unaware of the risks intrinsic to their activities. Working conditions and type of occupational activity are strong determinants of worker health and a major cause of occupational accidents. Health care workers must continuously cope with the pain, suffering and death of patients. This situation, associated with the complexity of certain technical actions, the responsibility level and speed inherent in some decisions, work regimen (...), precarious bonds at work, the pressure and demands work entails and competitive relations in the work environment, represent a permanent aggression to these workers.23 In order to improve adherence to PPE use, institutions must ensure access and availability of PPE that is compatible with the activities performed by workers and is sufficiently comfortable. Employers are also responsible for providing instructions and supervision of PPE use.The use of PPE is influenced by three factors, which include organizational issues.It is important to note that the complexity of accidents extends beyond the presence or absence of PPE use. Accident prevention also requires control and participative management strategies to improve the organization of work processes and working conditions.The development of institutional strategies that involve the provision of training before employees begin work is crucial for effective work performance and accident prevention. However, these strategies must reach all workers and be part of a continuous process, which adapts to changes in knowledge and identifies new sources of risk, in addition to focusing on specific themes that are relevant to the activities of each worker.The present findings showed that, although there are protocols to manage biological exposure incidents at the INCA, these are not known to many of the workers, who are also unfamiliar with the procedures to be followed after an accident occurs. This calls attention to the need to promote continuous initiatives to disseminate information on these protocols and any updates, especially regarding the provision of immediate assistance to workers with occupational accidents.It is important that all workers, especially those who provide assistance to individuals who experience accidental exposure to biological materials and potentially contaminated sharps, are trained in the INCA protocol, learning to fill out the forms (A total of 87 incidents involving sharp instruments were reported in the study period, with 21 of these involving biological fluids. The analysis of the total number of incidents and the near absence of reports from clinical sites CH2, CH3 and CH4, which employ over 3,000 workers, is indicative of underreporting.The medical staff was most affected by these incidents. The discrepancy between this finding and those of previous studies, which have found nursing staff to report the highest number of accidents, may be attributable to underreporting. A significant number of workers did not report their accidents and/or complete their follow-up care at the OHD, as recommended by institutional protocols. This reaffirms the need for strategies to raise awareness of the protocol and the worker assistance procedures.This study underscored the importance of improving accident reporting systems, since collecting quality data is an important step in the development of any intervention. There is a clear need to raise awareness among workers of the importance of reporting, preventing and managing sharps injuries, as well as developing permanent training and education programs to address these issues within the institution. In light of these findings, although sharps injuries are frequent and inherent to the professional practice of health care workers, the analysis of these occurrences, the development of prevention strategies and the medical follow-up of these instances still represent a challenge.