Abstract

This study aimed to describe strategies and policies necessary to provide care for people with disabilities during periods of public health emergencies, especially COVID-19. Twenty-nine studies and 49 strategies were included, grouped into eight categories: 1) housing, mobility, and infrastructure; 2) work, occupation, and income; 3) social assistance; 4) telehealth; 5) comprehensive health care; 6) planning and management; 7) communication; and 8) education. The overview of the strategies can help to guide public policies, with feasible actions that promote more significant equity for disabled people.

Key words:
COVID-19; People with disabilities; Declaration of emergency; Policy making; Systematic review

Introduction

The COVID-19 pandemic affected more than 35 million people, resulting in more than 680,000 deaths in Brazil¹1 Conselho Nacional de Secretários de Saúde (CONASS). COVID-19 [Internet]. 2022. [acessado 2022 ago 3]. Disponível em: https://www.conass.org.br/coronavirus/
https://www.conass.org.br/coronavirus... . Due to the pandemic, complications arose directly and indirectly from the disease, such as the collapse of healthcare systems due to high demand, in such a way that other health conditions were harmed, producing an even more serious impact on the lives of people who were already facing a situation of social vulnerability²2 Estrela FM, Soares CFSE, Cruz MAD, Silva AFD, Santos JRL, Moreira TMO, Lima AB, Silva MG. Pandemia da Covid 19: refletindo as vulnerabilidades à luz do gênero, raça e classe. Cien Saude Colet 2020; 25(9):3431-3436..

The spread of the disease was uneven among the population, as there are social vulnerabilities that led to greater losses for specific population groups²2 Estrela FM, Soares CFSE, Cruz MAD, Silva AFD, Santos JRL, Moreira TMO, Lima AB, Silva MG. Pandemia da Covid 19: refletindo as vulnerabilidades à luz do gênero, raça e classe. Cien Saude Colet 2020; 25(9):3431-3436.. The homeless population, those in extreme poverty, prisoners, and the disabled population suffered more losses and injuries than did the general population. The difficulty in achieving a minimum income³3 Vaitsman J, Lobato LVC. Benefício de Prestação Continuada (BPC) para pessoas com deficiência: barreiras de acesso e lacunas intersetoriais. Cien Saude Colet 2017; 22(11):3527-3536., the informality of work, poor housing conditions, and difficulty in accessing health services are factors linked to the social determination of health, which were intensified due to the COVID-19²2 Estrela FM, Soares CFSE, Cruz MAD, Silva AFD, Santos JRL, Moreira TMO, Lima AB, Silva MG. Pandemia da Covid 19: refletindo as vulnerabilidades à luz do gênero, raça e classe. Cien Saude Colet 2020; 25(9):3431-3436. pandemic.

Even before, people with disabilities were more prone to situations of social vulnerability, especially concerning health care⁴4 World Health Organization (WHO). Disability considerations during the COVID-19 outbreak [Internet]. 2022. [cited 2022 nov 13]. Available from: https://www.who.int/publications/i/item/WHO-2019-nCoV-Disability-2020-1
https://www.who.int/publications/i/item/... . It is estimated that there are 17 million people over two years of age with at least one function compromised by disability in Brazil, according to the 2019 National Health Survey (NHS)⁵5 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2019 [Internet]. 2019. [acessado 2022 ago 3]. Disponível em: http://downloads.ibge.gov.br/downloads_estatisticas.htm?caminho=PNS/2019/Microdados/Dados
http://downloads.ibge.gov.br/downloads_e... . This group reported regular and poor self-rated health more frequently (49%), when compared to the general population (9%)⁶6 Alexander D, Council of Europe. Disabled persons in viral pandemics: the example of Covid-19 [Internet]. 2021. [cited 2022 ago 3]. Available from: https://rm.coe.int/publication-disabled-persons-in-viral-pandemics-the-example-of-covid-1/1680a44c46
https://rm.coe.int/publication-disabled-... .

In Brazil, a lack of information and training was identified, both for professionals and for family members and informal caregivers, as regards how to handle people with disabilities and the full complexity of care, especially in public health emergencies²2 Estrela FM, Soares CFSE, Cruz MAD, Silva AFD, Santos JRL, Moreira TMO, Lima AB, Silva MG. Pandemia da Covid 19: refletindo as vulnerabilidades à luz do gênero, raça e classe. Cien Saude Colet 2020; 25(9):3431-3436.. Health equipment is incipient in including processes and physical adaptations to meet the complexity of needs, in the physical, social, and psychological dimensions⁷7 Pinto A, Köptcke LS, David R, Kuper H. A national accessibility audit of primary health care facilities in Brazil - are people with disabilities being denied their right to health? Int J Environ Res Public Health 2021; 18(6):2953.. There is a lack of specialized teams, duly qualified, to treat neurodevelopmental disorders from primary to tertiary care⁸8 Santos CAS, Santo EE. Análise das causas e consequências da superlotação dos serviços de emergências hospitalares: uma revisão bibliográfica. Rev Saude Desenvolv 2014; 5(3):31-44.. The different health institutions in the public system offer fragmented assistance, moving away from the ideal model of comprehensive care for people with disabilities⁹9 Bezerra TV, Silva MA, Maia ER. Acesso da pessoa com deficiência à atenção primária no Brasil: limites e possibilidades. Cad Cult Cienc 2015; 14(2):65-74.. Patient and family education takes place sporadically and unsystematically, and the culture of health professionals and families regarding disability care is focused on hospital and specialized care²2 Estrela FM, Soares CFSE, Cruz MAD, Silva AFD, Santos JRL, Moreira TMO, Lima AB, Silva MG. Pandemia da Covid 19: refletindo as vulnerabilidades à luz do gênero, raça e classe. Cien Saude Colet 2020; 25(9):3431-3436.^,1010 Brasil. Ministério da Saúde (MS). Protocolo de atenção à saúde e resposta à ocorrência de microcefalia - versão 3. Brasília: MS; 2016..

Given the above, this review aimed to describe care strategies for people with disabilities in public health emergencies, especially during the COVID-19 pandemic period.

Methods

A systematic review (SR) was conducted following the PRISMA¹¹11 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372:n71. guidelines. The PECO question was used, characterized by the acronym: P - population: adult people with disabilities, with no restrictions regarding the type of disability, which can be visual, auditory, intellectual, physical, or multiple; E - exposure: COVID-19 pandemic; C - comparator: not applied; O - outcomes: strategies that aim to improve prevention and health care for these people during the pandemic period.

Eligibility criteria

For conceptual purposes, people with disabilities were considered to be those who have long-term impairments of a physical, mental, intellectual, or sensory nature, which, in interaction with various barriers, can obstruct their full participation in society on equal terms with other people, in accordance with the Convention on the Rights of Persons with Disabilities¹²12 Brasil. Presidência da República. Convenção sobre os Direitos das Pessoas com Deficiência: Protocolo Facultativo à Convenção sobre os Direitos das Pessoas com Deficiência [Internet]. 2007. [acessado 2022 ago 3]. Disponível em: http://portal.mec.gov.br/index.php?option=com_docman&view=download&alias=424-cartilha-c&category_slug=documentos-pdf&Itemid=30192
http://portal.mec.gov.br/index.php?optio... . The types of disability and specific populations were not defined a priori because this is an exploratory SR.

Furthermore, the concept of “public health emergency” was used in accordance with International Health Regulations, which consider events of great repercussion that require immediate action, or outbreaks of disease with epidemic potential, regardless of their nature, origin, or source, whose risk of propagation imposes restrictions on trade and/or human trafficking, and brings high morbidity and/or mortality rates that are different from usual¹³13 World Health Organization (WHO). International Health Regulations [Internet]. 2016. [cited 2022 ago 3] Available from: https://www.who.int/publications/i/item/9789241580496
https://www.who.int/publications/i/item/... .

Articles that addressed care, work, income, health, and social security strategies that aimed to reduce the effects of public health emergencies, especially COVID-19, on people with disabilities, as set forth by law, who are over 18 years of age, were considered eligible. Studies that addressed the general population were included if they presented strategies during periods of health emergencies. A comprehensive approach was chosen, including SR, narrative or integrative studies, qualitative and quantitative studies, and opinion articles. Studies that addressed disability or COVID-19 alone, etiology; pathophysiology and clinic pathology; other types of public health emergencies arising from earthquakes and hurricanes; and types of studies, such as reports, editorials, conference proceedings, newspaper comments, and case reports; as well as those written in a language other than English, Portuguese, or Spanish, were excluded.

Search for scientific evidence

A structured literature search was conducted in June 2021 and updated in November 2022. The PubMed, Web of Science, Scopus, VHL, CINAHL, PDQ, Health System Evidence, PEDro, Psycinfo databases were used. The descriptors used were: “COVID-19”, “SARS-CoV-2”, “Pandemics”, “Emergency Responders”, “Disabled Persons”, and their cross-referenced synonyms; according to the complete strategy available in Annex 1 of the supplementary material: https://doi.org/10.48331/scielodata.2WZPVJ. The search strategies were adapted for each database.The PROSPERO protocol was published, whose identifier is CRD42021266341.

Study selection, data extraction and analysis

Two independent reviewers performed the selection by title and abstract, and the selection after complete reading using the Rayyan¹⁴14 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan - a web and mobile app for systematic reviews. Syst Rev 2016; 5(1): 210. software, with discrepancies being checked by a third reviewer. The studies excluded, with justification, after having read the full article are presented in Chart 1.

An excel spreadsheet, prepared by the authors, was used for data extraction, which was carried out by a reviewer and checked by the other two. Information was collected on the variables: author, year, country where the study was conducted, objective of the study, method, main results containing the strategies reported by the authors.

The list of strategies underwent a qualitative synthesis based on a deductive thematic analysis¹⁵15 Alencar ES, Almouloud SA. A metodologia de pesquisa: metassíntese qualitativa. Reflexão Ação 2017; 25(3):204.^,1616 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3(2):77-101., which allowed for the creation of intervention categories that provide guidance for the improvement of possible public policies for people with disabilities, whose approach covered dimensions of the social determination of health¹⁷17 Garbois JA, Sodré F, Dalbello-Araujo M. Da noção de determinação social à de determinantes sociais da saúde. Saude Debate 2017; 41(112):63-76.. Conceptually, social determination was characterized as a set of economic, social, political, governmental, and cultural situations that positively or negatively affect the health of individuals, social segments, communities, populations, and territories¹⁷17 Garbois JA, Sodré F, Dalbello-Araujo M. Da noção de determinação social à de determinantes sociais da saúde. Saude Debate 2017; 41(112):63-76.. Such contextual situations are remarkable, as they perpetuate social disparities for people with disabilities¹⁸18 Jesus TS, Landry MD, Jacobs K. A 'new normal' following COVID-19 and the economic crisis: Using systems thinking to identify challenges and opportunities in disability, telework, and rehabilitation. Work 2020; 67(1):37-46..

The critical analysis of the list of strategies was carried out by two reviewers, generating a grouping table, validated by two other reviewers in three work meetings of the research team. The critical analysis of the contents of each strategy generated a connection with dimensions adapted from the model cited by Garbois et al.¹⁷17 Garbois JA, Sodré F, Dalbello-Araujo M. Da noção de determinação social à de determinantes sociais da saúde. Saude Debate 2017; 41(112):63-76., namely: a) socioeconomic context: strategies grouped into housing, mobility and infrastructure, and work, occupation, and income, b) conditions of unequal access to goods and services: strategies grouped into access to services and goods, including telehealth and comprehensive health care, and social assistance, and c) social cohesion: strategies grouped into planning and organization contingency plans, communication, and education for people with disabilities, focusing on the centrality of the participation of disabled persons.

Quality assessment

To assess methodological quality, instruments from the global Joanna Briggs Institute (available at: https://jbi.global/critical-appraisal-tools) were used, according to the methodology reported in each of the included studies.

Results

A total of 2,703 references were identified. Of the total of 1,589 unique studies, 62 were selected for full reading, 36 of which¹⁸18 Jesus TS, Landry MD, Jacobs K. A 'new normal' following COVID-19 and the economic crisis: Using systems thinking to identify challenges and opportunities in disability, telework, and rehabilitation. Work 2020; 67(1):37-46.

19 Subramaniam P, Villeneuve M. Advancing emergency preparedness for people with disabilities and chronic health conditions in the community: a scoping review. Disabil Rehabil 2020; 42(22):3256-3264.

20 Saldanha JHS, Pereira APM, Santos AOC, et al. Pessoas com deficiência na pandemia da COVID-19: garantia de direitos fundamentais e equidade no cuidado. Cad Saude Publica 2021; 37(9):e00291720.

21 Croft S, Fraser S. A scoping review of barriers and facilitators affecting the lives of people with disabilities during COVID-19. Front Rehabil Sci 2022; 2:784450.

22 Sakellariou D, Malfitano APS, Rotarou ES. Disability inclusiveness of government responses to COVID-19 in South America: a framework analysis study. Int J Equity Health 2020; 19(1):131.

23 Zaagsma M, Volkers KM, Swart EAK, Schippers AP, Van Hove G. The use of online support by people with intellectual disabilities living independently during COVID-19. J Intellect Disabil Res 2020; 64(10):750-756.

24 Epstein S, Campanile J, Cerilli C, Gajwani P, Varadaraj V, Swenor BK. New obstacles and widening gaps: A qualitative study of the effects of the COVID-19 pandemic on U.S. adults with disabilities. Disabil Health J. 2021; 14(3): 101103.

25 Lugo-Agudelo L, Brunal MAS, Borrero AMP, Sarmiento KMC, Correa JCV, Di Dio Castagna Iannini R, Zuluaga MG, Ospina VA, Lugo DFP, Franco LFM, Gutenbrunner C. Countries response for people with disabilities during the COVID-19 pandemic. Front Rehabil Sci 2022; 2:796074.

26 Mzini LB. COVID-19 pandemic planning and preparedness for institutions serving people living with disabilities in South Africa: an opportunity for continued service and food security. J Intellect Disabil Diagnosis Treat 2021; 9(1):11-20.

27 Oviedo-Cáceres MDP, Arias-Pineda KN, Yepes-Camacho MDR, Montoya Falla P. COVID-19 pandemic: experiences of people with visual impairment. Invest Educ Enferm 2021; 39(1):e09.

28 Scheffers F, Moonen X, van Vugt E. Assessing the quality of support and discovering sources of resilience during COVID-19 measures in people with intellectual disabilities by professional carers. Res Dev Disabil 2021; 111:103889.

29 Marotta N, Demeco A, Moggio L, Ammendolia M. Why is telerehabilitation necessary? A pre-post COVID-19 comparative study of ICF activity and participation. J Enabling Technol 2021; 15(2):117-121.

30 Navas P, Amor AM, Crespo M, Wolowiec Z, Verdugo MA. Supports for people with intellectual and developmental disabilities during the COVID-19 pandemic from their own perspective. Res Dev Disabil 2021; 108:103813.

31 Smith EM, Toro Hernandez ML, Ebuenyi ID, Syurina EV, Barbareschi G, Best KL, Danemayer J, Oldfrey B, Ibrahim N, Holloway C, MacLachlan M. Assistive Technology Use and Provision During COVID-19: Results From a Rapid Global Survey. Int J Heal policy Manag 2022; 11(6):747-756.

32 Boldrini P, Garcea M, Brichetto G, Reale N, Tonolo S, Falabella V, Fedeli F, Cnops AA, Kiekens C. Living with a disability during the pandemic. 'Instant paper from the field' on rehabilitation answers to the COVID-19 emergency. Eur J Phys Rehabil Med 2020; 56(3):331-334.

33 Jayarajan D, Sivakumar T, Torous JB, Thirthalli J. Telerehabilitation in Psychiatry. Indian J Psychol Med 2020; 42(suppl. 5):57S-62S.

34 Kendall E, Ehrlich C, Chapman K, Shirota C, Allen G, Gall A, Kek-Pamenter JA, Cocks K, Palipana D. Immediate and long-term implications of the COVID-19 pandemic for people with disabilities. Am J Public Health 2020; 110(12):1774-1779.

35 Kwak E-J, Kim J, Perinpanayagam H, Kun K-Y. Guidance for dental treatment of patients with disabilities during COVID-19 pandemic. J Dent Sci 2021; 16(1):540-543.

36 Sabatello M, Burke TB, McDonald KE, Appelbaum PS. Disability, ethics, and health care in the COVID-19 pandemic. Am J Public Health 2020; 110(10):1523-1527.

37 Nwachukwu PTT, Asuelime L. UN COVID 19 disability inclusion strategy: assessing the impact on cultural-safety and capability information approach. J Intellect Disabil Diagnosis Treat 2021; 9(1):29-38.

38 Naami A, Mfoafo-M'Carthy M. COVID-19: vulnerabilities of persons with disabilities in Ghana. African J Soc Work 2020; 10(3):9-16.

39 Nankervis K, Chan J. Applying the CRPD to people with intellectual and developmental disability with behaviors of concern during COVID-19. J Policy Pract Intellect Disabil 2021; 18(3):197-202.

40 Senjam SS. A persons-centered approach for prevention of COVID-19 disease and its impacts in persons with disabilities. Front Public Heal 2021; 8:608958

41 Campbell VA, Gilyard JA, Sinclair L, Sternberg T, Kailes JI. Preparing for and responding to pandemic influenza: implications for people with disabilities. Am J Public Health. 2009; 99(suppl. 2):S294-S300.

42 Hutchins SS, Truman BI, Merlin TL, Redd SC. Protecting vulnerable populations from pandemic influenza in the United States: a strategic imperative. Am J Public Health. 2009; 99(suppl. 2):S243-S248.

43 Boyle CA, Fox MH, Havercamp SM, Zubler J. The public health response to the COVID-19 pandemic for people with disabilities. Disabil Health J 2020; 13(3):10094.

44 Jalali M, Shahabi S, Lankarani KB, Kamali M, Mojgani P. COVID-19 and disabled people: perspectives from Iran. Disabil Soc 2020; 35(5):844-847.

45 Jumreornvong O, Tabacof L, Cortes M, Tosto J, Kellner CP, Herrera JE, Putrini D. Ensuring equity for people living with disabilities in the age of COVID-19. Disabil Soc 2020; 35(10):1682-1687.

46 Kavanagh A, Dickinson H, Carey G, Llewellyn G, Emerson E, Disney G, Hatton C. Improving health care for disabled people in COVID-19 and beyond: lessons from Australia and England. Disabil Health J 2021; 14(2):101050.

47 Zeng B, Chen D, Qiu Z, Zhang M, Wang G; Rehabilitation Group of Geriatric Medicine branch of Chinese Medical Association, division of Management of Medical Rehabilitation Institution of Chinese Hospital Association, Rehabilitation Institution Management division of Chinese Rehabilitation Medical Association, division of Rehabilitation Psychology, Chinese Psychological Association, division of Disability Classification Research, Chinese Association of Rehabilitation of Disabled Persons; Wang J, Yu P, Wu X, An B, Bai D, Chen Z, Deng J, Guo Q, He C, Hu X, Huang C, Huang Q, Huang X, Huang Z, Li X, Liang Z, Liu G, Liu P, Ma C, Ma H, Mi Z, Pan C, Shi X, Sun H, Xi J, Xiao X, Xu T, Xu W, Yang J, Yang S, Yang W, Ye X, Yun X, Zhang A, Zhang C, Zhang P, Zhang Q, Zhao M, Zhao J. Expert consensus on protocol of rehabilitation for COVID-19 patients using framework and approaches of WHO International Family Classifications. AGING Med 2020; 3(2):82-94.

48 Banks LM, Davey C, Shakespeare T, Kuper H. Disability-inclusive responses to COVID-19: Lessons learnt from research on social protection in low- and middle-income countries. World Dev 2021; 137:105178.

49 Secretaria de Saúde do Estado do Piauí. Nota técnica: Recomendações de Proteção e Prevenção à Saúde das Pessoas com Deficiência Frente à Pandemia pelo Novo Coronavírus (COVID-19) [Internet]. [acessado 2022 ago 3] 2021. Disponível em: http://www.saude.pi.gov.br/uploads/warning_document/file/598/NOTA_TECNICA_PESSOA_COM_DEFICIENCIA__reduzida.pdf
http://www.saude.pi.gov.br/uploads/warni...

50 Velasco JV, Obnial JC, Pastrana A, Ang HK, Viacrusis PM, Lucero-Prisno Iii DE. COVID-19 and persons with disabilities in the Philippines: a policy analysis. Heal Promot Perspect 2021; 11(3):299-306.

51 Valdez RS, Rogers CC, Claypool H, Trieshmann L, Frye O, Wellbeloved-Stone C, Kushalnagar P. Ensuring full participation of people with disabilities in an era of telehealth. J Am Med Inform Assoc 2021; 28(2):389-392.

52 Sarju JP. Nothing About Us Without Us - Towards Genuine Inclusion of Disabled Scientists and Science Students Post Pandemic. Chemistry 2021; 27(3):10489-10494.^-5353 Qi F, Wu YQ, Wang Q. Experience and discussion: safeguards for people with disabilities during the COVID-19 pandemic in China. Front Public Heal 2021; 9:744706. were included after applying eligibility criteria (Figure 1). In assessing the methodological quality of the included studies, although some presented uncertainties in the JBI¹⁹19 Subramaniam P, Villeneuve M. Advancing emergency preparedness for people with disabilities and chronic health conditions in the community: a scoping review. Disabil Rehabil 2020; 42(22):3256-3264.^,2626 Mzini LB. COVID-19 pandemic planning and preparedness for institutions serving people living with disabilities in South Africa: an opportunity for continued service and food security. J Intellect Disabil Diagnosis Treat 2021; 9(1):11-20.^,3434 Kendall E, Ehrlich C, Chapman K, Shirota C, Allen G, Gall A, Kek-Pamenter JA, Cocks K, Palipana D. Immediate and long-term implications of the COVID-19 pandemic for people with disabilities. Am J Public Health 2020; 110(12):1774-1779.^,3636 Sabatello M, Burke TB, McDonald KE, Appelbaum PS. Disability, ethics, and health care in the COVID-19 pandemic. Am J Public Health 2020; 110(10):1523-1527.^,3737 Nwachukwu PTT, Asuelime L. UN COVID 19 disability inclusion strategy: assessing the impact on cultural-safety and capability information approach. J Intellect Disabil Diagnosis Treat 2021; 9(1):29-38. assessment fields, no study was excluded from this synthesis.

Among the studies included, 27.78% are theoretical studies, presenting recommendations for strategies based on regulations or documents prepared by organizations in the area of assistance, health, or social security. Opinion articles and qualitative studies totaled 19.44% each. Moreover, three scoping reviews, two cross-sectional studies, one observational study, one trial, one technical note, one consensus review, one document analysis, and two studies with no informed methodology were included.

As for the country of the study, the United States accounted for 16.67%, followed by Australia (8.33%); South Africa, Brazil, China, the Netherlands, India, and Italy (5.56% each); and Colombia, South Korea, Spain, North Korea, Philippines, Ghana, and Iran (2.78% each). Three studies reported broader definitions of location as their origin: South America, and low and middle income countries (LMIC) (3.57%, each). Seven studies had no defined country of origin (19.44%). Detailed information with the characterization of the studies is available in Annex 2 of the supplementary material: https://doi.org/10.48331/scielodata.2WZPVJ.

The strategies identified in the articles were grouped into categories (Table 2) systematized by the authors in order to address social determination in the living conditions of people with disabilities.

The included studies showed that people with disabilities still require greater care in times of public health emergencies. Among the strategies selected, the majority had exclusive approaches for people with disabilities (92.8%); however, options were also reported to meet the needs of the vulnerable population in general.

In the housing, mobility, and infrastructure category - dimension of socioeconomic context in the process of social determination - four strategies were identified. One study highlights the need for emergency accommodations (such as temporary shelters in population evacuation scenarios, such as in cases of natural disasters) to be close to access points to the healthcare and social assistance network, in addition to accessibility issues that must be observed⁴⁸48 Banks LM, Davey C, Shakespeare T, Kuper H. Disability-inclusive responses to COVID-19: Lessons learnt from research on social protection in low- and middle-income countries. World Dev 2021; 137:105178.. One study was identified on the importance of protection programs for people living in institutions/shelters, due to a greater vulnerability to infections, suggesting restrictions on visits and referral of suspected cases to health services within two hours after identifying the first symptoms, in addition to the already recommended isolation measures²²22 Sakellariou D, Malfitano APS, Rotarou ES. Disability inclusiveness of government responses to COVID-19 in South America: a framework analysis study. Int J Equity Health 2020; 19(1):131.. Also in this category, two strategies were identified in the field of mobility. The first brought the strategy of special transport for people with disabilities and their care in times of public health emergencies²⁵25 Lugo-Agudelo L, Brunal MAS, Borrero AMP, Sarmiento KMC, Correa JCV, Di Dio Castagna Iannini R, Zuluaga MG, Ospina VA, Lugo DFP, Franco LFM, Gutenbrunner C. Countries response for people with disabilities during the COVID-19 pandemic. Front Rehabil Sci 2022; 2:796074.. The second, the need to allow for the mobility of family members within the national territory to care for people with disabilities in times of social isolation⁵⁴54 Zidan T. Disability and health emergencies. In: Fronek P, Casares KS, editors. Social Work In Health Emergencies: Global Perspectives. South Bend (IN): Routledge; 2022. p. 188-200..

In the work, occupation, and income category - dimension of socioeconomic context in the process of social determination - five strategies were found that aimed to guarantee the financial dignity and job security of people with disabilities during health emergencies. Studies have recommended flexible work arrangements, especially for people with disabilities, as they are more vulnerable to infections²⁶26 Mzini LB. COVID-19 pandemic planning and preparedness for institutions serving people living with disabilities in South Africa: an opportunity for continued service and food security. J Intellect Disabil Diagnosis Treat 2021; 9(1):11-20.^,5252 Sarju JP. Nothing About Us Without Us - Towards Genuine Inclusion of Disabled Scientists and Science Students Post Pandemic. Chemistry 2021; 27(3):10489-10494.. In view of this, the importance of infection control mechanisms in the workplace was also mentioned in order to increase the safety of workers in these places²⁶26 Mzini LB. COVID-19 pandemic planning and preparedness for institutions serving people living with disabilities in South Africa: an opportunity for continued service and food security. J Intellect Disabil Diagnosis Treat 2021; 9(1):11-20.. The findings revealed that even in teleworking spaces, disparities were present, requiring adjustments in accommodations and structural conditions in the environment in which the disabled person works¹⁸18 Jesus TS, Landry MD, Jacobs K. A 'new normal' following COVID-19 and the economic crisis: Using systems thinking to identify challenges and opportunities in disability, telework, and rehabilitation. Work 2020; 67(1):37-46.. Despite the reservations, teleworking was considered a great opportunity for people with disabilities and could be a way of leveling employment opportunities during periods without health emergencies¹⁸18 Jesus TS, Landry MD, Jacobs K. A 'new normal' following COVID-19 and the economic crisis: Using systems thinking to identify challenges and opportunities in disability, telework, and rehabilitation. Work 2020; 67(1):37-46..

The need to create and back support networks for employees with disabilities was also highlighted⁵²52 Sarju JP. Nothing About Us Without Us - Towards Genuine Inclusion of Disabled Scientists and Science Students Post Pandemic. Chemistry 2021; 27(3):10489-10494.. One of the studies²²22 Sakellariou D, Malfitano APS, Rotarou ES. Disability inclusiveness of government responses to COVID-19 in South America: a framework analysis study. Int J Equity Health 2020; 19(1):131. identified several strategies from South American countries addressed as options for employment and financial aid for people with disabilities, such as: emergency family income, extra transfers to families, paid leave for those who cannot continue working during the pandemic, permission for online registration of new people with disabilities, and automatic renewal for longer periods by security bodies and employment protection policies²²22 Sakellariou D, Malfitano APS, Rotarou ES. Disability inclusiveness of government responses to COVID-19 in South America: a framework analysis study. Int J Equity Health 2020; 19(1):131.^,4040 Senjam SS. A persons-centered approach for prevention of COVID-19 disease and its impacts in persons with disabilities. Front Public Heal 2021; 8:608958. A tax exemption strategy for people with disabilities⁵⁰50 Velasco JV, Obnial JC, Pastrana A, Ang HK, Viacrusis PM, Lucero-Prisno Iii DE. COVID-19 and persons with disabilities in the Philippines: a policy analysis. Heal Promot Perspect 2021; 11(3):299-306. was also identified.

Regarding the social assistance category - dimension of unequal access to goods and services - the limited control that people with disabilities have over their health benefits has been reported in the literature⁴⁸48 Banks LM, Davey C, Shakespeare T, Kuper H. Disability-inclusive responses to COVID-19: Lessons learnt from research on social protection in low- and middle-income countries. World Dev 2021; 137:105178.. Such benefits, especially when they are minimum income benefits, must be transferred directly to people with disabilities, with transfer to guardians only in cases authorized under law⁴⁸48 Banks LM, Davey C, Shakespeare T, Kuper H. Disability-inclusive responses to COVID-19: Lessons learnt from research on social protection in low- and middle-income countries. World Dev 2021; 137:105178.^,5050 Velasco JV, Obnial JC, Pastrana A, Ang HK, Viacrusis PM, Lucero-Prisno Iii DE. COVID-19 and persons with disabilities in the Philippines: a policy analysis. Heal Promot Perspect 2021; 11(3):299-306.. Furthermore, these benefit packages must take into account the needs of people with disabilities, allowing for comprehensive care to be provided to this population in periods of public health emergencies²⁵25 Lugo-Agudelo L, Brunal MAS, Borrero AMP, Sarmiento KMC, Correa JCV, Di Dio Castagna Iannini R, Zuluaga MG, Ospina VA, Lugo DFP, Franco LFM, Gutenbrunner C. Countries response for people with disabilities during the COVID-19 pandemic. Front Rehabil Sci 2022; 2:796074.^,4141 Campbell VA, Gilyard JA, Sinclair L, Sternberg T, Kailes JI. Preparing for and responding to pandemic influenza: implications for people with disabilities. Am J Public Health. 2009; 99(suppl. 2):S294-S300.^,4848 Banks LM, Davey C, Shakespeare T, Kuper H. Disability-inclusive responses to COVID-19: Lessons learnt from research on social protection in low- and middle-income countries. World Dev 2021; 137:105178., with the possibility of registering online, by telephone, or with automatic enrollment through government registration²¹21 Croft S, Fraser S. A scoping review of barriers and facilitators affecting the lives of people with disabilities during COVID-19. Front Rehabil Sci 2022; 2:784450..

The telehealth category - dimension of unequal access to goods and services - covered several strategies aimed at accessing telecare services for the assessment and treatment (teleconsultation and telerehabilitation) of people with disabilities²¹21 Croft S, Fraser S. A scoping review of barriers and facilitators affecting the lives of people with disabilities during COVID-19. Front Rehabil Sci 2022; 2:784450.^,2525 Lugo-Agudelo L, Brunal MAS, Borrero AMP, Sarmiento KMC, Correa JCV, Di Dio Castagna Iannini R, Zuluaga MG, Ospina VA, Lugo DFP, Franco LFM, Gutenbrunner C. Countries response for people with disabilities during the COVID-19 pandemic. Front Rehabil Sci 2022; 2:796074.^,2626 Mzini LB. COVID-19 pandemic planning and preparedness for institutions serving people living with disabilities in South Africa: an opportunity for continued service and food security. J Intellect Disabil Diagnosis Treat 2021; 9(1):11-20.^,2929 Marotta N, Demeco A, Moggio L, Ammendolia M. Why is telerehabilitation necessary? A pre-post COVID-19 comparative study of ICF activity and participation. J Enabling Technol 2021; 15(2):117-121.^,3131 Smith EM, Toro Hernandez ML, Ebuenyi ID, Syurina EV, Barbareschi G, Best KL, Danemayer J, Oldfrey B, Ibrahim N, Holloway C, MacLachlan M. Assistive Technology Use and Provision During COVID-19: Results From a Rapid Global Survey. Int J Heal policy Manag 2022; 11(6):747-756.^,3232 Boldrini P, Garcea M, Brichetto G, Reale N, Tonolo S, Falabella V, Fedeli F, Cnops AA, Kiekens C. Living with a disability during the pandemic. 'Instant paper from the field' on rehabilitation answers to the COVID-19 emergency. Eur J Phys Rehabil Med 2020; 56(3):331-334.^,3636 Sabatello M, Burke TB, McDonald KE, Appelbaum PS. Disability, ethics, and health care in the COVID-19 pandemic. Am J Public Health 2020; 110(10):1523-1527.^,4040 Senjam SS. A persons-centered approach for prevention of COVID-19 disease and its impacts in persons with disabilities. Front Public Heal 2021; 8:608958^,4444 Jalali M, Shahabi S, Lankarani KB, Kamali M, Mojgani P. COVID-19 and disabled people: perspectives from Iran. Disabil Soc 2020; 35(5):844-847.^,4545 Jumreornvong O, Tabacof L, Cortes M, Tosto J, Kellner CP, Herrera JE, Putrini D. Ensuring equity for people living with disabilities in the age of COVID-19. Disabil Soc 2020; 35(10):1682-1687.^,5151 Valdez RS, Rogers CC, Claypool H, Trieshmann L, Frye O, Wellbeloved-Stone C, Kushalnagar P. Ensuring full participation of people with disabilities in an era of telehealth. J Am Med Inform Assoc 2021; 28(2):389-392., allowing access to various health services without putting people at risk of the contamination and spread of COVID-19⁴⁵45 Jumreornvong O, Tabacof L, Cortes M, Tosto J, Kellner CP, Herrera JE, Putrini D. Ensuring equity for people living with disabilities in the age of COVID-19. Disabil Soc 2020; 35(10):1682-1687.. Telerehabilitation approaches as an alternative to in-person care were useful and viable at the expense of the development of internet infrastructures and widespread use of smartphones and computers⁴⁴44 Jalali M, Shahabi S, Lankarani KB, Kamali M, Mojgani P. COVID-19 and disabled people: perspectives from Iran. Disabil Soc 2020; 35(5):844-847.. However, there is a need for such technologies to be inclusive, with multiple communication modes available, along with an intuitive interface and user-centered design³¹31 Smith EM, Toro Hernandez ML, Ebuenyi ID, Syurina EV, Barbareschi G, Best KL, Danemayer J, Oldfrey B, Ibrahim N, Holloway C, MacLachlan M. Assistive Technology Use and Provision During COVID-19: Results From a Rapid Global Survey. Int J Heal policy Manag 2022; 11(6):747-756..

In the comprehensive health care category - dimension of unequal access to goods and services - 16 strategies were found, in the field of continuing education for health professionals to better serve people with disabilities, eliminating accessibility barriers to health facilities, the comprehensiveness of health care, and the identification and use of the strength of the support network for people with disabilities to plan and support health actions. Our study identified the importance of expanding rehabilitation services³²32 Boldrini P, Garcea M, Brichetto G, Reale N, Tonolo S, Falabella V, Fedeli F, Cnops AA, Kiekens C. Living with a disability during the pandemic. 'Instant paper from the field' on rehabilitation answers to the COVID-19 emergency. Eur J Phys Rehabil Med 2020; 56(3):331-334., the need for specialized services for people with disabilities³⁹39 Nankervis K, Chan J. Applying the CRPD to people with intellectual and developmental disability with behaviors of concern during COVID-19. J Policy Pract Intellect Disabil 2021; 18(3):197-202., the expansion of access to psychosocial services during periods of health emergencies³⁹39 Nankervis K, Chan J. Applying the CRPD to people with intellectual and developmental disability with behaviors of concern during COVID-19. J Policy Pract Intellect Disabil 2021; 18(3):197-202., the availability of interpreters in healthcare services²⁵25 Lugo-Agudelo L, Brunal MAS, Borrero AMP, Sarmiento KMC, Correa JCV, Di Dio Castagna Iannini R, Zuluaga MG, Ospina VA, Lugo DFP, Franco LFM, Gutenbrunner C. Countries response for people with disabilities during the COVID-19 pandemic. Front Rehabil Sci 2022; 2:796074., the decentralization of these services⁴¹41 Campbell VA, Gilyard JA, Sinclair L, Sternberg T, Kailes JI. Preparing for and responding to pandemic influenza: implications for people with disabilities. Am J Public Health. 2009; 99(suppl. 2):S294-S300.^,4343 Boyle CA, Fox MH, Havercamp SM, Zubler J. The public health response to the COVID-19 pandemic for people with disabilities. Disabil Health J 2020; 13(3):10094., virtual leisure and physical exercise programs²¹21 Croft S, Fraser S. A scoping review of barriers and facilitators affecting the lives of people with disabilities during COVID-19. Front Rehabil Sci 2022; 2:784450., and a free and equitable vaccination program for people with disabilities in countries where access to health care is not free⁵⁰50 Velasco JV, Obnial JC, Pastrana A, Ang HK, Viacrusis PM, Lucero-Prisno Iii DE. COVID-19 and persons with disabilities in the Philippines: a policy analysis. Heal Promot Perspect 2021; 11(3):299-306.^,5353 Qi F, Wu YQ, Wang Q. Experience and discussion: safeguards for people with disabilities during the COVID-19 pandemic in China. Front Public Heal 2021; 9:744706..

Studies point to ongoing education for health professionals to better serve people with disabilities, including the development of skills for health planning in cases of emergencies⁴⁶46 Kavanagh A, Dickinson H, Carey G, Llewellyn G, Emerson E, Disney G, Hatton C. Improving health care for disabled people in COVID-19 and beyond: lessons from Australia and England. Disabil Health J 2021; 14(2):101050.; personalized management, considering individualities¹⁹19 Subramaniam P, Villeneuve M. Advancing emergency preparedness for people with disabilities and chronic health conditions in the community: a scoping review. Disabil Rehabil 2020; 42(22):3256-3264.^,2626 Mzini LB. COVID-19 pandemic planning and preparedness for institutions serving people living with disabilities in South Africa: an opportunity for continued service and food security. J Intellect Disabil Diagnosis Treat 2021; 9(1):11-20.^,2828 Scheffers F, Moonen X, van Vugt E. Assessing the quality of support and discovering sources of resilience during COVID-19 measures in people with intellectual disabilities by professional carers. Res Dev Disabil 2021; 111:103889.^,3434 Kendall E, Ehrlich C, Chapman K, Shirota C, Allen G, Gall A, Kek-Pamenter JA, Cocks K, Palipana D. Immediate and long-term implications of the COVID-19 pandemic for people with disabilities. Am J Public Health 2020; 110(12):1774-1779.^,3737 Nwachukwu PTT, Asuelime L. UN COVID 19 disability inclusion strategy: assessing the impact on cultural-safety and capability information approach. J Intellect Disabil Diagnosis Treat 2021; 9(1):29-38.^,4848 Banks LM, Davey C, Shakespeare T, Kuper H. Disability-inclusive responses to COVID-19: Lessons learnt from research on social protection in low- and middle-income countries. World Dev 2021; 137:105178.; and the development of skills to instruct caregivers to provide support for people with disabilities concerning their needs⁴⁰40 Senjam SS. A persons-centered approach for prevention of COVID-19 disease and its impacts in persons with disabilities. Front Public Heal 2021; 8:608958. A strategy was also identified to train caregivers to assess and support the health conditions of people with disabilities in order to support the multidisciplinary team⁴⁸48 Banks LM, Davey C, Shakespeare T, Kuper H. Disability-inclusive responses to COVID-19: Lessons learnt from research on social protection in low- and middle-income countries. World Dev 2021; 137:105178.. Accessibility to health facilities and providing access close to home were also reported strategies³⁷37 Nwachukwu PTT, Asuelime L. UN COVID 19 disability inclusion strategy: assessing the impact on cultural-safety and capability information approach. J Intellect Disabil Diagnosis Treat 2021; 9(1):29-38.^,4040 Senjam SS. A persons-centered approach for prevention of COVID-19 disease and its impacts in persons with disabilities. Front Public Heal 2021; 8:608958.

In the planning and management of contingency plans category - dimension of social cohesion in the process of social determination - six strategies were found, namely: decision-making with the participation of people with disabilities to define contingency plans in cases of natural disasters; specific evacuation and contingency planning for vulnerable individuals¹⁸18 Jesus TS, Landry MD, Jacobs K. A 'new normal' following COVID-19 and the economic crisis: Using systems thinking to identify challenges and opportunities in disability, telework, and rehabilitation. Work 2020; 67(1):37-46.

19 Subramaniam P, Villeneuve M. Advancing emergency preparedness for people with disabilities and chronic health conditions in the community: a scoping review. Disabil Rehabil 2020; 42(22):3256-3264.^-2020 Saldanha JHS, Pereira APM, Santos AOC, et al. Pessoas com deficiência na pandemia da COVID-19: garantia de direitos fundamentais e equidade no cuidado. Cad Saude Publica 2021; 37(9):e00291720.^,2626 Mzini LB. COVID-19 pandemic planning and preparedness for institutions serving people living with disabilities in South Africa: an opportunity for continued service and food security. J Intellect Disabil Diagnosis Treat 2021; 9(1):11-20.^,3434 Kendall E, Ehrlich C, Chapman K, Shirota C, Allen G, Gall A, Kek-Pamenter JA, Cocks K, Palipana D. Immediate and long-term implications of the COVID-19 pandemic for people with disabilities. Am J Public Health 2020; 110(12):1774-1779.^,5050 Velasco JV, Obnial JC, Pastrana A, Ang HK, Viacrusis PM, Lucero-Prisno Iii DE. COVID-19 and persons with disabilities in the Philippines: a policy analysis. Heal Promot Perspect 2021; 11(3):299-306.^,5252 Sarju JP. Nothing About Us Without Us - Towards Genuine Inclusion of Disabled Scientists and Science Students Post Pandemic. Chemistry 2021; 27(3):10489-10494.^,5353 Qi F, Wu YQ, Wang Q. Experience and discussion: safeguards for people with disabilities during the COVID-19 pandemic in China. Front Public Heal 2021; 9:744706.. Such plans should be developed at government and community levels, based on data from each community obtained from local tracking and surveillance³⁴34 Kendall E, Ehrlich C, Chapman K, Shirota C, Allen G, Gall A, Kek-Pamenter JA, Cocks K, Palipana D. Immediate and long-term implications of the COVID-19 pandemic for people with disabilities. Am J Public Health 2020; 110(12):1774-1779..

Another recommended strategy was to ensure the definition of disability and accessibility in accordance with the United Nations Convention on the Rights of Persons with Disabilities, in order to facilitate access for people with disabilities to health services, as well as to programs and resources made available in health emergency scenarios⁴⁸48 Banks LM, Davey C, Shakespeare T, Kuper H. Disability-inclusive responses to COVID-19: Lessons learnt from research on social protection in low- and middle-income countries. World Dev 2021; 137:105178.. Inclusion of people with disabilities in the planning process of actions against COVID-19, in order to strengthen national legislation and policies, identify and eliminate obstacles and barriers to accessibility in health facilities, improve coverage and access for people with disabilities. Training of health professionals on the inclusion of people with disabilities, prohibition of discriminatory practices in insurance companies and health plans, inclusion of rehabilitation in supplementary health, and the improvement of data collection for the assessment and monitoring of actions aimed at this population in health systems³⁷37 Nwachukwu PTT, Asuelime L. UN COVID 19 disability inclusion strategy: assessing the impact on cultural-safety and capability information approach. J Intellect Disabil Diagnosis Treat 2021; 9(1):29-38..

The communication category - dimension of social cohesion in the process of social determination - covered five strategies. Accessible communication, whose definition goes beyond the provision of closed captions, translation into sign language or braille, also requiring the translation of knowledge for the creation of informative and communicative materials in order to offer information in a language that is easy to understand and comprehend¹⁸18 Jesus TS, Landry MD, Jacobs K. A 'new normal' following COVID-19 and the economic crisis: Using systems thinking to identify challenges and opportunities in disability, telework, and rehabilitation. Work 2020; 67(1):37-46.^,2222 Sakellariou D, Malfitano APS, Rotarou ES. Disability inclusiveness of government responses to COVID-19 in South America: a framework analysis study. Int J Equity Health 2020; 19(1):131.^,2424 Epstein S, Campanile J, Cerilli C, Gajwani P, Varadaraj V, Swenor BK. New obstacles and widening gaps: A qualitative study of the effects of the COVID-19 pandemic on U.S. adults with disabilities. Disabil Health J. 2021; 14(3): 101103.

25 Lugo-Agudelo L, Brunal MAS, Borrero AMP, Sarmiento KMC, Correa JCV, Di Dio Castagna Iannini R, Zuluaga MG, Ospina VA, Lugo DFP, Franco LFM, Gutenbrunner C. Countries response for people with disabilities during the COVID-19 pandemic. Front Rehabil Sci 2022; 2:796074.^-2626 Mzini LB. COVID-19 pandemic planning and preparedness for institutions serving people living with disabilities in South Africa: an opportunity for continued service and food security. J Intellect Disabil Diagnosis Treat 2021; 9(1):11-20.^,3434 Kendall E, Ehrlich C, Chapman K, Shirota C, Allen G, Gall A, Kek-Pamenter JA, Cocks K, Palipana D. Immediate and long-term implications of the COVID-19 pandemic for people with disabilities. Am J Public Health 2020; 110(12):1774-1779.^,3636 Sabatello M, Burke TB, McDonald KE, Appelbaum PS. Disability, ethics, and health care in the COVID-19 pandemic. Am J Public Health 2020; 110(10):1523-1527.^,3939 Nankervis K, Chan J. Applying the CRPD to people with intellectual and developmental disability with behaviors of concern during COVID-19. J Policy Pract Intellect Disabil 2021; 18(3):197-202.^,4040 Senjam SS. A persons-centered approach for prevention of COVID-19 disease and its impacts in persons with disabilities. Front Public Heal 2021; 8:608958^,4242 Hutchins SS, Truman BI, Merlin TL, Redd SC. Protecting vulnerable populations from pandemic influenza in the United States: a strategic imperative. Am J Public Health. 2009; 99(suppl. 2):S243-S248.^,4444 Jalali M, Shahabi S, Lankarani KB, Kamali M, Mojgani P. COVID-19 and disabled people: perspectives from Iran. Disabil Soc 2020; 35(5):844-847.^,4545 Jumreornvong O, Tabacof L, Cortes M, Tosto J, Kellner CP, Herrera JE, Putrini D. Ensuring equity for people living with disabilities in the age of COVID-19. Disabil Soc 2020; 35(10):1682-1687.^,5050 Velasco JV, Obnial JC, Pastrana A, Ang HK, Viacrusis PM, Lucero-Prisno Iii DE. COVID-19 and persons with disabilities in the Philippines: a policy analysis. Heal Promot Perspect 2021; 11(3):299-306.^,5252 Sarju JP. Nothing About Us Without Us - Towards Genuine Inclusion of Disabled Scientists and Science Students Post Pandemic. Chemistry 2021; 27(3):10489-10494..

Furthermore, studies highlighted the sharing of information and systems on social media platforms, along with accessible personalized tools to solve clinical or practical problems related to pharmacotherapy, nutrition, physical activity and healthy habits, and self-managed practical activities³²32 Boldrini P, Garcea M, Brichetto G, Reale N, Tonolo S, Falabella V, Fedeli F, Cnops AA, Kiekens C. Living with a disability during the pandemic. 'Instant paper from the field' on rehabilitation answers to the COVID-19 emergency. Eur J Phys Rehabil Med 2020; 56(3):331-334.. The communication and dialogue between different actors is essential in raising awareness concerning the vulnerability of people with disabilities, as well as in raising the awareness of health professionals so as to offer equal opportunities, and maintain dignity and respect for people with disabilities⁴⁰40 Senjam SS. A persons-centered approach for prevention of COVID-19 disease and its impacts in persons with disabilities. Front Public Heal 2021; 8:608958.

To conclude the category, the use of personalized messages, together with the engagement of community groups that form support networks for people with disabilities, was recommended⁴⁶46 Kavanagh A, Dickinson H, Carey G, Llewellyn G, Emerson E, Disney G, Hatton C. Improving health care for disabled people in COVID-19 and beyond: lessons from Australia and England. Disabil Health J 2021; 14(2):101050.. Non-governmental organizations, religious and self-help groups, among others, help to create a favorable environment for social support for people with disabilities, as well as support for daily needs⁴⁰40 Senjam SS. A persons-centered approach for prevention of COVID-19 disease and its impacts in persons with disabilities. Front Public Heal 2021; 8:608958.

Finally, in the education category - dimension of social cohesion in the process of social determination - the importance of accessibility and digital literacy was reported, especially for people with visual impairments²⁷27 Oviedo-Cáceres MDP, Arias-Pineda KN, Yepes-Camacho MDR, Montoya Falla P. COVID-19 pandemic: experiences of people with visual impairment. Invest Educ Enferm 2021; 39(1):e09.. Technological tools would allow people with disabilities to access everyday activities more easily, which is important for educational and labor inclusion²⁷27 Oviedo-Cáceres MDP, Arias-Pineda KN, Yepes-Camacho MDR, Montoya Falla P. COVID-19 pandemic: experiences of people with visual impairment. Invest Educ Enferm 2021; 39(1):e09.. Furthermore, the importance of establishing universal learning guidelines was also identified, seeking to favor the teaching process and the right of access to educational environments that are adapted to and focused on their needs²⁷27 Oviedo-Cáceres MDP, Arias-Pineda KN, Yepes-Camacho MDR, Montoya Falla P. COVID-19 pandemic: experiences of people with visual impairment. Invest Educ Enferm 2021; 39(1):e09..

Discussion

From the articles analyzed in this study, strategies were identified that aimed to meet the needs of people with disabilities during public health emergencies. Such strategies were grouped into eight intervention categories involving dimensions within the context of social determinates of health - socioeconomic, conditions of unequal access to goods and services, and social cohesion.

Regarding work, occupation, and income, the Brazilian scenario can be observed, in which people without disabilities have a higher percentage of employment in formal jobs as compared to those who have some type of disability. And the situation becomes even more worrisome when one includes the racial aspect in the analysis of working conditions: within the group of people with disabilities, even if the employment level of black and brown people is higher than that of white people, the formalization rate is noticeably smaller⁵⁵55 Instituto Brasileiro de Geografia e Estatística (IBGE). Pessoas com deficiência e as desigualdades sociais no Brasil [Internet]. 2022 [acessado 2022 dez 10]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/populacao/34889-pessoas-com-deficiencia-e-as-desigualdades-sociais-no-brasil.html?=&t=resultados
https://www.ibge.gov.br/estatisticas/soc... . Therefore, considering labor inequalities as a structural problem, which permeates the experience of people with disabilities when health emergencies are absent, global and local development plans must take into account the specific needs of the population with disabilities and the maximization of jobs set aside for vulnerable populations¹⁸18 Jesus TS, Landry MD, Jacobs K. A 'new normal' following COVID-19 and the economic crisis: Using systems thinking to identify challenges and opportunities in disability, telework, and rehabilitation. Work 2020; 67(1):37-46..

Regarding access to telehealth, Senjam et al.⁴⁰40 Senjam SS. A persons-centered approach for prevention of COVID-19 disease and its impacts in persons with disabilities. Front Public Heal 2021; 8:608958 corroborate the strategies found, as they state that teleconsultations have educational potential for caregivers or the support network of people with disabilities. Such strategies were reinforced during the COVID-19 pandemic, in which, in addition to mitigating the effects of social distancing through calls and teleconferences, technologies were also tools used for healthcare relationships. However, it is important to highlight the importance of defining guidelines for teleservices, in addition to specific training for online interventions³³33 Jayarajan D, Sivakumar T, Torous JB, Thirthalli J. Telerehabilitation in Psychiatry. Indian J Psychol Med 2020; 42(suppl. 5):57S-62S.^,5151 Valdez RS, Rogers CC, Claypool H, Trieshmann L, Frye O, Wellbeloved-Stone C, Kushalnagar P. Ensuring full participation of people with disabilities in an era of telehealth. J Am Med Inform Assoc 2021; 28(2):389-392.. For Jayarajan et al., telecare has several challenges, which include concerns about the privacy of patient data, access to devices that enable remote care, in addition to the limitation of care provided within the scope of telerehabilitation, which cannot be only remote, as it hinders socialization and practical training³³33 Jayarajan D, Sivakumar T, Torous JB, Thirthalli J. Telerehabilitation in Psychiatry. Indian J Psychol Med 2020; 42(suppl. 5):57S-62S.. Furthermore, it is important to observe whether or not the caregiver of a person with a disability supervises the activities carried out remotely, as the emotions expressed and behavior may in fact be different in the presence of third parties³³33 Jayarajan D, Sivakumar T, Torous JB, Thirthalli J. Telerehabilitation in Psychiatry. Indian J Psychol Med 2020; 42(suppl. 5):57S-62S..

In relation to comprehensive health care, the findings showed the need to strengthen local legislation and health policies, whose fundamental rights for people with disabilities should include access to health, whether public or private³¹31 Smith EM, Toro Hernandez ML, Ebuenyi ID, Syurina EV, Barbareschi G, Best KL, Danemayer J, Oldfrey B, Ibrahim N, Holloway C, MacLachlan M. Assistive Technology Use and Provision During COVID-19: Results From a Rapid Global Survey. Int J Heal policy Manag 2022; 11(6):747-756.^,3737 Nwachukwu PTT, Asuelime L. UN COVID 19 disability inclusion strategy: assessing the impact on cultural-safety and capability information approach. J Intellect Disabil Diagnosis Treat 2021; 9(1):29-38.. Therefore, discriminatory practices in the supplementary health sector (such as exorbitant prices and needs for people with disabilities, low coverage of rehabilitation procedures, and denial of specialized care) must be combatted and duly punished³⁷37 Nwachukwu PTT, Asuelime L. UN COVID 19 disability inclusion strategy: assessing the impact on cultural-safety and capability information approach. J Intellect Disabil Diagnosis Treat 2021; 9(1):29-38.^,4646 Kavanagh A, Dickinson H, Carey G, Llewellyn G, Emerson E, Disney G, Hatton C. Improving health care for disabled people in COVID-19 and beyond: lessons from Australia and England. Disabil Health J 2021; 14(2):101050..

In the context of ways of planning and organizing contingency plans, it was noted that few plans or guidelines provided details on how planners could meet the needs of people with disabilities before, during, and after public health crises. Campbell et al.⁴¹41 Campbell VA, Gilyard JA, Sinclair L, Sternberg T, Kailes JI. Preparing for and responding to pandemic influenza: implications for people with disabilities. Am J Public Health. 2009; 99(suppl. 2):S294-S300. pointed out the lack of consistency in contingency plans, the type of approach to be used, and evidence of their effectiveness. Both the population with disabilities and their caregivers must be included in the planning of actions to deal with emergencies in order to guarantee feasible alternatives⁴¹41 Campbell VA, Gilyard JA, Sinclair L, Sternberg T, Kailes JI. Preparing for and responding to pandemic influenza: implications for people with disabilities. Am J Public Health. 2009; 99(suppl. 2):S294-S300.. People with disabilities, their caregivers, and supporters must be involved in the development, evaluation, and execution of planning and responding to public health crises⁴¹41 Campbell VA, Gilyard JA, Sinclair L, Sternberg T, Kailes JI. Preparing for and responding to pandemic influenza: implications for people with disabilities. Am J Public Health. 2009; 99(suppl. 2):S294-S300..

Regarding communication aspects, gaps are discussed in terms of having information regarding contingency needs, target population, and effective prevention and intervention strategies for these situations, proposing records of identifiers related to disability in surveillance systems in health and other assistance systems, aimed at monitoring epidemiological and social patterns of people with disabilities⁴³43 Boyle CA, Fox MH, Havercamp SM, Zubler J. The public health response to the COVID-19 pandemic for people with disabilities. Disabil Health J 2020; 13(3):10094.. In this sense, there was a need to improve information system instruments and expand their use in order to strengthen the assessment and monitoring of actions geared toward people with disabilities and provide greater support for decision-making in future health emergencies³⁴34 Kendall E, Ehrlich C, Chapman K, Shirota C, Allen G, Gall A, Kek-Pamenter JA, Cocks K, Palipana D. Immediate and long-term implications of the COVID-19 pandemic for people with disabilities. Am J Public Health 2020; 110(12):1774-1779.^,3737 Nwachukwu PTT, Asuelime L. UN COVID 19 disability inclusion strategy: assessing the impact on cultural-safety and capability information approach. J Intellect Disabil Diagnosis Treat 2021; 9(1):29-38..

Moreover, in relation to electronic means of communication, it was observed that electronic services and internet pages in Brazilian municipalities still present a significant gap when compared to available digital technologies that guarantee a greater accessibility of these systems. Of the Brazilian municipalities, only 39.1% allow navigation through all interactive items on the page without the need for a mouse; 34.1% describe the content of the images; 34% describe the content of the pages with the text that appears in the browser tab; 17.7% allow the user of assistive technology to skip repeated items on the page; 16% use CAPTCHA for requests; and 6.9% include the translation of content into LIBRAS; whereas 21.3% do not adopt any of the alternatives⁵⁵55 Instituto Brasileiro de Geografia e Estatística (IBGE). Pessoas com deficiência e as desigualdades sociais no Brasil [Internet]. 2022 [acessado 2022 dez 10]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/populacao/34889-pessoas-com-deficiencia-e-as-desigualdades-sociais-no-brasil.html?=&t=resultados
https://www.ibge.gov.br/estatisticas/soc... .

For social cohesion, in addition to the participation of people with disabilities in contingency plans and inclusive communication processes, there is also the strengthening of support networks, a recurring theme¹⁹19 Subramaniam P, Villeneuve M. Advancing emergency preparedness for people with disabilities and chronic health conditions in the community: a scoping review. Disabil Rehabil 2020; 42(22):3256-3264.^,2424 Epstein S, Campanile J, Cerilli C, Gajwani P, Varadaraj V, Swenor BK. New obstacles and widening gaps: A qualitative study of the effects of the COVID-19 pandemic on U.S. adults with disabilities. Disabil Health J. 2021; 14(3): 101103.^,2626 Mzini LB. COVID-19 pandemic planning and preparedness for institutions serving people living with disabilities in South Africa: an opportunity for continued service and food security. J Intellect Disabil Diagnosis Treat 2021; 9(1):11-20.^,3030 Navas P, Amor AM, Crespo M, Wolowiec Z, Verdugo MA. Supports for people with intellectual and developmental disabilities during the COVID-19 pandemic from their own perspective. Res Dev Disabil 2021; 108:103813.. One study¹⁹19 Subramaniam P, Villeneuve M. Advancing emergency preparedness for people with disabilities and chronic health conditions in the community: a scoping review. Disabil Rehabil 2020; 42(22):3256-3264. stated that strengthening support networks for people with disabilities must be a constant activity, carried out by establishing relationships of trust between users and local emergency services, neighbors, and community groups, highlighting that care measures must also be geared toward caregivers. Once the link between a person with a disability and the service and support network is established, this network contributes to the communication of the complexities of disabilities which, in turn, aids in discussions to guarantee funding for health equipment for this population²⁴24 Epstein S, Campanile J, Cerilli C, Gajwani P, Varadaraj V, Swenor BK. New obstacles and widening gaps: A qualitative study of the effects of the COVID-19 pandemic on U.S. adults with disabilities. Disabil Health J. 2021; 14(3): 101103.^,2626 Mzini LB. COVID-19 pandemic planning and preparedness for institutions serving people living with disabilities in South Africa: an opportunity for continued service and food security. J Intellect Disabil Diagnosis Treat 2021; 9(1):11-20..

During COVID-19, the literature highlighted the fragility of online education programs, with few adaptations aimed at the population with disabilities, highlighting the need for programs that promote digital inclusion for this population²⁷27 Oviedo-Cáceres MDP, Arias-Pineda KN, Yepes-Camacho MDR, Montoya Falla P. COVID-19 pandemic: experiences of people with visual impairment. Invest Educ Enferm 2021; 39(1):e09.. The democratization of technology, which has been a necessity since the pre-pandemic period, in which only 68.8% of all people with disabilities had home access to the internet, has proven to be even more urgent in the context of the crisis and the emergence of access barriers for people with disabilities to online education²⁷27 Oviedo-Cáceres MDP, Arias-Pineda KN, Yepes-Camacho MDR, Montoya Falla P. COVID-19 pandemic: experiences of people with visual impairment. Invest Educ Enferm 2021; 39(1):e09..

Finally, aspects that must be considered when implementing the strategies are under debate, as are the levels responsible for each stage of design and the strategy target levels (Annex 3, available at: https://doi.org/10.48331/scielodata.2WZPVJ). It was observed that the implementation must occur with public policies that promote intersectoral actions.

In this sense, the present article contributes to the adaptation of healthcare measures in future health crises, as well as those that can be included outside of health emergencies, such as inclusive and adapted communication for visual, hearing, and intellectual disabilities, which must be considered and carried out for any type of health action. The growth of teleservices demands further debate, as they can be a solution to the problem of transport for people with disabilities, commonly considered an obstacle, in addition to reducing physical contact between the attendant and the patient in order to reduce the spread of infectious diseases to vulnerable populations, among other strategies that, in addition to theory, must be put into practice in an accessible manner.

One such study²²22 Sakellariou D, Malfitano APS, Rotarou ES. Disability inclusiveness of government responses to COVID-19 in South America: a framework analysis study. Int J Equity Health 2020; 19(1):131. analyzed government responses for people with disabilities in Brazil, Argentina, and Chile, and concluded that, despite there being recommendations, the countries did not develop concrete responses to put into practice, with policy planning and access improvements and with few changes made to help people with disabilities adapt to the reality of COVID-19.

In Brazil, although some government guidance initiatives have been implemented, the health scenario of people with disabilities in the pandemic context is still unknown, with epidemiological and social information on this population being mostly scarce and incipient²⁰20 Saldanha JHS, Pereira APM, Santos AOC, et al. Pessoas com deficiência na pandemia da COVID-19: garantia de direitos fundamentais e equidade no cuidado. Cad Saude Publica 2021; 37(9):e00291720.. The government actions that have been implemented were aimed at SARS-CoV-2 prevention guidelines for people with disabilities⁵⁶56 Brasil. Conselho Nacional de Saúde (CNS). Recomendação no 031, de 30 de abril de 2020. Recomenda medidas emergenciais complementares que visam a garantia dos direitos e da proteção social das pessoas com deficiência no contexto da Covid-19 [Internet]. 2020. [acessado 2022 dez 10]. Available from: https://conselho.saude.gov.br/recomendacoes-cns/1146-recomendacao-n-031-de-30-de-abril-de-2020
https://conselho.saude.gov.br/recomendac... , recommendations for professionals who care for people with disabilities in the context of the pandemic⁵⁷57 Brasil. Ministério da Mulher da Família e dos Direitos Humanos Recomendações aos profissionais que atendem as pessoas com deficiência e com doenças raras: Coronavírus [Internet]. 2020. [acessado 2022 dez 10]. Dosponível em: https://bibliotecadigital.mdh.gov.br/jspui/handle/192/1156
https://bibliotecadigital.mdh.gov.br/jsp... , and recommendations for complementary emergency measures to guarantee disabled people’s rights and social protection in the context of COVID-19⁵⁶56 Brasil. Conselho Nacional de Saúde (CNS). Recomendação no 031, de 30 de abril de 2020. Recomenda medidas emergenciais complementares que visam a garantia dos direitos e da proteção social das pessoas com deficiência no contexto da Covid-19 [Internet]. 2020. [acessado 2022 dez 10]. Available from: https://conselho.saude.gov.br/recomendacoes-cns/1146-recomendacao-n-031-de-30-de-abril-de-2020
https://conselho.saude.gov.br/recomendac... .

However, these were general guidelines with no binding implementation, given the position of the National Health Council (Recommendation no. 031), which brought instructions to the Ministry of Health, Ministry of Economy, Ministry of Citizenship, Ministry of Women, Family and Human Rights, Ministry of Education, and Professional Class Councils. The recommendations made at the time converged with the strategies identified in this review, addressing topics such as accessibility and access to health and rehabilitation services, opportunities for teleconsultations and teleguidance, inclusive communication, economic aid, and job security, among others⁵⁶56 Brasil. Conselho Nacional de Saúde (CNS). Recomendação no 031, de 30 de abril de 2020. Recomenda medidas emergenciais complementares que visam a garantia dos direitos e da proteção social das pessoas com deficiência no contexto da Covid-19 [Internet]. 2020. [acessado 2022 dez 10]. Available from: https://conselho.saude.gov.br/recomendacoes-cns/1146-recomendacao-n-031-de-30-de-abril-de-2020
https://conselho.saude.gov.br/recomendac... .

The WHO recommendations for governments and health services also corroborate the findings of this review, with recommended actions, including accessible communication, actions for support networks for people with disabilities and for service providers (including health professionals), emergency contingency plans, among others⁵⁸58 Organização Pan-Americana da Saúde (OPAS). Considerações sobre pessoas com deficiência durante o surto de COVID-19 [Internet]. 2020. [acessado 2022 dez 10]. Disponível em: https://iris.paho.org/bitstream/handle/10665.2/52063/OPASBRACOVID1920017_por.pdf?sequence=7
https://iris.paho.org/bitstream/handle/1... ^,5959 World Health Organization (WHO). Critical preparedness, readiness and response actions for COVID-19 [Internet]. 2021. [cited 2022 dez 10] Available from: https://www.who.int/publications/i/item/critical-preparedness-readiness-and-response-actions-for-covid-19
https://www.who.int/publications/i/item/... .

The findings shed light on several topics that demand attention in the field of public policies that focus on social determinants, the most frequently mentioned being accessibility policies, mainly in relation to information, education, and work and income benefits.

Study limitations

Despite the heterogeneity regarding the design of the studies, few of these were of low quality, as they were opinion-based articles. This methodological limitation did not interfere in the objective of providing an overview of the actions adopted for people with disabilities during times of public health emergencies. This comprehensive search included strategies adopted in different realities, which can support the improvement of public policies for people with disabilities.

Contributions to the area

Addressing strategies to aid people with disabilities during periods of public health emergencies made it possible to create strategies to formulate programs and policies aimed at health at the levels of health and social protection systems. It was also possible to observe strategies aimed at developing protocols and guidelines to support professional conduct when caring for people with disabilities and promoting cultural exchange among health professionals when interacting with people with disabilities.

Final considerations

This systematic review brought eight categories of strategies to deal with public health emergencies, such as COVID-19, for people with disabilities. Such an overview can help decision-making and the formulation of health policies and actions for populations in vulnerable scenarios, given that, during periods of health crises, these populations are more susceptible to diseases and suffer from structural factors of social determination.

The strategies provide guidance for policies that can be adopted on a routine basis, and not only in public health emergency situations, with feasible actions that promote greater equity. Health access and equity policies are essential and must be formulated with community members, considering that priorities and implementation aspects can be realistically identified.

References

Publication Dates

History