Strategies for persons with disabilities in public health emergencies, especially the COVID-19 pandemic

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.


Introduction
The COVID-19 pandemic affected more than 35 million people, resulting in more than 680,000 deaths in Brazil 1 .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 vulnerability 2 .
The spread of the disease was uneven among the population, as there are social vulnerabilities that led to greater losses for specific population groups 2 .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 income 3 , 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-19 2 pandemic.
Even before, people with disabilities were more prone to situations of social vulnerability, especially concerning health care 4 .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) 5 .This group reported regular and poor self-rated health more frequently (49%), when compared to the general population (9%) 6 .
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 emergencies 2 .Health equipment is incipient in including processes and physical adaptations to meet the complexity of needs, in the physical, social, and psychological dimensions 7 .There is a lack of specialized teams, duly qualified, to treat neurodevelopmental disorders from primary to tertiary care 8 .The different health institutions in the public system offer fragmented assistance, moving away from the ideal model of comprehensive care for people with disabilities 9 .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 care 2,10 .
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 PRISMA 11 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 longterm 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 Disabilities 12 .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 usual 13 .
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 hurri-canes; 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, CI-NAHL, 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 Rayyan 14 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 analysis 15,16 , 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 health 17 .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 territories 17 .Such contextual situations are remarkable, as they perpetuate social disparities for people with disabilities 18 .
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. 17 , 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 which  were included after applying eligibility criteria (Figure 1). In asessing the methodological quality of the included studies, although some presented uncertainties in the JBI 19,26,34,36,37 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, op-tions 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 observed 48 .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 measures 22 .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 emergencies 25 .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 isolation 54 .
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 Chart 2. Strategies to provide care to people with disabilities during periods of public health emergency, according to categories classified based on the findings of the included articles.

Category
Strategies Housing, Mobility, and Infrastructure 1. Emergency accommodation close to points of access to the health and social care network 42 2. Protection programs for institutionalized people with disabilities 41,44 3. Special transport for people with disabilities and their caregivers 50 4. Enable mobility of family members within the national territory to care for people with disabilities in times of social isolation 50 Work, Occupation, and Income 1. Flexible work arrangements 46,51 and infection control measures to be supported by employers 51 2. Policies to encourage in-person hiring and teleworking for people with disabilities 21,46 3. Support network for employees with disabilities 46 4. Income transfer programs with employment assistance and financial aid 41,33,44,47,50 5. Tax exemption programs for people with disabilities 44 Planning and management 1.Decision-making system, with the development of a contingency plan 18,27,25,51 together with people with disabilities 19,44,46,47 , in order to ensure that critical operations and essential services are maintained even during periods of crisis 21 2. Compliance between the International Convention on the Rights of Persons with Disabilities and local policies and laws 42 3. Formation of strategy planning councils for people with disabilities in partnership with the community 32,34,3542,47 4. Conducting studies that help define prevention, treatment, and risk mitigation measures for people with disabilities 26,29,36 5. Strengthening national health legislation and policies in accordance with the Convention on the Rights of Persons with Disabilities (CRPD) 22,29 6. Regulation of health plans to prohibit discriminatory practices 29,39,44 Social assistance 1. Benefits packages delivered directly to people with disabilities 42,44 2. Social assistance providers must be in contact with health planners for intersectoral action 34 3. Support network for people with disabilities 18,21,51 with guaranteed access to appropriate PPE for this network 33,47 4. Guarantee of social assistance provided in a safe manner 31,39,50 , with the possibility of registering online, by telephone, or with automatic enrollment through government registration 30 5. Support networks in the community to help identify serious cases and monitor the wellbeing of the population with disabilities, offering specific support 33,41 and involving different sectors 33 6.People with disabilities should take control of their own health decisions whenever possible 29 Teleservice 1. Telecare services for assessment, treatment, and monitoring of people with disabiliti es 20,28,23,30,33,37,38,50,51 2. Telecare services in the field of rehabilitation, such as physiotherapy and occupational therapy 37,50 3. Adoption of inclusive digital technologies, with multiple communication modes available, intuitive interface, and user-centered design 22 , for telehealth services for people with disabilities 23,48,49 4. Definition of guidelines for telemedicine in psychiatry and social assistance to carry out online interventions 24,45 5. Creation of programs to adapt rehabilitation services and create a comprehensive system using remote rehabilitation and other technologies 37,38,40 it continues more vulnerable to infections 26,52 .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 places 26 .
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 works 18 .Despite the reservations, tele-working was considered a great opportunity for people with disabilities and could be a way of leveling employment opportunities during periods without health emergencies 18 .
The need to create and back support networks for employees with disabilities was also highlighted 52 .One of the studies 22 identified several strategies from South American countries addressed as options for employment and finan-Category Strategies Communication 1.Accessible communication, with the development of inclusive training and communicative materials for the visually and hearing impaired, among others 25,26,28,32,33,35,37,38,41,47,51,44,46,50,51, 2. Guidelines issued by health authorities for family members of people with disabilities in a public health emergency 23 3. Sharing of information about solving problems related to pharmacotherapy, nutrition, physical activity and healthy habits, and self-managed practical activities 23 4. Promote public awareness about the vulnerability, opportunities, dignity, and respect of people with disabilities 23,33,38 5. Personalized messages with the engagement of community groups that form support networks for people with disabilities, such as non-governmental organizations, religious groups, self-help groups, among others 39 Comprehensive Health Care 1.Continuing education of health professionals to provide personalized care and management, considering the individual limitations of people with disabilities 18,26,29,42,50 2. Availability of an interpreter in healthcare services 50 3.Health safety education and training for caregivers and family members during the pandemic 33 4. Identification and elimination of barriers and obstacles to accessibility in healthcare facilities 29,33,50 5. Home care services, whenever possible 44,50 6. Decentralization of care provided to users with disabilities regarding local health services 34,36 7. Improve health coverage and accessibility as part of the universal approach to health care 19,29,27,33,43 8. Specialized outpatient care services, such as psychologists, physiotherapists, and speech therapists 32 9. Access and support to psychosocial services to provide emotional support 32 10.Support from specialized professionals to define recreational or leisure activities that can be performed in isolated environments 19,21 11. Preparation and supply of emergency kits to people with disabilities, in accordance with care prescriptions, on an individual basis 18,44 12. Identification of sources of resilience for people with disabilities so that professionals can improve the way in which they provide health care to people with intellectual disabilities and caregivers can provide clear and understandable information about COVID-19 measures 19,53 13.Community informants to carry out health assessments and rehabilitation of people with disabilities in order to reduce dependence on medical staff 42 14.Involvement of schools and health bodies in planning health actions 39 15.Free and equitable vaccination program for people with disabilities 44,47 16.Virtual leisure and physical exercise programs 30 Education for Persons with Disabilities 1. Computer literacy to facilitate access to services during the pandemic 52 2. Construction of inclusive learning guidelines 52 Source: Authors.

Chart 2.
Strategies to provide care to people with disabilities during periods of public health emergency, according to categories classified based on the findings of the included articles.cial 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 policies 22,40 .A tax exemption strategy for people with disabilities 50 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 literature 48 .Such benefits, especially when they are minimum income benefits, must be transferred directly to people with disabilities, with transfer to guardians in cases authorized under law 48,50 .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 emergencies 25,41,48 , with the possibility of registering online, by telephone, or with automatic enrollment through government registration 21 .
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 disabilities 21,25,26,29,31,32,36,40,44,45,51 , allowing access to various health services without putting people at risk of the contamination and spread of COVID-19 45 .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 computers 44 .However, there is a need for such technologies to be inclusive, with multiple communication modes available, along with an intuitive interface and user-centered design 31 .
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 services 32 , the need for specialized services for people with disabilities 39 , the expansion of access to psychosocial services during periods of health emergencies 39 , the availability of interpreters in healthcare services 25 , the decentralization of these services 41,43 , virtual leisure and physical exercise programs 21 , and a free and equitable vaccination program for people with disabilities in countries where access to health care is not free 50,53 .
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 emergencies 46 ; personalized management, considering individualities 19,26,28,34,37,48 ; and the development of skills to instruct caregivers to provide support for people with disabilities concerning their needs 40 .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 team 48 .Accessibility to health facilities and providing access close to home were also reported strategies 37,40 .
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 individuals [18][19][20]26,34,50,52,53 . Such plans shold be developed at government and community levels, based on data from each community obtained from local tracking and surveillance 34 .
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 scenarios 48 .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 systems 37 .
The communication category -dimension of social cohesion in the process of social determi-nation -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 comprehend 18,22,[24][25][26]34,36,39,40,42,44,45,50,52 .
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 activities 32 .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 disabilities 40 .
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 recommended 46 .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 needs 40 .
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 impairments 27 .Technological tools would allow people with disabilities to access everyday activities more easily, which is important for educational and labor inclusion 27 .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 needs 27 .

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 smaller 55 .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 populations 18 .
Regarding access to telehealth, Senjam et al. 40 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 interventions 33,51 .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 training 33 .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 parties 33 .
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 private 31,37 .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 punished 37,46 .
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. 41 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 alternatives 41 .People with disabilities, their caregivers, and supporters must be involved in the development, evaluation, and execution of planning and responding to public health crises 41 .
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 disabilities 43 .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 emergencies 34,37 .
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 CAPT-CHA for requests; and 6.9% include the translation of content into LIBRAS; whereas 21.3% do not adopt any of the alternatives 55 .
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 theme 19,24,26,30 .One study 19 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, high-lighting 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 population 24,26 .
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 population 27 .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 education 27 .
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 study 22 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 incipient 20 .The government actions that have been implemented were aimed at SARS-CoV-2 prevention guidelines for people with disabilities 56 , recommendations for professionals who care for people with disabilities in the context of the pandemic 57 , and recommendations for complementary emergency measures to guarantee disabled people's rights and social protection in the context of COVID-19 56 .
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 others 56 .
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 others 58,59 .
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.

Figure 1 .
Figure 1.Flow chart of study selection.+ Web of Science; § Biblioteca Virtual da Saúde; * Chart 1 -list of excluded studies, with justification.Source: Authors.

Chart 1. List
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