Access to primary healthcare services for adults with disabilities in Latin America and the Caribbean: a review and meta-synthesis of qualitative studies.

PURPOSE: This review and meta-synthesis of qualitative studies aims to provide an overview of qualitative evidence on primary healthcare access of people with disability in Latin America and the Caribbean, as well as to identify barriers that exist in this region. METHODS: Six databases were searched for studies from 2000 to 2022. 34 qualitative studies were identified. RESULTS: Barriers exist on both demand and supply sides. The thematic synthesis process generated three broad overarching analytical themes, which authors have related to Levesque et al.'s aspects of "ability to perceive," "availability, accommodation and ability to reach" and "appropriateness and ability to engage." Access to information and health literacy are compromised due to a lack of tailored health education materials. Barriers in the urban environment, including inadequate transportation, and insufficient healthcare facility accessibility create challenges for people with disabilities to reach healthcare facilities independently. Attitudinal barriers contribute to suboptimal care experiences. CONCLUSION: People with disabilities face several barriers in accessing healthcare. Lack of healthcare provider training, inappropriate urban infrastructure, lack of accessible transport and inaccessibility in healthcare centers are barriers that need to be addressed. With these actions, people with disabilities will be closer to having their rights met.

The identification of barriers on both the supply and demand sides highlights implications for individuals with disabilities seeking access to primary healthcare services, primarily in Brazil, with similar concerns noted in Colombia and Trinidad and Tobago.Service providers should enhance access to people with disabilities by providing accessible information and reasonable accommodation for people with disabilities.More training of healthcare professionals is required to support the provision of care for people with disabilities.There is a need to improve healthcare centre accessibility, as well as local infrastructure and transportation to prevent people with disabilities from having their rights violated.Linkages should be strengthened between sectors like transportation, urban development, and health to enhance overall accessibility and prevent violations of the rights of individuals with disabilities.

Digital Platform for Continuous Monitoring of Patients Using a Smartwatch: Longitudinal Prospective Cohort Study.

BACKGROUND: Since the COVID-19 pandemic, there has been a boost in the digital transformation of the human society, where wearable devices such as a smartwatch can already measure vital signs in a continuous and naturalistic way; however, the security and privacy of personal data is a challenge to expanding the use of these data by health professionals in clinical follow-up for decision-making. Similar to the European General Data Protection Regulation, in Brazil, the Lei Geral de Proteção de Dados established rules and guidelines for the processing of personal data, including those used for patient care, such as those captured by smartwatches. Thus, in any telemonitoring scenario, there is a need to comply with rules and regulations, making this issue a challenge to overcome. OBJECTIVE: This study aimed to build a digital solution model for capturing data from wearable devices and making them available in a safe and agile manner for clinical and research use, following current laws. METHODS: A functional model was built following the Brazilian Lei Geral de Proteção de Dados (2018), where data captured by smartwatches can be transmitted anonymously over the Internet of Things and be identified later within the hospital. A total of 80 volunteers were selected for a 24-week follow-up clinical trial divided into 2 groups, one group with a previous diagnosis of COVID-19 and a control group without a previous diagnosis of COVID-19, to measure the synchronization rate of the platform with the devices and the accuracy and precision of the smartwatch in out-of-hospital conditions to simulate remote monitoring at home. RESULTS: In a 35-week clinical trial, >11.2 million records were collected with no system downtime; 66% of continuous beats per minute were synchronized within 24 hours (79% within 2 days and 91% within a week). In the limit of agreement analysis, the mean differences in oxygen saturation, diastolic blood pressure, systolic blood pressure, and heart rate were -1.280% (SD 5.679%), -1.399 (SD 19.112) mm Hg, -1.536 (SD 24.244) mm Hg, and 0.566 (SD 3.114) beats per minute, respectively. Furthermore, there was no difference in the 2 study groups in terms of data analysis (neither using the smartwatch nor the gold-standard devices), but it is worth mentioning that all volunteers in the COVID-19 group were already cured of the infection and were highly functional in their daily work life. CONCLUSIONS: On the basis of the results obtained, considering the validation conditions of accuracy and precision and simulating an extrahospital use environment, the functional model built in this study is capable of capturing data from the smartwatch and anonymously providing it to health care services, where they can be treated according to the legislation and be used to support clinical decisions during remote monitoring.

[Repercussions of the COVID-19 pandemic on health services for people with disabilities: report from rehabilitation professionals]. / Repercussões da pandemia de COVID-19 nos serviços de saúde para pessoas com deficiência: relato dos profissionais de reabilitação.

Several healthcare processes, including rehabilitation, require prompt initiation and cannot be interrupted. Therefore, these processes underwent important adaptations during the COVID-19 pandemic. However, it is not fully known how healthcare facilities adapted their strategies and what the results were. This study investigated how rehabilitation services were affected during the pandemic and what strategies were employed to maintain the provided services. From June 2020 to February 2021, 17 semi-structured interviews were conducted with healthcare professionals working in rehabilitation services from the Brazilian Unified National Health System (SUS), who work at one of the three levels of care, in the municipalities of Santos and São Paulo, state of São Paulo, Brazil. The interviews were recorded, transcribed, and analyzed via content analysis. The professionals reported organizational changes in their services, with the initial interruption of appointments and, subsequently, the adoption of new sanitary protocols and the gradual return to in-person and/or remote appointments. Working conditions were directly impacted, as there was a need for staffing, training, increased workloads, as well as physical and mental exhaustion among professionals. The pandemic caused a series of changes in healthcare services, some of which were interrupted due to the suspension of numerous services and appointments. Some in-person appointments were maintained exclusively for patients who presented a risk of short-term deterioration. Preventive sanitary measures and strategies for continuity of care were adopted.

Diversos processos que permeiam a assistência à saúde, incluindo a reabilitação, precisam de brevidade para ser iniciados ou não podem ser interrompidos. Sendo assim, estes passaram por importantes adaptações durante a pandemia de COVID-19. Porém, não se sabe ao certo como os equipamentos de saúde adaptaram suas estratégias e quais foram os resultados. O estudo investigou como os atendimentos em reabilitação foram afetados durante a pandemia e quais foram as estratégias para a manutenção dos serviços prestados. Entre junho de 2020 e fevereiro de 2021, realizaram-se 17 entrevistas semiestruturadas com profissionais de saúde da área da reabilitação do Sistema Único de Saúde (SUS), que atuam em um dos três níveis de atenção, nas cidades de Santos e São Paulo, Estado de São Paulo, Brasil. Os discursos foram gravados, transcritos e analisados por meio da análise de conteúdo. Os profissionais relataram mudanças organizacionais em seus serviços, com a interrupção inicial dos atendimentos e, posteriormente, com a adoção de novos protocolos sanitários e o retorno gradativo dos atendimentos presenciais e/ou a distância. As condições de trabalho foram diretamente impactadas, pois houve necessidade de dimensionamento, capacitação, ampliação de carga horária, além da sobrecarga de trabalho e do esgotamento físico e mental dos profissionais. A pandemia determinou uma série de mudanças nos serviços de saúde, por vezes descontínuas, com a suspensão de inúmeros serviços e atendimentos. Alguns atendimentos presenciais foram mantidos, apenas para os pacientes que apresentavam risco de agravo em curto prazo. Medidas sanitárias preventivas e estratégias de continuidade dos atendimentos foram adotadas.

Diversos procesos que impregnan la asistencia a la salud, incluida la rehabilitación, deben iniciarse con prontitud o no pueden interrumpirse. Por lo que estos sufrieron importantes adaptaciones durante la pandemia de COVID-19. Sin embargo, no se sabe con certeza cómo las instalaciones de salud adaptaron sus estrategias y cuáles fueron los resultados. El estudio investigó cómo se vieron afectados los servicios de rehabilitación durante la pandemia y cuáles fueron las estrategias para mantener los servicios prestados. Entre junio del 2020 y febrero del 2021, se realizaron 17 entrevistas semiestructuradas con profesionales de la salud del área de rehabilitación del Sistema Único de Salud (SUS), que actúan en uno de los tres niveles de atención, en las ciudades de Santos y São Paulo, estado de São Paulo, Brasil. Los discursos se grabaron, se transcribieron y se analizaron mediante análisis de contenido. Los profesionales relataron cambios organizacionales en sus servicios, con la interrupción inicial de la atención y, posteriormente, con la adopción de nuevos protocolos sanitarios y el regreso gradual de la atención presencial o a distancia. Las condiciones de trabajo se vieron directamente afectadas, ya que fue necesario el dimensionamiento, la capacitación, la ampliación de la carga horaria, además de la sobrecarga de trabajo y del agotamiento físico y mental de los profesionales. La pandemia determinó una serie de cambios en los servicios de salud, en ocasiones discontinuos, con la suspensión de numerosos servicios y atenciones. Se mantuvieron algunas atenciones presenciales, solo para los pacientes con riesgo de agravamiento a corto plazo. Se adoptaron medidas sanitarias preventivas y estrategias de continuidad de las atenciones.

Repercussões da pandemia de COVID-19 nos serviços de saúde para pessoas com deficiência: relato dos profissionais de reabilitação / Repercussions of the COVID-19 pandemic on health services for people with disabilities: report from rehabilitation professionals / Repercusiones de la pandemia de COVID-19 en los servicios de salud para personas con discapacidad: relato de los profesionales de la rehabilitación

Resumo: Diversos processos que permeiam a assistência à saúde, incluindo a reabilitação, precisam de brevidade para ser iniciados ou não podem ser interrompidos. Sendo assim, estes passaram por importantes adaptações durante a pandemia de COVID-19. Porém, não se sabe ao certo como os equipamentos de saúde adaptaram suas estratégias e quais foram os resultados. O estudo investigou como os atendimentos em reabilitação foram afetados durante a pandemia e quais foram as estratégias para a manutenção dos serviços prestados. Entre junho de 2020 e fevereiro de 2021, realizaram-se 17 entrevistas semiestruturadas com profissionais de saúde da área da reabilitação do Sistema Único de Saúde (SUS), que atuam em um dos três níveis de atenção, nas cidades de Santos e São Paulo, Estado de São Paulo, Brasil. Os discursos foram gravados, transcritos e analisados por meio da análise de conteúdo. Os profissionais relataram mudanças organizacionais em seus serviços, com a interrupção inicial dos atendimentos e, posteriormente, com a adoção de novos protocolos sanitários e o retorno gradativo dos atendimentos presenciais e/ou a distância. As condições de trabalho foram diretamente impactadas, pois houve necessidade de dimensionamento, capacitação, ampliação de carga horária, além da sobrecarga de trabalho e do esgotamento físico e mental dos profissionais. A pandemia determinou uma série de mudanças nos serviços de saúde, por vezes descontínuas, com a suspensão de inúmeros serviços e atendimentos. Alguns atendimentos presenciais foram mantidos, apenas para os pacientes que apresentavam risco de agravo em curto prazo. Medidas sanitárias preventivas e estratégias de continuidade dos atendimentos foram adotadas.

Abstract: Several healthcare processes, including rehabilitation, require prompt initiation and cannot be interrupted. Therefore, these processes underwent important adaptations during the COVID-19 pandemic. However, it is not fully known how healthcare facilities adapted their strategies and what the results were. This study investigated how rehabilitation services were affected during the pandemic and what strategies were employed to maintain the provided services. From June 2020 to February 2021, 17 semi-structured interviews were conducted with healthcare professionals working in rehabilitation services from the Brazilian Unified National Health System (SUS), who work at one of the three levels of care, in the municipalities of Santos and São Paulo, state of São Paulo, Brazil. The interviews were recorded, transcribed, and analyzed via content analysis. The professionals reported organizational changes in their services, with the initial interruption of appointments and, subsequently, the adoption of new sanitary protocols and the gradual return to in-person and/or remote appointments. Working conditions were directly impacted, as there was a need for staffing, training, increased workloads, as well as physical and mental exhaustion among professionals. The pandemic caused a series of changes in healthcare services, some of which were interrupted due to the suspension of numerous services and appointments. Some in-person appointments were maintained exclusively for patients who presented a risk of short-term deterioration. Preventive sanitary measures and strategies for continuity of care were adopted.

Resumen: Diversos procesos que impregnan la asistencia a la salud, incluida la rehabilitación, deben iniciarse con prontitud o no pueden interrumpirse. Por lo que estos sufrieron importantes adaptaciones durante la pandemia de COVID-19. Sin embargo, no se sabe con certeza cómo las instalaciones de salud adaptaron sus estrategias y cuáles fueron los resultados. El estudio investigó cómo se vieron afectados los servicios de rehabilitación durante la pandemia y cuáles fueron las estrategias para mantener los servicios prestados. Entre junio del 2020 y febrero del 2021, se realizaron 17 entrevistas semiestructuradas con profesionales de la salud del área de rehabilitación del Sistema Único de Salud (SUS), que actúan en uno de los tres niveles de atención, en las ciudades de Santos y São Paulo, estado de São Paulo, Brasil. Los discursos se grabaron, se transcribieron y se analizaron mediante análisis de contenido. Los profesionales relataron cambios organizacionales en sus servicios, con la interrupción inicial de la atención y, posteriormente, con la adopción de nuevos protocolos sanitarios y el regreso gradual de la atención presencial o a distancia. Las condiciones de trabajo se vieron directamente afectadas, ya que fue necesario el dimensionamiento, la capacitación, la ampliación de la carga horaria, además de la sobrecarga de trabajo y del agotamiento físico y mental de los profesionales. La pandemia determinó una serie de cambios en los servicios de salud, en ocasiones discontinuos, con la suspensión de numerosos servicios y atenciones. Se mantuvieron algunas atenciones presenciales, solo para los pacientes con riesgo de agravamiento a corto plazo. Se adoptaron medidas sanitarias preventivas y estrategias de continuidad de las atenciones.

The Institute of Physical Medicine and Rehabilitation, Hospital das Clínicas University of São Paulo School of Medicine comprehensive rehabilitation program for elderly people with knee osteoarthritis.

Background: Knee osteoarthritis (OA) is a leading cause of disability in the elderly population. Chronic disabling pain is associated with maladaptive neuroplastic changes in brain networks, commonly associated with central sensitization. The main clinical features of nociplastic pain conditions include combined peripheral and central sensitization, and it is crucial to recognize this type of pain, as it responds to different therapies than nociceptive and neuropathic pain. Objective: To report the effect of the Institute of Physical Medicine and Rehabilitation (IMREA) comprehensive rehabilitation program to reduce pain and to improve functioning in elderly people with knee OA, under the DEFINE cohort. Methods: This is a retrospective observational cohort of 96 patients with knee OA, recruited from October 2018 to December 2019. All patients were evaluated by a trained multidisciplinary team using the Kellgren Lawrence classification, bilateral knee ultrasonography, the visual analog scale (VAS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain, rigidity and difficulty scores, the Timed Up and Go Test (TUG), 10-m and 6-min walking test (10 and 6 MWT), Berg Balance Scale, isokinetic dynamometry for knee extension and flexion strength, and pain pressure thresholds. The rehabilitation program included paraspinous lidocaine blocks, focal extracorporeal shockwaves combined with radial pressure waves and functional electrical stimulation according to individual needs. The baseline was compred with the treatment results with a paired t-test. Results: The study sample is composed of 96 participants, mostly females (n = 81, 84.38%), with bilateral osteoarthritis (n = 91, 94.79%), and a mean age of 68.89 (SD 9.73) years. Functional improvement was observed in TUG (p = 0.019), 6-mwt (p = 0.033), right knee flexion strength (p < 0.0001), WOMAC rigidity and difficulty domains (p < 0.0001). Pain was reduced from baseline as measured by WOMAC pain domain (p < 0.0001), VAS for both knees (p < 0.0001), and SF-36 pain domain (p < 0.0001). Pressure pain threshold was modified above the patella (p = 0.005 and p = 0.002 for right and left knees, respectively), at the patellar tendons (p = 0.015 and p = 0.010 for right and left patellar tendons, respectively), left S2 dermatome (p = 0.017), and L1-L2 (p = 0.008). Conclusions: The IMREA comprehensive rehabilitation program improved functioning and reduced disabling pain in elderly people with knee OA. We highlight the relevance and discuss the implementation of our intervention protocol. Although this is an open cohort study, it is important to note the significant improvement with this clinical protocol.

Results from the International Spinal Cord Injury Community Survey: The Lived Experience of People with Spinal Cord Injury in South-Eastern Brazil.

OBJECTIVE: The incidence of spinal cord injury in Brazil is increasing. It is important to understand more about how individuals are living with spinal cord injury. DESIGN: Cross-sectional, observational study of individuals with spinal cord injury in south-eastern Brazil. SUBJECTS: A questionnaire with 125 questions was applied to individuals diagnosed with spinal cord injury. Participants were recruited by survey team from 2 rehabilitation centres (both in south-eastern Brazil) that treat persons diagnosed with SCI. Personal characteristics, associated health conditions, quality of life, work status, environmental factors, and other functioning-related aspects were evaluated. RESULTS: A total of 201 individuals participated in the survey. Of these, 79% were male, mean age 44 years, 60% were considered paraplegic, and the major causes of impairment were firearm injuries and road traffic accidents. Spasticity was the most frequently reported health condition, followed by neuropathic pain. 50% of subjects did not report any difficulty with participation in activities of daily living. However, only approximately 10% of subjects returned to work after spinal trauma. Their quality of life is reported 44% as good. CONCLUSION: Most people with spinal cord injury in south-eastern Brazil are male and paraplegic, health problems and spasticity is considered their most problematic health condition. Although they report having a good quality of life, they still encounter disabling environmental barriers that make their life more difficult, such as poor accessibility of public spaces, and only a small proportion (10%) returned to work after their injury. This study provides an initial overview of the lived experience of people with spinal cord injury in south-eastern Brazil and should serve as a starting point for future research on this population.

Facilitadores do acesso da pessoa com deficiência aos serviços de saúde: revisão de escopo / Facilitators of persons with disabilities' access to health services: a scope review

Objetivo: Este estudo tem como objetivo analisar as evidências científicas globais e locais relativas aos facilitadores que promovem o acesso de pessoas com deficiência aos serviços de saúde. Métodos: Realizou-se uma revisão de escopo, estabelecendo-se a pergunta norteadora: "Quais são os principais facilitadores que as pessoas com deficiência encontram no acesso a serviços de saúde?" O levantamento dos artigos foi realizado em julho de 2019, em seis bases de dados de literatura científica. Dos 1.155 documentos identificados nas buscas, após seleção por título e resumo, foram lidas 170 publicações na íntegra e incluídas 76 revisões da literatura, que foram categorizadas conforme referencial teórico. Resultados: A revisão elenca os facilitadores identificados por prestadores de serviços e por pessoas com deficiência e os seus familiares e/ou cuidadores, em todos os níveis de complexidade dos cuidados de saúde. Os facilitadores foram categorizados pelas diferentes dimensões do acesso e da Lei Brasileira de Inclusão. Os principais facilitadores identificados, tanto pelos usuários dos serviços quanto pelos prestadores de serviço, incluem a disponibilidade de programas de promoção à saúde, profissionais capacitados, informações sobre os serviços prestados, orientação em cuidados de saúde, serviços de cuidados específicos de reabilitação e suporte social. Conclusões: Evidenciamos que faltam estudos nacionais sobre esta temática e que os facilitadores para o acesso aos serviços de saúde para as pessoas com deficiência precisam ser mais profundamente abordados na literatura cientifica como um todo. O melhor entendimento desta realidade é de grande valia para o incremento de políticas públicas e implementação de estratégias voltadas à promoção do acesso aos serviços de saúde.

Objective: This study aims to analyze global and local scientific evidence regarding the facilitators that promote the access of people with disabilities to health services. Methods: A scope review was carried out, establishing the guiding question: "What are the main facilitators that people with disabilities find in accessing health services?" The search was carried out in July 2019, in six scientific literature databases. Of the 1,155 documents identified in the searches, after selection by title and abstract, 170 publications were read in full and 76 literature reviews were included, which were categorized according to the theoretical framework. Results: The review lists the facilitators identified by service providers and people with disabilities and their family members and/or caregivers, at all levels of healthcare. The facilitators were categorized by the different dimensions of access and the Brazilian Inclusion Law. Key facilitators identified by both service users and service providers include the availability of health promotion programs, trained professionals, information about services provided, healthcare guidance, specific rehabilitation care services, and social support. Conclusions: There is a lack of national studies on this topic and the facilitators of persons with disabilities' access to health services need to be more deeply addressed in the literature. A better understanding of this reality would be of great value for improving public policies and implementing strategies aimed at promoting access to health services.

Barriers to the access of people with disabilities to health services: a scoping review.

OBJECTIVE: To analyze the scientific evidence regarding barriers to the access of people with disabilities to health services. METHODS: A scoping review was carried out from the main question: "What are the main barriers that people with disabilities face in accessing health services?" The articles were surveyed in July 2019 in six scientific literature databases. Of the 1,155 documents identified in the searches, after selection by title and abstract, 170 publications were read in full and, thus, 96 articles were included and categorized according to the theoretical framework. RESULTS: The main barriers indicated by the users of the service were: communication failure between professionals and patient/caregiver; financial limitations; attitudinal/behavioral issues; scarce service provision; organizational and transport barriers. The main barriers presented by service providers were: lack of training to professionals; failure of the health system; physical barriers; lack of resources/technology; and language barriers. CONCLUSIONS: It was evident that people with disabilities face several barriers when trying to access the health services they need and that users and health professionals have distinct and complementary views on difficulties.

Uso de aplicativo para análise de movimento: estudo piloto / App for motion analysis: pilot study

Medidas alternativas e de baixo custo podem ser importantes para análise do movimento humano. Objetivo: Verificar a concordância de análise de movimento humano entre aplicativo de monitoramento por meio de inteligência artificial com análise tridimensional de movimento. Método: Estudo transversal observacional no qual voluntário sadio realizou movimentos de: flexão dos braços, flexão de cotovelos, flexão de tronco, inclinação de tronco e sentar e levantar. As imagens foram captadas por meio de sistema de análise tridimensional do movimento por câmeras infravermelhas e pelo aplicativo da Linkfit por meio de dois dispositivos móveis (smartphones). Foram comparados os ângulos estimados pelo aplicativo da Linkfit com os ângulos correspondentes medidos pelo sistema de análise tridimensional do movimento. Para comparar os ângulos da LinkFit com os ângulos mensurados pelo laboratório tridimensional de movimento, o teste de causalidade de Granger foi usado para cada série paralela dos dados. Resultados: A utilização de técnicas de visão computacional e deep learning para detecção de movimento utilizando câmeras de celular mostrou um grau de concordância de 84% em relação à medidas geradas por análise tridimensional de movimento realizadas em laboratório. Conclusão: A utilização de técnicas de visão computacional e deep learning é promissora para a realização de estudos que envolvem a detecção do movimento do corpo humano, quando comparadas com medidas de padrão-ouro de análise de movimento, podendo ser portanto, uma alternativa. Estudos futuros devem ser realizados utilizando maior número de voluntários e movimentos, com o intuito de consolidar os resultados obtidos nesse estudo.

Alternative and low-cost measures may be important for analyzing human movement. Objective: The objective of this study was to verify the agreement of human movement analysis of a monitoring app that uses artificial intelligence compared to three-dimensional movement analysis. Methods:Observational cross-sectional case report study in which a healthy volunteer performed arm flexion, elbow flexion, trunk flexion, lateral trunk bending, and sitting and standing. Images of the volunteer were simultaneously captured by a three-dimensional movement analysis system based on infrared cameras and the Linkfitapp of two mobile devices (smartphones). The body angles estimated by the Linkfitapp were compared with the corresponding angles measured by the three-dimensional movement analysis system. The Granger causality test was used to compare the pairs of angles for each parallel data series. Results:The use of smartphone cameras and deep learning techniques for motion detection had an 84% degree of agreement compared to measurements generated by the three-dimensional movement analysis performed in the laboratory. Conclusion:The use of smartphone cameras and deep learning techniques is promising for conducting studies for body movement detection compared to the gold standard measures of movement analysis. This technology may become an alternative for movement analysis. Future studies should consider a more significant number of volunteers and model movements to strengthen the results obtained in this study.

Barriers to the access of people with disabilities to health services: a scoping review / Barreiras ao acesso das pessoas com deficiência aos serviços de saúde: uma revisão de escopo

ABSTRACT OBJECTIVE To analyze the scientific evidence regarding barriers to the access of people with disabilities to health services. METHODS A scoping review was carried out from the main question: "What are the main barriers that people with disabilities face in accessing health services?" The articles were surveyed in July 2019 in six scientific literature databases. Of the 1,155 documents identified in the searches, after selection by title and abstract, 170 publications were read in full and, thus, 96 articles were included and categorized according to the theoretical framework. RESULTS The main barriers indicated by the users of the service were: communication failure between professionals and patient/caregiver; financial limitations; attitudinal/behavioral issues; scarce service provision; organizational and transport barriers. The main barriers presented by service providers were: lack of training to professionals; failure of the health system; physical barriers; lack of resources/technology; and language barriers. CONCLUSIONS It was evident that people with disabilities face several barriers when trying to access the health services they need and that users and health professionals have distinct and complementary views on difficulties.

RESUMO OBJETIVO Analisar as evidências científicas relativas às barreiras para o acesso de pessoas com deficiência aos serviços de saúde. MÉTODOS Realizou-se uma revisão de escopo estabelecendo-se a perguntanorteadora: "Quais são as principais barreiras que as pessoas com deficiência enfrentam no acesso a serviços de saúde?" O levantamento dos artigos foi realizado em julho de 2019, em seis bases de dados de literatura científica. Dos 1.155 documentos identificados nas buscas, após seleção por título e resumo, foram lidas na íntegra 170 publicações e, após leitura, 96 artigos foram incluídos e categorizados conforme referencial teórico. RESULTADOS As principais barreiras indicadas pelos usuários do serviço foram: comunicação falha entre profissionais e paciente/cuidador; limitações financeiras; questões atitudinais/comportamentais; oferta de serviços escassa; barreiras organizacionais e de transporte. As principais barreiras apresentadas pelos prestadores de serviços foram: falta de treinamento/capacitação aos profissionais; falha do sistema de saúde; barreiras físicas; falta de recursos/tecnologia e barreiras de idioma. CONCLUSÕES Ficou evidente que as pessoas com deficiência enfrentam diversas barreiras ao tentarem acesso aos serviços de saúde de que necessitam e que usuários e profissionais de saúde têm visões distintas e complementares sobre as dificuldades.

Measuring assistive technology supply and demand: A scoping review.

The supply of and market demand for assistive products (APs) are complex and influenced by diverse stakeholders. The methods used to collect AP population-level market data are similarly varied. In this paper, we review current population-level AP supply and demand estimation methods for five priority APs and provide recommendations for improving national and global AP market evaluation.Abstracts resulting from a systematic search were double-screened. Extracted data include WHO world region, publication year, age-groups, AP domain(s), study method, and individual assessment approach.497 records were identified. Vision-related APs comprised 65% (n = 321 studies) of the body of literature; hearing (n = 59), mobility (n = 24), cognitive (n = 2), and studies measuring multiple domains (n = 92) were proportionately underrepresented. To assess individual AP need, 4 unique approaches were identified among 392 abstracts; 45% (n = 177) used self-report and 84% (n = 334) used clinical evaluation. Study methods were categorized among 431 abstracts; Cross-sectional studies (n = 312, 72%) and secondary analyses of cross-sectional data (n = 61, 14%) were most common. Case studies illustrating all methods are provided.Employing approaches and methods in the contexts where they are most well-suited to generate standardized AP indicators will be critical to further develop comparable population-level research informing supply and demand, ultimately expanding sustainable access to APs.

Developing a rigid frame wheelchair in Brazil.

PURPOSE: Describing the development process of a rigid frame wheelchair using user-centered and open innovation approaches, as envisaged by the WHO Wheelchair Guidelines. METHODS: Unstructured interviews and group discussions with conveniently sampled active wheelchair users oriented the initial brief, product design and selection. The initially approved prototype was subject to ISO 7176 tests, leading to further product adjustments. The long-term follow-up was inclusive of a new group of purposively selected active wheelchair users and measured user satisfaction and safety, as well as user mobility and wheelchair fitting. Data on user satisfaction, safety and effectiveness was produced using QUEST 2.0 and WHO Wheelchair Service Training Package's forms and checklists in Portuguese. RESULTS: Iterative design and selection led to a prototype that was found appropriate by multiple stakeholders. ISO testing ensured its safety and durability. Follow-up trials included 40 active wheelchair users, who used the studied wheelchair for at least two months. They were 80% male, on average 36.3 years old, and had received their rigid frame wheelchair approximately 4.7 years after disability onset. 92.5% of them had SCI, 7.5% had bilateral transfemoral amputations. Users' assessments showed satisfaction with products (4.4) and services (4.1). Users spent an average of 4.2 h/day sat in their wheelchairs. 7.5% and 20% of users reported pressure sores and falls, respectively. CONCLUSION: A user-centered, open innovation approach led to the development of a good quality, affordable, and acceptable rigid frame wheelchair model that increased the range of manual wheelchairs available through the Brazilian public healthcare system.Implications for rehabilitationThe feedback of rehabilitation professionals with respect to new products' features is fundamental in order to understand how these devices will be adequately serviced and delivered to users.Engaging users of assistive products and rehabilitation professionals in developing new and innovative products facilitates the iteration and selection of the best project alternatives and saves considerable time and resources.Rehabilitation professionals are in the best position to work with user of assistive products and other stakeholders, such as the industry and research and development centres, to identify the impact of new assistive products in users' functionality, acknowledging their conditions and environments and exploring their potential.Working with users and other stakeholders from different backgrounds and areas of expertise makes the moto "Nothing about us, without us" real. Working towards improving functionality often requires developers to challenge the usual top-down development process in order to adopt a user-centered perspective.

Saúde global e direito a tecnologias essenciais: o caso do acesso à tecnologia assistiva / Global health and the right to essential technology: the case of access to assistive technology

Introdução: O acesso à tecnologia assistiva é tanto mediador quanto moderador de outras mudanças sociais para a equiparação de oportunidades e a promoção da justiça, o que inclui o direito à saúde e à participação social plena. O objetivo da tese é consolidar um conjunto de achados sobre os resultados obtidos pela política brasileira de provisão de tecnologia assistiva nos últimos anos e oferecer uma análise inédita, ainda que inicial, sobre o comércio internacional de produtos assistivos. Material e Métodos: A tese apresenta uma coletânea de três artigos (um deles inédito) que investigam diferentes aspectos da provisão e do acesso à tecnologia assistiva em nível subnacional, nacional e internacional, assim como distintos componentes de políticas, sistemas, serviços e produtos assistivos, incluindo análises quantitativas de bancos de dados públicos nacionais e internacionais, e estudos clínicos sobre o impacto da tecnologia assistiva. Resultados: Os artigos demonstram como o abandono de produtos assistivos em São Paulo se assemelha ao de outras localidades e oferece detalhes adicionais sobre os fatores que o influenciam; que será preciso manter o desempenho dos últimos anos e ainda corrigir desigualdades internas para que as metas do atual Plano Nacional de Saúde sobre a provisão de tecnologia assistiva sejam atingidas; e que há espaço para negociações internacionais que busquem maior previsibilidade e redução de tarifas, assim como a desconcentração de mercados no comércio internacional de produtos assistivos. Conclusões: O acesso à tecnologia assistiva, como uma estratégia valiosa para a busca da equidade no âmbito da saúde global, deve ser compreendido como instrumento e catalisador para a consecução de metas como os Objetivos de Desenvolvimento Sustentável e de outras mudanças sociais que incluem o direito à saúde e à participação social.

Introduction: Access to assistive technology is both a mediator and a moderator of other social changes for the equalization of opportunities and the promotion of justice, which includes the right to health and full social participation. The objective of the thesis is to consolidate a set of findings on the results obtained by the Brazilian policy on the provision of assistive technology in recent years and to offer an original, albeit initial, analysis of international trade in assistive products. Material and Methods: The thesis presents a collection of three articles (one of them unpublished) that investigate different aspects of the provision and access to assistive technology at a subnational, national, and international level, as well as different components of assistive technology policies, systems, services, and products, including quantitative analyzes of national and international public databases and clinical studies on the impact of assistive technology. Results: The articles demonstrate how the abandonment of assistive products in São Paulo is similar to that in other settings and provide additional details on the factors influencing it; that it will be necessary to maintain the performance of recent years and also to correct internal inequalities so that the goals of the current National Health Plan on the provision of assistive technology are achieved; and that there is room for international negotiations that seek greater predictability and reduction of tariffs, as well as the deconcentration of markets in the international trade of assistive products. Conclusions: Access to assistive technology, a valuable strategy towards global health equity, should be understood as both a means and an end to fulfilling the Sustainable Development Goals and other social changes that include the right to health and full social participation.

Assistive technology provision: towards an international framework for assuring availability and accessibility of affordable high-quality assistive technology.

PURPOSE: This is a position paper describing the elements of an international framework for assistive technology provision that could guide the development of policies, systems and service delivery procedures across the world. It describes general requirements, quality criteria and possible approaches that may help to enhance the accessibility of affordable and high quality assistive technology solutions. MATERIALS AND METHODS: The paper is based on the experience of the authors, an analysis of the existing literature and the inputs from many colleagues in the field of assistive technology provision. It includes the results of discussions of an earlier version of the paper during an international conference on the topic in August 2017. RESULTS AND CONCLUSION: The paper ends with the recommendation to develop an international standard for assistive technology provision. Such a standard can have a major impact on the accessibility of AT for people with disabilities. The paper outlines some the key elements to be included in a standard. Implications for Rehabilitation Assistive technology is a key element in rehabilitation, but many people have no access to affordable AT solutions. The recommendations in the paper aim to inform policies, systems and service delivery procedures on how to improve access to AT across the world.

Lucy Montoro Rehabilitation Network mobile unit: an alternative public healthcare policy.

PURPOSE: The aim is to analyze rehabilitation services provided by a mobile rehabilitation clinic (MU) in nine regions of the State of São Paulo, demonstrating the distribution of orthoses, prostheses and other mobility aids for persons with physical disabilities according to age groups and impairments, as well as the number of persons with physical disabilities as estimated by Brazilian official data sources. METHOD: The number of persons with disabilities in each region was obtained through estimations from the 2010 Brazilian IBGE Census. The number of assistive technologies suppliers and technicians were provided by the Brazilian Technical Orthopedics Association (ABOTEC). Patients were referred to the MU by Regional Health Departments. After examination of a multidisciplinary team, assistive devices are prescribed and delivered according to patients' needs. Data on patients were also assessed according to questionnaires on their age, diagnosis, gender, marital status and education level. RESULTS: From 2009 to 2011, the MU went through 15,000 km providing rehabilitation services through the Public Health System to 1801 patients. Additionally, 3328 devices were delivered in this period. Different age, diagnosis, gender, marital status and schooling profiles are highlighted in each of the analyzed regions. CONCLUSION: Data on patients' profiles were made available through services provided by the MU--including the average index of 1.85 devices delivered to each patient and demand projections--which can be used in the planning of public policies. The MU made rehabilitation services more accessible, trained professionals, raised awareness on the correct delivery and use of assistive devices, and identified and organized people's demand in each region. Implications for Rehabilitation Delivering prostheses, orthoses and other mobility aids fulfills the rights of persons with disabilities to personal mobility with the greatest possible independence, as foreseen by the Convention on the Rights of Persons with Disabilities, increasing their participation in society on an equal basis with others. The direct impact of actively reaching out into the community to provide quality rehabilitation services and assistive devices increases the level of access of persons with disabilities to health services and equalizes opportunities. Outreach initiatives to deliver rehabilitation services in the community must include a capacity-building component. Building the capacities of local practitioners and health personnel will further empower both these professionals and persons with disabilities, diminishing attitudinal barriers. Reaching out into the community allows gathering data on the prevalence of health conditions, local need and demand for assistive devices and rehabilitation services, and informs decision-making.