Barreiras ao acesso das pessoas com deficiência aos serviços de saúde: uma revisão de escopo

Clemente, Karina Aparecida Padilha; Silva, Simone Vieira da; Vieira, Gislene Inoue; Bortoli, Maritsa Carla de; Toma, Tereza Setsuko; Ramos, Vinícius Delgado; Brito, Christina May Moran de

Karina Aparecida Padilha Clemente

Universidade de São Paulo. Faculdade de Medicina. Departamento de Medicina Legal, Ética Médica, Medicina Social e do Trabalho. São Paulo, SP, Brasil.

http://orcid.org/0000-0002-0985-9626

Simone Vieira da Silva

Universidade de São Paulo. Faculdade de Medicina. Departamento de Medicina Legal, Ética Médica, Medicina Social e do Trabalho. São Paulo, SP, Brasil.

http://orcid.org/0000-0002-7430-5208

Gislene Inoue Vieira

Universidade de São Paulo. Faculdade de Medicina. Departamento de Medicina Legal, Ética Médica, Medicina Social e do Trabalho. São Paulo, SP, Brasil.

http://orcid.org/0000-0002-6536-9218

Maritsa Carla de Bortoli

Secretaria de Estado da Saúde de São Paulo. Instituto de Saúde. Departamento de Ciência e Tecnologia. São Paulo, SP, Brasil

http://orcid.org/0000-0001-8236-7233

Tereza Setsuko Toma

Secretaria de Estado da Saúde de São Paulo. Instituto de Saúde. Departamento de Ciência e Tecnologia. São Paulo, SP, Brasil

http://orcid.org/0000-0001-9531-9951

Vinícius Delgado Ramos

Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Instituto de Medicina Física e Reabilitação. São Paulo, SP, Brasil

http://orcid.org/0000-0002-4566-6637

Christina May Moran de Brito

Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Instituto do Câncer do Estado de São Paulo. São Paulo, SP, Brasil.

http://orcid.org/0000-0003-3775-6533

Correspondência: Karina Aparecida Padilha Clemente Av. Dr. Arnaldo, 455 - Cerqueira César 01246-903 São Paulo, SP, Brasil E-mail: karinaapclemente@yahoo.com.br

Contribuição dos Autores: Concepção e planejamento do estudo: KAPC, SVS, GIV, MCB, TST, VDR, CMMB. Coleta, análise e interpretação dos dados: KAPC, SVS, GIV, MCB, TST, VDR, CMMB. Elaboração ou revisão do manuscrito: KAPC, SVS, GIV, MCB, TST, VDR, CMMB. Aprovação da versão final: KAPC, SVS, GIV, MCB, TST, VDR, CMMB. Responsabilidade pública pelo conteúdo do artigo: KAPC, SVS, GIV, MCB, TST, VDR, CMMB.

Conflito de Interesses: Os autores declaram não haver conflito de interesses.

Figuras (1)
Tabelas (5)

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Figura
Fluxograma do processo de seleção e elegibilidade de estudos, adaptado de Prisma⁹9. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. https://doi.org/10.1136/bmj.n71
https://doi.org/10.1136/bmj.n71... .

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Quadro
Detalhamento do levantamento bibliográfico realizado nas bases de dados de literatura científica.

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Tabela 1
Barreiras ao acesso das pessoas com deficiências nos serviços de saúde, conforme nível de atenção (usuários).

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Tabela 2
Barreiras ao acesso das pessoas com deficiências nos serviços de saúde, conforme nível de atenção (oferta do serviço).

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Tabela 3
Apresentação das categorias de barreiras conforme componentes do referencial teórico, Levesque et al.⁷7. Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12:18. https://doi.org/10.1186/1475-9276-12-18
https://doi.org/10.1186/1475-9276-12-18... (2013) e LBI¹1. Brasil. Lei Nº 13.146 de 6 de julho de 2015. Institui a Lei Brasileira de Inclusão da Pessoa com Deficiência (Estatuto da Pessoa com Deficiência). Brasília, DF; 2015 [cited 2021 Jan 20]. Available from: http://www.planalto.gov.br/ccivil_03/_ato2015-2018/2015/lei/l13146.htm
http://www.planalto.gov.br/ccivil_03/_at... – usuários e cuidadores.

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Tabela 4
Apresentação das categorias de barreiras conforme componentes do referencial teórico Levesque et al.⁷7. Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12:18. https://doi.org/10.1186/1475-9276-12-18
https://doi.org/10.1186/1475-9276-12-18... (2013) e LBI¹1. Brasil. Lei Nº 13.146 de 6 de julho de 2015. Institui a Lei Brasileira de Inclusão da Pessoa com Deficiência (Estatuto da Pessoa com Deficiência). Brasília, DF; 2015 [cited 2021 Jan 20]. Available from: http://www.planalto.gov.br/ccivil_03/_ato2015-2018/2015/lei/l13146.htm
http://www.planalto.gov.br/ccivil_03/_at... – profissionais e serviços de saúde.

Base	Data	Estratégia
PubMed	06/07/2019	(((Disabled Person OR Person, Disabled OR Persons, Disabled OR Persons with Disabilities OR Disabilities, Persons with OR Disability, Persons with OR Persons with Disability OR Handicapped OR People with Disabilities OR Disabilities, People with OR People with Disability OR Physically Handicapped OR Handicapped, Physically OR Physically Disabled OR Disabled, Physically OR Physically Challenged)) AND (“Health Services Accessibility”[Mesh] OR Availability of Health Services OR Health Services Availability OR Accessibility, Health Services OR Access to Health Care OR Accessibility of Health Services OR Health Services Geographic Accessibility OR Program Accessibility OR Accessibility, Program)) AND (SYSTEMATIC REVIEW OR SYSTEMATIC REVIEWS)
PubMed	06/07/2019	(((Disabled Person OR Person, Disabled OR Persons, Disabled OR Persons with Disabilities OR Disabilities, Persons with OR Disability, Persons with OR Persons with Disability OR Handicapped OR People with Disabilities OR Disabilities, People with OR People with Disability OR Physically Handicapped OR Handicapped, Physically OR Physically Disabled OR Disabled, Physically OR Physically Challenged)) AND ((“Health Services for Persons with Disabilities”[Mesh] OR Health Services for the Disabled OR Health Services for People with Disabilities OR Health Services for Disabled Persons) AND Review[ptyp])) AND (SYSTEMATIC REVIEW OR SYSTEMATIC REVIEWS)
PubMed	06/07/2019	(((Disabled Person OR Person, Disabled OR Persons, Disabled OR Persons with Disabilities OR Disabilities, Persons with OR Disability, Persons with OR Persons with Disability OR Handicapped OR People with Disabilities OR Disabilities, People with OR People with Disability OR Physically Handicapped OR Handicapped, Physically OR Physically Disabled OR Disabled, Physically OR Physically Challenged)) AND ((“Healthcare Disparities”[Mesh] OR Disparity, Healthcare OR Health Care Inequalities OR Health Care Inequality OR Inequalities, Health Care OR Inequality, Health Care OR Healthcare Disparity OR Healthcare Inequalities OR Healthcare Inequality OR Inequalities, Healthcare OR Inequality, Healthcare OR Disparities, Healthcare OR Health Care Disparities OR Disparities, Health Care OR Disparity, Health Care OR Health Care Disparity) AND Review[ptyp])) AND (SYSTEMATIC REVIEW OR SYSTEMATIC REVIEWS)
Health Systems Evidence	06/07/2019	disability OR disabilities
Health Evidence	06/07/2019	[(disabled persons) OR disability OR disabilities]
Scopus	06/07/2019	TITLE-ABS-KEY(“disabled persons”ANDaccessibility)AND(LIMIT-TO(DOCTYPE,”re”))
EMBASE	06/07/2019	(‘disabled person’/exp OR ‘disabled person’ OR ‘disability’/exp OR disability) AND (‘accessibility’/exp OR accessibility) AND (‘health care facilities and services’/exp OR ‘health care facilities and services’) AND [review]/lim AND [embase]/lim
Lilacs via portal regional BVS	06/07/2019	(“pessoas com deficiência” OR “disabled persons” OR “personas con discapacidad” OR deficiência OR deficiências OR “deficiência física” OR “deficiências fisicas” OR “deficiente físico” OR incapacidade OR “incapacidade funcional” OR “limitação física” OR “pessoa com desvantagem” OR “pessoas com desvantagens” OR “pessoa com incapacidade” OR “pessoas com incapacidade” OR “pessoas com deficiências” OR “pessoas com incapacidades” OR “pessoa com incapacidade física” OR “pessoa com deficiência fisica” OR “pessoas com deficiência física” OR “pessoas com incapacidade física” OR “pessoas com deficiências físicas” OR “pessoa com limitação física” OR “pessoas com limitação física” OR “pessoas com limitações físicas” OR “pessoa com necessidade especial” OR “pessoas com necessidade especial” OR “pessoas com necessidades especiais”) AND (“acesso aos serviços de saúde” OR “health services accessibility” OR “accesibilidad a los servicios de salud” OR “disparidades em assistência à saúde” OR “healthcare disparities” OR “disparidades en atención de salud” OR “serviços de saúde para pessoas com deficiência” OR “health services for persons with disabilities” OR “servicios de salud para personas con discapacidad”) AND (instance:”regional”) AND ( db:(“LILACS” OR “BDENF” OR “BBO” OR “IBECS”))

Nível de atenção	Barreiras encontradas na literatura
Básico	Acesso limitado a apoio psicológico e pouco ou nenhum apoio de psiquiatria baseada na comunidade¹⁸18. Balogh R, McMorris CA, Lunsky Y, Ouellette‐Kuntz H, Bourne L, Colantonio A, et al. Organising healthcare services for persons with an intellectual disability. Cochrane Database Syst Rev. 2016;(4):CD007492. https://doi.org/10.1002/14651858.CD007492.pub2 https://doi.org/10.1002/14651858.CD00749... ; dificuldade em encontrar médicos dispostos a cuidar de pacientes gravemente incapacitados e complexos¹⁹19. Brown M, Macarthur J, Higgins A, Chouliara Z. Transitions from child to adult health care for young people with intellectual disabilities: a systematic review. J Adv Nurs. 2019;75(11):2418-34. https://doi.org/10.1111/jan.13985 https://doi.org/10.1111/jan.13985... ; dificuldade em encontrar serviços de saúde de que necessita¹⁸18. Balogh R, McMorris CA, Lunsky Y, Ouellette‐Kuntz H, Bourne L, Colantonio A, et al. Organising healthcare services for persons with an intellectual disability. Cochrane Database Syst Rev. 2016;(4):CD007492. https://doi.org/10.1002/14651858.CD007492.pub2 https://doi.org/10.1002/14651858.CD00749... ^,¹⁹19. Brown M, Macarthur J, Higgins A, Chouliara Z. Transitions from child to adult health care for young people with intellectual disabilities: a systematic review. J Adv Nurs. 2019;75(11):2418-34. https://doi.org/10.1111/jan.13985 https://doi.org/10.1111/jan.13985... ; falta da solicitação e realização de exames e cuidados preventivos²⁰20. Marrocco A, Krouse HJ. Obstacles to preventive care for individuals with disability: implications for nurse practitioners. J Am Assoc Nurse Pract. 2017;29(5):282-93. https://doi.org/10.1002/2327-6924.12449 https://doi.org/10.1002/2327-6924.12449... ; falta de acesso a informações sobre saúde sexual reprodutiva, serviços de planejamento familiar e serviços pré-natais e pós-natais²¹21. Mheta D, Mashamba-Thompson TP. Barriers and facilitators of access to maternal services for women with disabilities: scoping review protocol. Syst Rev. 2017;6:99. https://doi.org/10.1186/s13643-017-0494-7 https://doi.org/10.1186/s13643-017-0494-... ; falta de apoio profissional²²22. Andresen EM, Peterson-Besse JJ, Krahn GL, Walsh ES, Horner-Johnson W, Iezzoni LI. Pap, mammography, and clinical breast examination screening among women with disabilities: a systematic review. Womens Health Issues. 2013;23(4):205-14. https://doi.org/10.1016/j.whi.2013.04.002 https://doi.org/10.1016/j.whi.2013.04.00... ; falta de comunicação do profissional com o paciente ou cuidador^22–25; falta de informações aos cuidadores sobre condição de saúde do paciente e acesso insuficiente aos serviços de atendimento infantil²⁵25. Ziviani J, Feeney R, Rodger S, Watter P. Systematic review of early intervention programmes for children from birth to nine years who have a physical disability. Aust Occup Ther J. 2010;57(4):210-23. https://doi.org/10.1111/j.1440-1630.2010.00850.x https://doi.org/10.1111/j.1440-1630.2010... ; falta de seguro de saúde e incapacidade de pagar quaisquer despesas de serviços¹⁸18. Balogh R, McMorris CA, Lunsky Y, Ouellette‐Kuntz H, Bourne L, Colantonio A, et al. Organising healthcare services for persons with an intellectual disability. Cochrane Database Syst Rev. 2016;(4):CD007492. https://doi.org/10.1002/14651858.CD007492.pub2 https://doi.org/10.1002/14651858.CD00749... ^,²⁰20. Marrocco A, Krouse HJ. Obstacles to preventive care for individuals with disability: implications for nurse practitioners. J Am Assoc Nurse Pract. 2017;29(5):282-93. https://doi.org/10.1002/2327-6924.12449 https://doi.org/10.1002/2327-6924.12449... ^,²⁵25. Ziviani J, Feeney R, Rodger S, Watter P. Systematic review of early intervention programmes for children from birth to nine years who have a physical disability. Aust Occup Ther J. 2010;57(4):210-23. https://doi.org/10.1111/j.1440-1630.2010.00850.x https://doi.org/10.1111/j.1440-1630.2010... ; e medo e ansiedade em relação ao tratamento dos filhos com deficiência²⁰20. Marrocco A, Krouse HJ. Obstacles to preventive care for individuals with disability: implications for nurse practitioners. J Am Assoc Nurse Pract. 2017;29(5):282-93. https://doi.org/10.1002/2327-6924.12449 https://doi.org/10.1002/2327-6924.12449... .
Especializado	Falta de acesso aos serviços de saúde²⁶26. Oral A, Rapidi CA, Votava J, Roussos N, Michail X, Kujawa J, et al. Evidence based position paper on Physical and Rehabilitation Medicine (PRM) professional practice for ageing people with disabilities. The European PRM position (UEMS PRM Section). Eur J Phys Rehabil Med. 2017;53(5):802-11. https://doi.org/10.23736/S1973-9087.17.04864-X https://doi.org/10.23736/S1973-9087.17.0... ; falta de comunicação e de acesso à informação^27–29; falta de envolvimento na tomada de decisões sobre sua saúde²⁸28. Rose A, Rosewilliam S, Soundy A. Shared decision making within goal setting in rehabilitation settings: a systematic review. Patient Educ Couns. 2017;100(1):65-75. https://doi.org/10.1016/j.pec.2016.07.030 https://doi.org/10.1016/j.pec.2016.07.03... ; e problema de localização das unidades de saúde e dificuldades de transporte para chegar até os serviços, bem como o custo do transporte²⁹29. Lam N, Leat S J. Reprint of: Barriers to accessing low-vision care: the patient’s perspective. Can J Ophthalmol. 2015;50 Suppl 1:S34-9. https://doi.org/10.1016/j.jcjo.2015.04.007 https://doi.org/10.1016/j.jcjo.2015.04.0... .
Alta complexidade	Barreiras organizacionais, sociais e físicas para acessar serviços de saúde³⁰30. Dunn K, Hughes-McComack L, Cooper SA. Hospital admissions for physical health conditions for people with intellectual disabilities: systematic review. J Appl Res Intellect Disabil. 2018;31 Suppl 1:1-10. https://doi.org/10.1111/jar.12360 https://doi.org/10.1111/jar.12360... ; falta de informações sobre sua saúde e sobre o tratamento³¹31. Zhou H, Roberts P, Dhaliwal S, Della P. Transitioning adolescent and young adults with chronic disease and/or disabilities from paediatric to adult care services: an integrative review. J Clin Nurs. 2016;25(21-22):3113-30. https://doi.org/10.1111/jocn.13326 https://doi.org/10.1111/jocn.13326... ; e sensação de abandono por parte dos cuidadores em relação ao tratamento dos usuários³¹31. Zhou H, Roberts P, Dhaliwal S, Della P. Transitioning adolescent and young adults with chronic disease and/or disabilities from paediatric to adult care services: an integrative review. J Clin Nurs. 2016;25(21-22):3113-30. https://doi.org/10.1111/jocn.13326 https://doi.org/10.1111/jocn.13326... .
Nível de atenção não especificado	Dificuldades com transporte³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... ^,³³33. Hamilton C, Lovarini M, McCluskey A, Folly de Campos T, Hassett L. Experiences of therapists using feedback-based technology to improve physical function in rehabilitation settings: a qualitative systematic review. Disabil Rehabil. 2019;41(15):1739-50. https://doi.org/10.1080/09638288.2018.1446187 https://doi.org/10.1080/09638288.2018.14... ; dificuldades financeiras^{14,16,34–36}; discriminação de prestadores de serviços de saúde^{14,16,34–36}; falta de apoio ao paciente no processo de reabilitação³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... ; falta de comunicação por parte dos profissionais³⁷37. Homeyard C, Montgomery E, Chinn D, Patelarou E. Current evidence on antenatal care provision for women with intellectual disabilities: a systematic review. Midwifery. 2016;32:45-57. https://doi.org/10.1016/j.midw.2015.10.002 https://doi.org/10.1016/j.midw.2015.10.0... ^,³⁸38. Robertson J, Hatton C, Emerson E, Baines S. The impact of health checks for people with intellectual disabilities: an updated systematic review of evidence. Res Dev Disabil. 2014;35(10):2450-62. https://doi.org/10.1016/j.ridd.2014.06.007 https://doi.org/10.1016/j.ridd.2014.06.0... ; falta de conscientização da comunidade em relação à deficiência³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... ; falta de cuidadores para adultos com deficiência física³⁹39. Lawang W, Horey D, Blackford J, Sunsern R, Riewpaiboon W. Support interventions for caregivers of physically disabled adults: a systematic review. Nurs Health Sci. 2013;15(4):534-45. https://doi.org/10.1111/nhs.12063 https://doi.org/10.1111/nhs.12063... ; falta de informações “acessíveis” sobre o tratamento e os serviços de saúde³⁴34. Bright T, Wallace S, Kuper H. A systematic review of access to rehabilitation for people with disabilities in low-and middle-income countries. Int J Environ Res Public Health. 2018;15(10):2165. https://doi.org/10.3390/ijerph15102165 https://doi.org/10.3390/ijerph15102165... ^,³⁵35. Robertson J, Raghavan R, Emerson E, Baines S, Hatton C. What do we know about the health and healthcare of people with intellectual disabilities from minority ethnic groups in the United Kingdom? A systematic review. J Appl Res Intellect Disabil. 2019;32(6):1310-34. https://doi.org/10.1111/jar.12630 https://doi.org/10.1111/jar.12630... ^,³⁷37. Homeyard C, Montgomery E, Chinn D, Patelarou E. Current evidence on antenatal care provision for women with intellectual disabilities: a systematic review. Midwifery. 2016;32:45-57. https://doi.org/10.1016/j.midw.2015.10.002 https://doi.org/10.1016/j.midw.2015.10.0... ^,³⁸38. Robertson J, Hatton C, Emerson E, Baines S. The impact of health checks for people with intellectual disabilities: an updated systematic review of evidence. Res Dev Disabil. 2014;35(10):2450-62. https://doi.org/10.1016/j.ridd.2014.06.007 https://doi.org/10.1016/j.ridd.2014.06.0... ; e longo período de espera para consultas hospitalares após o encaminhamento³⁸38. Robertson J, Hatton C, Emerson E, Baines S. The impact of health checks for people with intellectual disabilities: an updated systematic review of evidence. Res Dev Disabil. 2014;35(10):2450-62. https://doi.org/10.1016/j.ridd.2014.06.007 https://doi.org/10.1016/j.ridd.2014.06.0... .

Nível de atenção	Barreiras encontradas na literatura
Básico	Falta de transporte confiável e acessível para os usuários chegarem nas consultas²⁰20. Marrocco A, Krouse HJ. Obstacles to preventive care for individuals with disability: implications for nurse practitioners. J Am Assoc Nurse Pract. 2017;29(5):282-93. https://doi.org/10.1002/2327-6924.12449 https://doi.org/10.1002/2327-6924.12449... ^,²²22. Andresen EM, Peterson-Besse JJ, Krahn GL, Walsh ES, Horner-Johnson W, Iezzoni LI. Pap, mammography, and clinical breast examination screening among women with disabilities: a systematic review. Womens Health Issues. 2013;23(4):205-14. https://doi.org/10.1016/j.whi.2013.04.002 https://doi.org/10.1016/j.whi.2013.04.00... ^,²⁵25. Ziviani J, Feeney R, Rodger S, Watter P. Systematic review of early intervention programmes for children from birth to nine years who have a physical disability. Aust Occup Ther J. 2010;57(4):210-23. https://doi.org/10.1111/j.1440-1630.2010.00850.x https://doi.org/10.1111/j.1440-1630.2010... ; falta de treinamento e habilidades inadequadas por parte de profissionais, questões ambientais como unidades de saúde distantes, tempo insuficiente para as consultas, atitude negativa e falta de cuidados coordenados por parte dos profissionais¹⁸18. Balogh R, McMorris CA, Lunsky Y, Ouellette‐Kuntz H, Bourne L, Colantonio A, et al. Organising healthcare services for persons with an intellectual disability. Cochrane Database Syst Rev. 2016;(4):CD007492. https://doi.org/10.1002/14651858.CD007492.pub2 https://doi.org/10.1002/14651858.CD00749... ^,²⁰20. Marrocco A, Krouse HJ. Obstacles to preventive care for individuals with disability: implications for nurse practitioners. J Am Assoc Nurse Pract. 2017;29(5):282-93. https://doi.org/10.1002/2327-6924.12449 https://doi.org/10.1002/2327-6924.12449... ; e falhas dos sistemas de saúde em responder adequadamente à morbidade tratável identificada⁴⁰40. Robertson J, Roberts H, Emerson E, Turner S, Greig R. The impact of health checks for people with intellectual disabilities: a systematic review of evidence. J Intellect Disabil Res. 2011;55(11):1009-19. https://doi.org/10.1111/j.1365-2788.2011.01436.x https://doi.org/10.1111/j.1365-2788.2011... .
Especializado	Acesso deficiente às edificações, dificuldade de transportar cadeiras de rodas e instalações precárias de estacionamento para deficientes físicos, ambientes comunitários e sociais geralmente impróprios para o acesso de cadeira de rodas⁴¹41. Bray N, Noyes J, Edwards RT, Harris N. Wheelchair interventions, services and provision for disabled children: a mixed-method systematic review and conceptual framework. BMC Health Serv Res. 2014;14:309. https://doi.org/10.1186/1472-6963-14-309 https://doi.org/10.1186/1472-6963-14-309... ; dificuldade no acesso oportuno a serviços apropriados²⁷27. Cohen E, Jovcevska V, Kuo DZ, Mahant S. Hospital-based comprehensive care programs for children with special health care needs: a systematic review. Arch Pediatr Adolesc Med. 2011;165(6):554-61. https://doi.org/10.1001/archpediatrics.2011.74 https://doi.org/10.1001/archpediatrics.2... ; falta de atenção a cuidados secundários em saúde²⁶26. Oral A, Rapidi CA, Votava J, Roussos N, Michail X, Kujawa J, et al. Evidence based position paper on Physical and Rehabilitation Medicine (PRM) professional practice for ageing people with disabilities. The European PRM position (UEMS PRM Section). Eur J Phys Rehabil Med. 2017;53(5):802-11. https://doi.org/10.23736/S1973-9087.17.04864-X https://doi.org/10.23736/S1973-9087.17.0... ; falta de treinamento e habilidades necessárias para os profissionais e fragmentação do sistema de saúde²⁸28. Rose A, Rosewilliam S, Soundy A. Shared decision making within goal setting in rehabilitation settings: a systematic review. Patient Educ Couns. 2017;100(1):65-75. https://doi.org/10.1016/j.pec.2016.07.030 https://doi.org/10.1016/j.pec.2016.07.03... ^,⁴²42. Liebel DV, Friedman B, Watson NM, Powers BA. Review of nurse home visiting interventions for community-dwelling older persons with existing disability. Med Care Res Rev. 2009;66(2):119-46. https://doi.org/10.1177/1077558708328815 https://doi.org/10.1177/1077558708328815... ; e longo tempo de espera para atendimento e procedimentos inadequados para os tratamentos e manutenção de produtos assistivos⁴¹41. Bray N, Noyes J, Edwards RT, Harris N. Wheelchair interventions, services and provision for disabled children: a mixed-method systematic review and conceptual framework. BMC Health Serv Res. 2014;14:309. https://doi.org/10.1186/1472-6963-14-309 https://doi.org/10.1186/1472-6963-14-309... .
Alta complexidade	Ausência de autocuidado orientado a políticas e promoção de saúde, dificuldades de acessibilidade, disponibilidade limitada de profissionais treinados, falta de apoio social, discriminação, restrições financeiras, falta de informação e intervenções educacionais direcionadas aos usuários⁴³43. Lindsay S, Kingsnorth S, Mcdougall C, Keating H. A systematic review of self-management interventions for children and youth with physical disabilities. Disabil Rehabil. 2014;36(4):276-88. https://doi.org/10.3109/09638288.2013.785605 https://doi.org/10.3109/09638288.2013.78... ; falta de comunicação por parte dos profissionais³¹31. Zhou H, Roberts P, Dhaliwal S, Della P. Transitioning adolescent and young adults with chronic disease and/or disabilities from paediatric to adult care services: an integrative review. J Clin Nurs. 2016;25(21-22):3113-30. https://doi.org/10.1111/jocn.13326 https://doi.org/10.1111/jocn.13326... ^,⁴⁴44. O’Halloran R, Grohn B, Worrall L. Environmental factors that influence communication for patients with a communication disability in acute hospital stroke units: a qualitative metasynthesis. Arch Phys Med Rehabil. 2012;93 (1 Suppl):S77-85. https://doi.org/10.1016/j.apmr.2011.06.039 https://doi.org/10.1016/j.apmr.2011.06.0... e falta de financiamento para compra de aparelhos necessários para tratamento⁴⁴44. O’Halloran R, Grohn B, Worrall L. Environmental factors that influence communication for patients with a communication disability in acute hospital stroke units: a qualitative metasynthesis. Arch Phys Med Rehabil. 2012;93 (1 Suppl):S77-85. https://doi.org/10.1016/j.apmr.2011.06.039 https://doi.org/10.1016/j.apmr.2011.06.0... .
Nível de atenção não especificado	Barreira ao uso da tecnologia por terapeutas, falta de treinamento e/ou recursos para apoiar o uso de tecnologia na prática³³33. Hamilton C, Lovarini M, McCluskey A, Folly de Campos T, Hassett L. Experiences of therapists using feedback-based technology to improve physical function in rehabilitation settings: a qualitative systematic review. Disabil Rehabil. 2019;41(15):1739-50. https://doi.org/10.1080/09638288.2018.1446187 https://doi.org/10.1080/09638288.2018.14... , barreiras de comunicação entre profissionais e pacientes e entre a própria equipe de saúde¹⁶16. Breckenridge JP, Devaney J, Kroll T, Lazenbatt A, Taylor J, Bradbury-Jones C. Access and utilisation of maternity care for disabled women who experience domestic abuse: a systematic review. BMC Pregnancy Childbirth. 2014;14:234. https://doi.org/10.1186/1471-2393-14-234 https://doi.org/10.1186/1471-2393-14-234... ^,³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... ^,³⁴34. Bright T, Wallace S, Kuper H. A systematic review of access to rehabilitation for people with disabilities in low-and middle-income countries. Int J Environ Res Public Health. 2018;15(10):2165. https://doi.org/10.3390/ijerph15102165 https://doi.org/10.3390/ijerph15102165... ; barreiras de idioma e de compreensão cultural³⁵35. Robertson J, Raghavan R, Emerson E, Baines S, Hatton C. What do we know about the health and healthcare of people with intellectual disabilities from minority ethnic groups in the United Kingdom? A systematic review. J Appl Res Intellect Disabil. 2019;32(6):1310-34. https://doi.org/10.1111/jar.12630 https://doi.org/10.1111/jar.12630... ; barreiras físicas ao cuidado¹⁶16. Breckenridge JP, Devaney J, Kroll T, Lazenbatt A, Taylor J, Bradbury-Jones C. Access and utilisation of maternity care for disabled women who experience domestic abuse: a systematic review. BMC Pregnancy Childbirth. 2014;14:234. https://doi.org/10.1186/1471-2393-14-234 https://doi.org/10.1186/1471-2393-14-234... ; barreiras no financiamento da reabilitação⁴⁵45. Pereira S, Graham JR, Shahabaz A, Salter K, Foley N, Meyer M, et al. Rehabilitation of individuals with severe stroke: synthesis of best evidence and challenges in implementation. Top Stroke Rehabil. 2012;19(2):122-31. https://doi.org/10.1310/tsr1902-122 https://doi.org/10.1310/tsr1902-122... e de tecnologias³³33. Hamilton C, Lovarini M, McCluskey A, Folly de Campos T, Hassett L. Experiences of therapists using feedback-based technology to improve physical function in rehabilitation settings: a qualitative systematic review. Disabil Rehabil. 2019;41(15):1739-50. https://doi.org/10.1080/09638288.2018.1446187 https://doi.org/10.1080/09638288.2018.14... ; barreiras para a realização de exames de saúde³⁸38. Robertson J, Hatton C, Emerson E, Baines S. The impact of health checks for people with intellectual disabilities: an updated systematic review of evidence. Res Dev Disabil. 2014;35(10):2450-62. https://doi.org/10.1016/j.ridd.2014.06.007 https://doi.org/10.1016/j.ridd.2014.06.0... ; discriminação do prestador de serviços de saúde³⁴34. Bright T, Wallace S, Kuper H. A systematic review of access to rehabilitation for people with disabilities in low-and middle-income countries. Int J Environ Res Public Health. 2018;15(10):2165. https://doi.org/10.3390/ijerph15102165 https://doi.org/10.3390/ijerph15102165... ^,³⁶36. Pelleboer-Gunnink HA, Van Oorsouw WMWJ, Van Weeghel J, Embregts PJCM. Mainstream health professionals’ stigmatising attitudes towards people with intellectual disabilities: a systematic review. J Intellect Disabil Res. 2017;61(5):411-34. https://doi.org/10.1111/jir.12353 https://doi.org/10.1111/jir.12353... ; falha no agendamento de consultas³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... ; falta de habilidades dos profissionais⁴⁶46. King G, Williams L, Hahn Goldberg S. Family‐oriented services in pediatric rehabilitation: a scoping review and framework to promote parent and family wellness. Child Care Health Dev. 2017;43(3):334-47. https://doi.org/10.1111/cch.12435 https://doi.org/10.1111/cch.12435... ; falta de iniciativas de educação sobre serviços de saúde e incompreensão da reabilitação pelas pessoas com deficiências³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... ; falta de motivação pessoal dos profissionais³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... ; falta de paciência dos profissionais, falta de empatia, pouca compreensão das questões relativas à deficiência¹⁶16. Breckenridge JP, Devaney J, Kroll T, Lazenbatt A, Taylor J, Bradbury-Jones C. Access and utilisation of maternity care for disabled women who experience domestic abuse: a systematic review. BMC Pregnancy Childbirth. 2014;14:234. https://doi.org/10.1186/1471-2393-14-234 https://doi.org/10.1186/1471-2393-14-234... ^,³⁷37. Homeyard C, Montgomery E, Chinn D, Patelarou E. Current evidence on antenatal care provision for women with intellectual disabilities: a systematic review. Midwifery. 2016;32:45-57. https://doi.org/10.1016/j.midw.2015.10.002 https://doi.org/10.1016/j.midw.2015.10.0... ; falta de recursos nas áreas de psicologia, fonoaudiologia e neuropsicologia³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... ; e medo e ansiedade entre os profissionais³⁶36. Pelleboer-Gunnink HA, Van Oorsouw WMWJ, Van Weeghel J, Embregts PJCM. Mainstream health professionals’ stigmatising attitudes towards people with intellectual disabilities: a systematic review. J Intellect Disabil Res. 2017;61(5):411-34. https://doi.org/10.1111/jir.12353 https://doi.org/10.1111/jir.12353... .

Uso do serviço: indivíduos, famílias, comunidades e populações
Barreiras	Habilidade de perceber	Habilidade de procurar	Habilidade de alcançar	Habilidade de pagar	Habilidade de se envolver	Outras
Urbanísticas			Problema de localização das unidades de saúde²⁹29. Lam N, Leat S J. Reprint of: Barriers to accessing low-vision care: the patient’s perspective. Can J Ophthalmol. 2015;50 Suppl 1:S34-9. https://doi.org/10.1016/j.jcjo.2015.04.007 https://doi.org/10.1016/j.jcjo.2015.04.0... .
Arquitetônicas			Barreiras organizacionais, sociais e físicas para acessar serviços de saúde³⁰30. Dunn K, Hughes-McComack L, Cooper SA. Hospital admissions for physical health conditions for people with intellectual disabilities: systematic review. J Appl Res Intellect Disabil. 2018;31 Suppl 1:1-10. https://doi.org/10.1111/jar.12360 https://doi.org/10.1111/jar.12360... .
Transporte			Dificuldades de transporte²⁹29. Lam N, Leat S J. Reprint of: Barriers to accessing low-vision care: the patient’s perspective. Can J Ophthalmol. 2015;50 Suppl 1:S34-9. https://doi.org/10.1016/j.jcjo.2015.04.007 https://doi.org/10.1016/j.jcjo.2015.04.0... ^,³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... ^,³³33. Hamilton C, Lovarini M, McCluskey A, Folly de Campos T, Hassett L. Experiences of therapists using feedback-based technology to improve physical function in rehabilitation settings: a qualitative systematic review. Disabil Rehabil. 2019;41(15):1739-50. https://doi.org/10.1080/09638288.2018.1446187 https://doi.org/10.1080/09638288.2018.14... para chegar até as unidades de saúde, bem como o custo do transporte²⁹29. Lam N, Leat S J. Reprint of: Barriers to accessing low-vision care: the patient’s perspective. Can J Ophthalmol. 2015;50 Suppl 1:S34-9. https://doi.org/10.1016/j.jcjo.2015.04.007 https://doi.org/10.1016/j.jcjo.2015.04.0... .
Comunicação			Falta de acesso a informações sobre sua saúde^27–29, sobre o tratamento e os serviços de saúde^31,34–37, e sobre saúde sexual reprodutiva²¹21. Mheta D, Mashamba-Thompson TP. Barriers and facilitators of access to maternal services for women with disabilities: scoping review protocol. Syst Rev. 2017;6:99. https://doi.org/10.1186/s13643-017-0494-7 https://doi.org/10.1186/s13643-017-0494-... ; e falta de comunicação³⁷37. Homeyard C, Montgomery E, Chinn D, Patelarou E. Current evidence on antenatal care provision for women with intellectual disabilities: a systematic review. Midwifery. 2016;32:45-57. https://doi.org/10.1016/j.midw.2015.10.002 https://doi.org/10.1016/j.midw.2015.10.0... do profissional com o paciente ou cuidador²²22. Andresen EM, Peterson-Besse JJ, Krahn GL, Walsh ES, Horner-Johnson W, Iezzoni LI. Pap, mammography, and clinical breast examination screening among women with disabilities: a systematic review. Womens Health Issues. 2013;23(4):205-14. https://doi.org/10.1016/j.whi.2013.04.002 https://doi.org/10.1016/j.whi.2013.04.00... ^,²⁵25. Ziviani J, Feeney R, Rodger S, Watter P. Systematic review of early intervention programmes for children from birth to nine years who have a physical disability. Aust Occup Ther J. 2010;57(4):210-23. https://doi.org/10.1111/j.1440-1630.2010.00850.x https://doi.org/10.1111/j.1440-1630.2010... ^,³⁷37. Homeyard C, Montgomery E, Chinn D, Patelarou E. Current evidence on antenatal care provision for women with intellectual disabilities: a systematic review. Midwifery. 2016;32:45-57. https://doi.org/10.1016/j.midw.2015.10.002 https://doi.org/10.1016/j.midw.2015.10.0... ^,³⁸38. Robertson J, Hatton C, Emerson E, Baines S. The impact of health checks for people with intellectual disabilities: an updated systematic review of evidence. Res Dev Disabil. 2014;35(10):2450-62. https://doi.org/10.1016/j.ridd.2014.06.007 https://doi.org/10.1016/j.ridd.2014.06.0... .
Atitudinais	Falta de acesso a serviços de planejamento familiar e serviços pré-natais e pós-natais²¹21. Mheta D, Mashamba-Thompson TP. Barriers and facilitators of access to maternal services for women with disabilities: scoping review protocol. Syst Rev. 2017;6:99. https://doi.org/10.1186/s13643-017-0494-7 https://doi.org/10.1186/s13643-017-0494-... ; acesso insuficiente aos serviços de atendimento infantil²⁵25. Ziviani J, Feeney R, Rodger S, Watter P. Systematic review of early intervention programmes for children from birth to nine years who have a physical disability. Aust Occup Ther J. 2010;57(4):210-23. https://doi.org/10.1111/j.1440-1630.2010.00850.x https://doi.org/10.1111/j.1440-1630.2010... ; falta de acesso aos serviços de saúde²⁸28. Rose A, Rosewilliam S, Soundy A. Shared decision making within goal setting in rehabilitation settings: a systematic review. Patient Educ Couns. 2017;100(1):65-75. https://doi.org/10.1016/j.pec.2016.07.030 https://doi.org/10.1016/j.pec.2016.07.03... ; sensação de abandono por parte dos cuidadores em relação ao tratamento dos usuários³¹31. Zhou H, Roberts P, Dhaliwal S, Della P. Transitioning adolescent and young adults with chronic disease and/or disabilities from paediatric to adult care services: an integrative review. J Clin Nurs. 2016;25(21-22):3113-30. https://doi.org/10.1111/jocn.13326 https://doi.org/10.1111/jocn.13326... ; discriminação de prestadores de serviços de saúde^{14,16, 34–36}; e falta de apoio ao paciente no processo de reabilitação³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... .	Medo e ansiedade em relação ao tratamento dos filhos com deficiência²⁰20. Marrocco A, Krouse HJ. Obstacles to preventive care for individuals with disability: implications for nurse practitioners. J Am Assoc Nurse Pract. 2017;29(5):282-93. https://doi.org/10.1002/2327-6924.12449 https://doi.org/10.1002/2327-6924.12449... ; falta de apoio profissional²²22. Andresen EM, Peterson-Besse JJ, Krahn GL, Walsh ES, Horner-Johnson W, Iezzoni LI. Pap, mammography, and clinical breast examination screening among women with disabilities: a systematic review. Womens Health Issues. 2013;23(4):205-14. https://doi.org/10.1016/j.whi.2013.04.002 https://doi.org/10.1016/j.whi.2013.04.00... ; acesso limitado ao apoio psicológico e pouco ou nenhum apoio de psiquiatria baseada na comunidade¹⁸18. Balogh R, McMorris CA, Lunsky Y, Ouellette‐Kuntz H, Bourne L, Colantonio A, et al. Organising healthcare services for persons with an intellectual disability. Cochrane Database Syst Rev. 2016;(4):CD007492. https://doi.org/10.1002/14651858.CD007492.pub2 https://doi.org/10.1002/14651858.CD00749... ; dificuldade em encontrar médicos dispostos a cuidar de pacientes gravemente incapacitados e complexos¹⁹19. Brown M, Macarthur J, Higgins A, Chouliara Z. Transitions from child to adult health care for young people with intellectual disabilities: a systematic review. J Adv Nurs. 2019;75(11):2418-34. https://doi.org/10.1111/jan.13985 https://doi.org/10.1111/jan.13985... ; e dificuldade em encontrar serviços de saúde de que necessita¹⁸18. Balogh R, McMorris CA, Lunsky Y, Ouellette‐Kuntz H, Bourne L, Colantonio A, et al. Organising healthcare services for persons with an intellectual disability. Cochrane Database Syst Rev. 2016;(4):CD007492. https://doi.org/10.1002/14651858.CD007492.pub2 https://doi.org/10.1002/14651858.CD00749... ^,¹⁹19. Brown M, Macarthur J, Higgins A, Chouliara Z. Transitions from child to adult health care for young people with intellectual disabilities: a systematic review. J Adv Nurs. 2019;75(11):2418-34. https://doi.org/10.1111/jan.13985 https://doi.org/10.1111/jan.13985... .				Falta de conscientização da comunidade em relação à deficiência³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... .
Tecnológicas
Outras			Longo período de espera para consultas hospitalares após o encaminhamento³⁸38. Robertson J, Hatton C, Emerson E, Baines S. The impact of health checks for people with intellectual disabilities: an updated systematic review of evidence. Res Dev Disabil. 2014;35(10):2450-62. https://doi.org/10.1016/j.ridd.2014.06.007 https://doi.org/10.1016/j.ridd.2014.06.0... .	Falta de seguro de saúde e incapacidade de pagar quaisquer despesas de serviços¹⁸18. Balogh R, McMorris CA, Lunsky Y, Ouellette‐Kuntz H, Bourne L, Colantonio A, et al. Organising healthcare services for persons with an intellectual disability. Cochrane Database Syst Rev. 2016;(4):CD007492. https://doi.org/10.1002/14651858.CD007492.pub2 https://doi.org/10.1002/14651858.CD00749... ^,²⁰20. Marrocco A, Krouse HJ. Obstacles to preventive care for individuals with disability: implications for nurse practitioners. J Am Assoc Nurse Pract. 2017;29(5):282-93. https://doi.org/10.1002/2327-6924.12449 https://doi.org/10.1002/2327-6924.12449... ^,²⁵25. Ziviani J, Feeney R, Rodger S, Watter P. Systematic review of early intervention programmes for children from birth to nine years who have a physical disability. Aust Occup Ther J. 2010;57(4):210-23. https://doi.org/10.1111/j.1440-1630.2010.00850.x https://doi.org/10.1111/j.1440-1630.2010... ; e dificuldades financeiras^{14,16,34–36}.	Falta de envolvimento na tomada de decisões sobre sua saúde²⁸28. Rose A, Rosewilliam S, Soundy A. Shared decision making within goal setting in rehabilitation settings: a systematic review. Patient Educ Couns. 2017;100(1):65-75. https://doi.org/10.1016/j.pec.2016.07.030 https://doi.org/10.1016/j.pec.2016.07.03... .	Falta da solicitação e realização de exames e cuidados preventivos²⁰20. Marrocco A, Krouse HJ. Obstacles to preventive care for individuals with disability: implications for nurse practitioners. J Am Assoc Nurse Pract. 2017;29(5):282-93. https://doi.org/10.1002/2327-6924.12449 https://doi.org/10.1002/2327-6924.12449... e falta de cuidadores para adultos com deficiência física³⁹39. Lawang W, Horey D, Blackford J, Sunsern R, Riewpaiboon W. Support interventions for caregivers of physically disabled adults: a systematic review. Nurs Health Sci. 2013;15(4):534-45. https://doi.org/10.1111/nhs.12063 https://doi.org/10.1111/nhs.12063... .

Oferta do serviço: sistemas, instituições, organizações e provedores de saúde
BARREIRAS	Abordagem	Aceitabilidade	Disponibilidade e acomodação	Acessibilidade financeira	Adequação	Outras
Urbanísticas			Acesso deficiente às edificações; dificuldade de transportar cadeiras de rodas⁴¹41. Bray N, Noyes J, Edwards RT, Harris N. Wheelchair interventions, services and provision for disabled children: a mixed-method systematic review and conceptual framework. BMC Health Serv Res. 2014;14:309. https://doi.org/10.1186/1472-6963-14-309 https://doi.org/10.1186/1472-6963-14-309... ; barreiras físicas ao cuidado¹⁶16. Breckenridge JP, Devaney J, Kroll T, Lazenbatt A, Taylor J, Bradbury-Jones C. Access and utilisation of maternity care for disabled women who experience domestic abuse: a systematic review. BMC Pregnancy Childbirth. 2014;14:234. https://doi.org/10.1186/1471-2393-14-234 https://doi.org/10.1186/1471-2393-14-234... ; e dificuldades de acessibilidade⁴³43. Lindsay S, Kingsnorth S, Mcdougall C, Keating H. A systematic review of self-management interventions for children and youth with physical disabilities. Disabil Rehabil. 2014;36(4):276-88. https://doi.org/10.3109/09638288.2013.785605 https://doi.org/10.3109/09638288.2013.78... .		Unidades de saúde distantes¹⁸18. Balogh R, McMorris CA, Lunsky Y, Ouellette‐Kuntz H, Bourne L, Colantonio A, et al. Organising healthcare services for persons with an intellectual disability. Cochrane Database Syst Rev. 2016;(4):CD007492. https://doi.org/10.1002/14651858.CD007492.pub2 https://doi.org/10.1002/14651858.CD00749... ^,²⁰20. Marrocco A, Krouse HJ. Obstacles to preventive care for individuals with disability: implications for nurse practitioners. J Am Assoc Nurse Pract. 2017;29(5):282-93. https://doi.org/10.1002/2327-6924.12449 https://doi.org/10.1002/2327-6924.12449... .
Arquitetônicas			Instalações precárias de estacionamento para deficientes físicos, ambientes comunitários e sociais geralmente impróprios para o acesso de cadeira de rodas⁴¹41. Bray N, Noyes J, Edwards RT, Harris N. Wheelchair interventions, services and provision for disabled children: a mixed-method systematic review and conceptual framework. BMC Health Serv Res. 2014;14:309. https://doi.org/10.1186/1472-6963-14-309 https://doi.org/10.1186/1472-6963-14-309... e dificuldades de acessibilidade⁴³43. Lindsay S, Kingsnorth S, Mcdougall C, Keating H. A systematic review of self-management interventions for children and youth with physical disabilities. Disabil Rehabil. 2014;36(4):276-88. https://doi.org/10.3109/09638288.2013.785605 https://doi.org/10.3109/09638288.2013.78... .
Transporte			Falta de transporte confiável e acessível para os usuários chegarem nas consultas²⁰20. Marrocco A, Krouse HJ. Obstacles to preventive care for individuals with disability: implications for nurse practitioners. J Am Assoc Nurse Pract. 2017;29(5):282-93. https://doi.org/10.1002/2327-6924.12449 https://doi.org/10.1002/2327-6924.12449... ^,²²22. Andresen EM, Peterson-Besse JJ, Krahn GL, Walsh ES, Horner-Johnson W, Iezzoni LI. Pap, mammography, and clinical breast examination screening among women with disabilities: a systematic review. Womens Health Issues. 2013;23(4):205-14. https://doi.org/10.1016/j.whi.2013.04.002 https://doi.org/10.1016/j.whi.2013.04.00... ^,²⁵25. Ziviani J, Feeney R, Rodger S, Watter P. Systematic review of early intervention programmes for children from birth to nine years who have a physical disability. Aust Occup Ther J. 2010;57(4):210-23. https://doi.org/10.1111/j.1440-1630.2010.00850.x https://doi.org/10.1111/j.1440-1630.2010... .
Comunicação	Falta de comunicação por parte dos profissionais³¹31. Zhou H, Roberts P, Dhaliwal S, Della P. Transitioning adolescent and young adults with chronic disease and/or disabilities from paediatric to adult care services: an integrative review. J Clin Nurs. 2016;25(21-22):3113-30. https://doi.org/10.1111/jocn.13326 https://doi.org/10.1111/jocn.13326... ^,⁴⁴44. O’Halloran R, Grohn B, Worrall L. Environmental factors that influence communication for patients with a communication disability in acute hospital stroke units: a qualitative metasynthesis. Arch Phys Med Rehabil. 2012;93 (1 Suppl):S77-85. https://doi.org/10.1016/j.apmr.2011.06.039 https://doi.org/10.1016/j.apmr.2011.06.0... ; barreiras de comunicação entre profissionais e pacientes e entre a própria equipe de saúde¹⁶16. Breckenridge JP, Devaney J, Kroll T, Lazenbatt A, Taylor J, Bradbury-Jones C. Access and utilisation of maternity care for disabled women who experience domestic abuse: a systematic review. BMC Pregnancy Childbirth. 2014;14:234. https://doi.org/10.1186/1471-2393-14-234 https://doi.org/10.1186/1471-2393-14-234... ^,³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... ^,³⁴34. Bright T, Wallace S, Kuper H. A systematic review of access to rehabilitation for people with disabilities in low-and middle-income countries. Int J Environ Res Public Health. 2018;15(10):2165. https://doi.org/10.3390/ijerph15102165 https://doi.org/10.3390/ijerph15102165... ; barreiras de idioma e de compreensão cultural³⁵35. Robertson J, Raghavan R, Emerson E, Baines S, Hatton C. What do we know about the health and healthcare of people with intellectual disabilities from minority ethnic groups in the United Kingdom? A systematic review. J Appl Res Intellect Disabil. 2019;32(6):1310-34. https://doi.org/10.1111/jar.12630 https://doi.org/10.1111/jar.12630... ; e falta de informação e intervenções educacionais direcionadas aos usuários⁴³43. Lindsay S, Kingsnorth S, Mcdougall C, Keating H. A systematic review of self-management interventions for children and youth with physical disabilities. Disabil Rehabil. 2014;36(4):276-88. https://doi.org/10.3109/09638288.2013.785605 https://doi.org/10.3109/09638288.2013.78... .
Atitudinais	Falta de iniciativas de educação sobre serviços de saúde e incompreensão da reabilitação pelas pessoas com deficiências³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... .		Longo tempo de espera para atendimento⁴¹41. Bray N, Noyes J, Edwards RT, Harris N. Wheelchair interventions, services and provision for disabled children: a mixed-method systematic review and conceptual framework. BMC Health Serv Res. 2014;14:309. https://doi.org/10.1186/1472-6963-14-309 https://doi.org/10.1186/1472-6963-14-309... ; falha no agendamento de consultas³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... ; falta de motivação pessoal dos profissionais³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... ; falta de paciência dos profissionais; e falta de empatia e pouca compreensão das questões relativas à deficiência¹⁶16. Breckenridge JP, Devaney J, Kroll T, Lazenbatt A, Taylor J, Bradbury-Jones C. Access and utilisation of maternity care for disabled women who experience domestic abuse: a systematic review. BMC Pregnancy Childbirth. 2014;14:234. https://doi.org/10.1186/1471-2393-14-234 https://doi.org/10.1186/1471-2393-14-234... ^,³⁷37. Homeyard C, Montgomery E, Chinn D, Patelarou E. Current evidence on antenatal care provision for women with intellectual disabilities: a systematic review. Midwifery. 2016;32:45-57. https://doi.org/10.1016/j.midw.2015.10.002 https://doi.org/10.1016/j.midw.2015.10.0... .		Falta de treinamento e habilidades inadequadas por parte de profissionais⁴⁶46. King G, Williams L, Hahn Goldberg S. Family‐oriented services in pediatric rehabilitation: a scoping review and framework to promote parent and family wellness. Child Care Health Dev. 2017;43(3):334-47. https://doi.org/10.1111/cch.12435 https://doi.org/10.1111/cch.12435... ; atitude negativa e falta de cuidados coordenados por parte dos profissionais¹⁸18. Balogh R, McMorris CA, Lunsky Y, Ouellette‐Kuntz H, Bourne L, Colantonio A, et al. Organising healthcare services for persons with an intellectual disability. Cochrane Database Syst Rev. 2016;(4):CD007492. https://doi.org/10.1002/14651858.CD007492.pub2 https://doi.org/10.1002/14651858.CD00749... ^,²⁰20. Marrocco A, Krouse HJ. Obstacles to preventive care for individuals with disability: implications for nurse practitioners. J Am Assoc Nurse Pract. 2017;29(5):282-93. https://doi.org/10.1002/2327-6924.12449 https://doi.org/10.1002/2327-6924.12449... ; falhas dos sistemas de saúde em responder adequadamente à morbidade tratável identificada⁴⁰40. Robertson J, Roberts H, Emerson E, Turner S, Greig R. The impact of health checks for people with intellectual disabilities: a systematic review of evidence. J Intellect Disabil Res. 2011;55(11):1009-19. https://doi.org/10.1111/j.1365-2788.2011.01436.x https://doi.org/10.1111/j.1365-2788.2011... ; falta de atenção a cuidados secundários em saúde²⁶26. Oral A, Rapidi CA, Votava J, Roussos N, Michail X, Kujawa J, et al. Evidence based position paper on Physical and Rehabilitation Medicine (PRM) professional practice for ageing people with disabilities. The European PRM position (UEMS PRM Section). Eur J Phys Rehabil Med. 2017;53(5):802-11. https://doi.org/10.23736/S1973-9087.17.04864-X https://doi.org/10.23736/S1973-9087.17.0... ; falta de treinamento e habilidades necessárias para os profissionais e fragmentação do sistema de saúde²2. Organização Mundial da Saúde; Banco Mundial. Relatório mundial sobre a deficiência (World Report on Disability). Lexicus Serviços Linguísticos, tradutor. São Paulo: Secretaria de Estado dos Direitos da Pessoa com Deficiência; 2011 [cited 2021 Jan 20]. Available from: https://apps.who.int/iris/bitstream/handle/10665/44575/9788564047020_por.pdf. https://apps.who.int/iris/bitstream/hand... ^,⁴²42. Liebel DV, Friedman B, Watson NM, Powers BA. Review of nurse home visiting interventions for community-dwelling older persons with existing disability. Med Care Res Rev. 2009;66(2):119-46. https://doi.org/10.1177/1077558708328815 https://doi.org/10.1177/1077558708328815... ; falta de apoio social e discriminação⁴³43. Lindsay S, Kingsnorth S, Mcdougall C, Keating H. A systematic review of self-management interventions for children and youth with physical disabilities. Disabil Rehabil. 2014;36(4):276-88. https://doi.org/10.3109/09638288.2013.785605 https://doi.org/10.3109/09638288.2013.78... .
Tecnológicas			Procedimentos inadequados para os tratamentos e manutenção de produtos assistivos⁴¹41. Bray N, Noyes J, Edwards RT, Harris N. Wheelchair interventions, services and provision for disabled children: a mixed-method systematic review and conceptual framework. BMC Health Serv Res. 2014;14:309. https://doi.org/10.1186/1472-6963-14-309 https://doi.org/10.1186/1472-6963-14-309... .	Falta de financiamento para compra de aparelhos necessários para tratamento⁴⁴44. O’Halloran R, Grohn B, Worrall L. Environmental factors that influence communication for patients with a communication disability in acute hospital stroke units: a qualitative metasynthesis. Arch Phys Med Rehabil. 2012;93 (1 Suppl):S77-85. https://doi.org/10.1016/j.apmr.2011.06.039 https://doi.org/10.1016/j.apmr.2011.06.0... ; e barreiras no financiamento da reabilitação⁴⁵45. Pereira S, Graham JR, Shahabaz A, Salter K, Foley N, Meyer M, et al. Rehabilitation of individuals with severe stroke: synthesis of best evidence and challenges in implementation. Top Stroke Rehabil. 2012;19(2):122-31. https://doi.org/10.1310/tsr1902-122 https://doi.org/10.1310/tsr1902-122... e de tecnologias³³33. Hamilton C, Lovarini M, McCluskey A, Folly de Campos T, Hassett L. Experiences of therapists using feedback-based technology to improve physical function in rehabilitation settings: a qualitative systematic review. Disabil Rehabil. 2019;41(15):1739-50. https://doi.org/10.1080/09638288.2018.1446187 https://doi.org/10.1080/09638288.2018.14... .	Barreira ao uso da tecnologia por terapeutas e falta de treinamento e/ou recursos para apoiar o uso de tecnologia na prática³³33. Hamilton C, Lovarini M, McCluskey A, Folly de Campos T, Hassett L. Experiences of therapists using feedback-based technology to improve physical function in rehabilitation settings: a qualitative systematic review. Disabil Rehabil. 2019;41(15):1739-50. https://doi.org/10.1080/09638288.2018.1446187 https://doi.org/10.1080/09638288.2018.14... .
Outras			Medo e ansiedade entre os profissionais³⁶36. Pelleboer-Gunnink HA, Van Oorsouw WMWJ, Van Weeghel J, Embregts PJCM. Mainstream health professionals’ stigmatising attitudes towards people with intellectual disabilities: a systematic review. J Intellect Disabil Res. 2017;61(5):411-34. https://doi.org/10.1111/jir.12353 https://doi.org/10.1111/jir.12353... .	Dificuldades de acessibilidade e restrições financeiras⁴³43. Lindsay S, Kingsnorth S, Mcdougall C, Keating H. A systematic review of self-management interventions for children and youth with physical disabilities. Disabil Rehabil. 2014;36(4):276-88. https://doi.org/10.3109/09638288.2013.785605 https://doi.org/10.3109/09638288.2013.78... .	Tempo insuficiente para a consulta¹⁸18. Balogh R, McMorris CA, Lunsky Y, Ouellette‐Kuntz H, Bourne L, Colantonio A, et al. Organising healthcare services for persons with an intellectual disability. Cochrane Database Syst Rev. 2016;(4):CD007492. https://doi.org/10.1002/14651858.CD007492.pub2 https://doi.org/10.1002/14651858.CD00749... ^,²⁰20. Marrocco A, Krouse HJ. Obstacles to preventive care for individuals with disability: implications for nurse practitioners. J Am Assoc Nurse Pract. 2017;29(5):282-93. https://doi.org/10.1002/2327-6924.12449 https://doi.org/10.1002/2327-6924.12449... ; dificuldade no acesso oportuno a serviços apropriados²⁷27. Cohen E, Jovcevska V, Kuo DZ, Mahant S. Hospital-based comprehensive care programs for children with special health care needs: a systematic review. Arch Pediatr Adolesc Med. 2011;165(6):554-61. https://doi.org/10.1001/archpediatrics.2011.74 https://doi.org/10.1001/archpediatrics.2... ; barreiras para a realização de exames de saúde³⁸38. Robertson J, Hatton C, Emerson E, Baines S. The impact of health checks for people with intellectual disabilities: an updated systematic review of evidence. Res Dev Disabil. 2014;35(10):2450-62. https://doi.org/10.1016/j.ridd.2014.06.007 https://doi.org/10.1016/j.ridd.2014.06.0... ; discriminação do prestador de serviços de saúde³⁴34. Bright T, Wallace S, Kuper H. A systematic review of access to rehabilitation for people with disabilities in low-and middle-income countries. Int J Environ Res Public Health. 2018;15(10):2165. https://doi.org/10.3390/ijerph15102165 https://doi.org/10.3390/ijerph15102165... ^,³⁶36. Pelleboer-Gunnink HA, Van Oorsouw WMWJ, Van Weeghel J, Embregts PJCM. Mainstream health professionals’ stigmatising attitudes towards people with intellectual disabilities: a systematic review. J Intellect Disabil Res. 2017;61(5):411-34. https://doi.org/10.1111/jir.12353 https://doi.org/10.1111/jir.12353... ; falta de recursos nas áreas de psicologia, fonoaudiologia e neuropsicologia³²32. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1): 22. https://doi.org/10.4102/ajod.v2i1.22 https://doi.org/10.4102/ajod.v2i1.22... ; ausência de autocuidado orientado a políticas e promoção de saúde⁴³43. Lindsay S, Kingsnorth S, Mcdougall C, Keating H. A systematic review of self-management interventions for children and youth with physical disabilities. Disabil Rehabil. 2014;36(4):276-88. https://doi.org/10.3109/09638288.2013.785605 https://doi.org/10.3109/09638288.2013.78... ; disponibilidade limitada de profissionais treinados e falta de apoio⁴³43. Lindsay S, Kingsnorth S, Mcdougall C, Keating H. A systematic review of self-management interventions for children and youth with physical disabilities. Disabil Rehabil. 2014;36(4):276-88. https://doi.org/10.3109/09638288.2013.785605 https://doi.org/10.3109/09638288.2013.78... .

[1] Correspondência: Karina Aparecida Padilha Clemente Av. Dr. Arnaldo, 455 - Cerqueira César 01246-903 São Paulo, SP, Brasil E-mail: karinaapclemente@yahoo.com.br

Brasil

Brasil

Barreiras ao acesso das pessoas com deficiência aos serviços de saúde: uma revisão de escopo

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