Open Journal Systems

RESEARCH

How to cite this article:

Salcedo-Álvarez RA, Bustamante-Edquén S. El análisis institucional de la atención a la salud diferenciada de los adultos mayores. Rev Enferm Inst Mex Seguro Soc. 2015;23(3):177-86

Institutional analysis of differential health care of older adults

Rey Arturo Salcedo-Álvarez,¹ José Cruz-Rivas-Herrera,¹ Blanca Consuelo González-Caamaño,¹ Sebastián Bustamante-Edquén²

¹Escuela Nacional de Enfermería y Obstetricia, Universidad Nacional Autónoma de México, Distrito Federal, México; ²Facultad de Enfermería y Escuela de Postgrado de la Universidad Nacional de Trujillo, Trujillo, Perú

Correspondence: Rey Arturo Salcedo-Álvarez

Email: rasalced@hotmail.com

Received: June 9^th 2014

Judged: November 19^th 2014

Accepted: January 21^st 2015

Abstract

Introduction: Demographic and health aspects of older adults are described, and based on René Lourau’s position an institutional analysis of care for this age group is offered.

Objective: To characterize the institutionalization of differentiated services to older adults and the ways it is perceived and justified.

Methodology: A descriptive, qualitative, inductive design with naturalistic approach where participants were interviewed during the first half of 2013 in southern Mexico City. Information was obtained by analyzing the speech in twelve semi-structured interviews with older adults, their families, and health staff (nurses and doctors); public policies and regulations established for the care of the elderly are analyzed, as are observations made during data collection in the natural setting.

Results: Healthcare to older adults in Mexico City has high quality characteristics in the field, which is supported by an extensive legal framework; however, in terms of institutionalization, long waiting times, disrespectful treatment, and lack of resources are key aspects that users would like to improve.

Conclusions: The balance between the instituted and the instituting is the institutionalized. In the population studied more positive than negative aspects are highlighted, so it is possible to say that care is differentiated, but it is mostly focused on favoring older adults.

Keywords: Elderly; Nursing care

---

Older adults, some demographic and health aspects

During the twentieth century the Mexican population experienced significant social, economic, demographic, political, and cultural transformations. These changes involved major changes in the age structure of the population, in which the relative amount of older people gradually increased and that of children decreased.¹ In 2001 older adults accounted for 5% of the population in Mexico, and it was estimated that in 2030 they would reach 12.6%.² Last census data³ indicated that in 2010 their population was 8.8%; Also, the Consejo Nacional de Población estimated that the worldwide population of older adults will rise to 16.6% in 2030 and to 21.4% in 2050.⁴

While older adults now live longer, this does not necessarily indicate that they have good health: chronic, degenerative, neoplastic, mental, or infectious diseases are frequent and significantly limit their health. A multicenter study conducted in seven cities of Latin America and the Caribbean (including the​Mexico City metropolitan area) that aimed to assess the state of health of older adults has shown that people in this group are aging with more functional problems, poorer healthcare and greater limitations compared to older adults in developed countries.⁵ In Mexico the morbidity of this population has also increased; in 1990 a rate of 14,710 was recorded, which rose to 38,970 per 100,000 older adults for the year 2005.⁶

The health of this age group has a specific burden that falls on the health system and impacts its efficiency: two of the priority chronic diseases in the Instituto Mexicano del Seguro Social (IMSS) are diabetes and high blood pressure. In 1996 280,000 older adults with diagnoses of these diseases were treated. By 2000, this figure increased to 670,000. It was estimated that in 2010 1.1 million cases were presented and 2020 there will be 1,500,000. The current budget resources are already insufficient, and an increase in staffing and health infrastructure for their care is neither happening nor is it expected.⁷

It is an indisputable fact that the consequences on the health of older adults depend largely on socioeconomic status, lifestyle, nutritional status, physical activity, tobacco, alcohol, and other drug use, and each individual’s care habits. However, it also depends on the type of health service where they are served, so giving safe, high-quality nursing care in an equitable, just, and fair environment is essential not only for the good care of people, but also to achieve their satisfaction and gain their trust.

Differentiated healthcare

The concept of differentiated service does not appear in the "descriptors of the scientific literature for health sciences".⁸ The World Health Organization (WHO) states that this includes the attitude of the service provider, and is individualized so that all persons attended leave satisfied, according to the level of resolution that can be offered.
For the particular case of this study, differentiated care was defined as "The act of receiving from healthcare staff different care than that given to other people, mainly unfavorable attention."

In Mexico, as in many other countries, it is the medical area that has participated most in the design of public health policies. Therefore, "healthcare" has been defined as the synonym of "medical care", but the reality is that there are many professions that interact to carry out healthcare.

According to the Pan American Health Organization (PAHO),⁹ medical care is defined as "care actions addressing people and the environment, performed in order to promote, protect, or restore health, or reduce or offset unrecoverable disability, regardless of the public, state, non-state, or private nature of health workers."

In Mexico, healthcare is conceptualized as "The set of services provided to the individual, in order to protect, promote, and restore health".¹⁰ The specific activities of this care are: preventive, including general promotion and specific protection; curative actions, which aim to make an early diagnosis and provide timely treatment; rehabilitation, including actions to correct disability; and finally, palliative, which refers to comprehensive care to preserve the quality of life of patients through prevention, treatment, and control of pain and other physical and emotional symptoms by a multidisciplinary professional team.

Therefore, healthcare represents the set of actions based on scientific knowledge, skills, and abilities within an ethical context to pursue the promotion, protection, and recovery of individual and collective health; it is also how society organizes and allocates its resources based on public health policies to attend and address the population’s health risks by offering services of development, prevention, assistance, and rehabilitation, all under conditions of fairness, equity, and justice.

Institutional analysis

According to René Lourau, institutions are legal and cultural policy bodies, composed of ideas, values, beliefs, and laws that determine the forms of social interaction and characterize social practices.

Institutional analysis, described by Lourau and George Lapassade in the late 60’s, is presented as theory and method. In a broad sense, in the words of Lourau, it is a "critical theory of social forms" of a "method of scientific work that emphasizes the description of the conditions for research on permanent engagement, not just given promptly, on the link between engagement and institutionalization".¹¹

Lourau defines the institution based on three concepts:12 the instituted, the instituting, and the institutionalized. These concepts were described as follows:

• The instituted is synonymous with established order and social law, as opposed to the instituting, i.e., it is the antithesis, which is characterized by the informal, spontaneous and explosive;
• The instituting is the potential of the informal group that embodies the opposite of the instituted, it is the moment when an institution is founded, that is, the notion that aims to overcome existing institutions, so it is a denial that means anarchy for the established order, and
• The institutionalized happens when rules and regulations are already in the unconscious of the individual and the collective, and when its rules, guidelines, and precepts continue to govern social life.

One of the contributions of institutional analysis is to consider the institution concept in its historical and dialectical dimension.

However, returning to the institution concept and dialectically analyzing it through Lourau, this has three stages:

1. The universality itself (the instituted / universality of ideology) that is considered the legal, jurisprudent, regulatory, and ideological apparatus that sustains care; for example, nursing care provides health and welfare to people.
2. Particularity (the instituting / particularity of the social base) which would become "the process" of the macro-processes, of how the universal conditions the particular (programs, rules, regulations, and procedures of nursing through which care happens).
3. Singularity, which according to the proposal mentioned would become the institutionalized, and would be the base demonstrations of nursing care resulting from this interaction.

Lourau says "Institutionalization is a process, a transformation, a struggle that concerns all aspects of the social phenomenon".¹¹ The first refers to the abstract, general dimension, the positive unit of the concept of universality, which is denied insofar as different cultural, political, economic, and historical conditions particularize it.

Nursing care is an institution, so for this to happen and to be accepted even unconsciously as an activity of the health sciences in charge of caring for people and having the characteristics of legitimacy and humanism that creates a social good, the relations necessary for this care to happen (curricula, schools, university degrees, students, teachers, clinics, hospitals, etc.) associate nursing care with a series of norms, standards, and values ​​of specific behavior within a society.

This makes clear the levels of authority, autonom,y and responsibility that are expected from a student, an assistant, a general nurse, a licensed practitioner, a specialist, a teacher or doctor.

While they are three very different moments of the concept of institution, they can be dialectically analyzed into the following:

• Moment of universality. This is the positive moment of conception. This is fully true in the abstract: a nurse can give highly technical care to a patient who presents with a complex health problem in a national institute, or may be performing a home visit for checking an elderly diabetic patient, and in neither case could the care be considered superior to that of the other. Example: nursing care is a positive and universal social fact in the abstract.
• Moment of particularity. This concept is embodied in certain, specific conditions. Every universal carries in itself its opposite; in the example above: an adult with diabetes who comes unbalanced surely will require highly specialized care and at least at the most critical moments the home visit will surely be expendable. For example: nursing care cannot be given the same for everyone, as it depends on the care needs of each person.
• Moment of the singularity of the concept. Universal standards are not embodied in individuals directly: they go through the mediation of particular social standards, such as: nursing care can be given to everyone equally but it depends on the culture of each person how they accept care.
• Crossing over. This is the intersection of instances that refers to the whole social system. Every social form has a specific functionality, but these functions taken cross-sectionally give official and other latent functions, usually ignored. Every social form has an official purpose and a division of labor, where each individual occupies a place as part of an organization; thus, nursing care is a necessary experience for which people who need it have to travel and are forced to stay by the logic of social order, cultural heritage, and custom prevailing in the centers of care.

Nursing care is a relationship between the instituting and instituted leading to an unfinished space in constant motion. The institution is captured as a contradictory space, crossed by forces beyond the limits set by physical establishment. So, we cannot investigate the organization's work if not in relation to other institutions.
Derived from the background posed, the following guiding question was formulated: What is the institutionalization of differentiated healthcare of older adults in Mexico City?

The objective of this research was to characterize the institutionalization of differentiated care for older adults and the ways it is perceived and justified.

Methodology

The research was qualitative descriptive with a naturalistic inductive approach.¹² It was attempted to describe, classify, interpret, and analyze events, facts, and phenomena related to differentiated healthcare for older adults in southern Mexico City, which is the capital and seat of the federal powers of the United States of Mexico. This is a federal entity of Mexico which is not part of the 31 Mexican states but belongs to the federation, which together consists of the 32 federal entities of the nation.

Mexico City is the country's largest urban center, and the main political, academic, economic, fashion, financial, business, and cultural center. In it the main hospitals in the country, the national institutes of health and high specialty hospitals with the most advanced and modern technology in the world are concentrated. 

The study participants were older adults and their families who were interviewed in their homes; it also consisted of nurses and doctors, who were interviewed at their workplaces.

The basic criteria for selection were older adults who had required medical attention as well as their families who had been their primary caregivers; operating health services personnel serving older adults; health personnel directors of health units.

All research subjects mentioned above were obtained by saturation and redundancy criteria, which was reached when the investigator obtained the same or similar information; i.e. respondents did not say anything different from what was already said in the interviews.

For data collection a semi-structured interview was used with three different approaches, depending on who was targeted: One for older adults and their families, one for nurses and physicians.

To organize the information, the total transcription of the interviews was included and the speech analyzed, for which live code was included, that was the sentences expressed by the interviewee. This was called Emic.

For information processing, substance code, abstractions were derived from the theoretical framework and empirical experience (Etic).

From the instituting and instituted perspectives according to the three main actors in this work, the instituted, instituting aspects, and the interviews with older adults, health workers, and older adults’ family members, were linked vertically, horizontally and transversely.

Comparative tables were created for each question with the answers of the three participating actors. The categories were contrasted with the analysis classifiers. Later this information was compared with existing public policies for the care of older adults. Then the results and final conclusions were written.

Registration units and cataloging elements were established. The fundamental criterion of categorization of content analysis was semantic, that is, units were grouped by similarities in their meaning.

The analysis done on twelve surveys (three older adults, three family members of the elderly, three nurses and three physicians) allowed the creation of the following lines of analysis:

• Categories: instituted, institutionalized and instituting.
• Classifiers: care provided, care received, and consistency of the system.

Given that this paper had three sources of information (one, the current official discourse in Mexican legislation or the scientific literature; two, discourse of older adults and their families; and three, that of the nurses and doctors), the description of the results was made from the contrast of the three types of information for each of the classifiers established.

During the development of the research, ethical principles were observed. All research subjects were guaranteed anonymity and confidentiality. Before authorization, they were informed about the purpose of the investigation, respect for privacy, and their freedom to participate or not in the study.^13,14

They were also asked for permission to record the interview, prior to authorization, and the full names were removed and only the patronymic followed by the initials of the surnames were used in the interview transcription and the final report from the investigation.

For the aspects of qualitative research rigor, the criteria of credibility, auditability and transferability were considered.

Results and discussion

Institutional analysis is a method and theory that since its philosophical conception has had defined analytical categories; for the first case they are instituted, instituting and institutionalized.

The 131 units of analysis (Table I) were pooled, because the categories of institutional analysis and of this study were instituted, instituting and institutionalized, and classifiers care provided, care received, and system consistency, plus each one of these can have positive or negative connotation.

For a description of the results we focus on the institutionalized category, as we find that the institutionalized aspect is the midpoint between the instituted and instituting, as in the institutionalized aspect the positive connotation of discourse is more attached to the instituted field, and therefore discourses found in instituting aspect are more focused on the negative connotation of the institutionalized category.

Category II: institutionalized. Classifier: care provided. Positive connotation.

Institutional analysis, in the words of Lourau, is a "critical theory of social forms". However, in Mexico there are many official discourse affirming, boasting, and touting the benefits, strengths and achievements in health; for example, the SICALIDAD program.¹⁵ This has the fundamental objective to promote decent and appropriate treatment for patients and their families, as well as providing more effective health services in all institutions. In this regard, two of the nurses interviewed commented as follows: 

E1PS Enf, P 2, R 1-2 and 3-5 Yes, I treat them well, since I also have grandparents and I would not want them to be treated badly because they are seen as older ... To me personally I do not like dealing with older adults, but I don’t discriminate either; rather, I try to serve them as well as possible.

E1PS Enf, P7, R 1-5 Doctors are a little cold and do not have the tact for treating adults. The nursing staff treats them with more kindness and gentleness. I always try to give the best of my care.

As for the category of institutionalized and the classifier of care provided with positive connotation, we find that in the 20 grouped units of analysis, speeches relate mostly to the professional satisfaction that both nurses and doctors have in trying to provide all their patients with care and equal treatment, despite the difficulties they might find in terms of providing both material and human resources. We also note that nurses are those who maintain more contact with patients and, in the case of older adults, seek to provide proper treatment for their needs and abilities.

Category II: institutionalized. Classifier: care provided. Negative connotation.

Institutionalization is a "process, a transformation, a struggle that concerns all aspects of the social phenomenon".¹¹ The first refers to the abstract, general dimension, the positive unit of the concept of universality, which is denied insofar as different cultural, political, economic, and historical conditions particularize it. In this regard, during the Twenty-Seventh Pan American Sanitary Conference, held by the Pan American Health Organization in October 2007, the importance of regional policy and strategy to ensure quality of care was stressed. The agency stressed the importance of quality of care and patient safety as an essential quality for achieving national health objectives, improving the health of the population and the sustainable future of the healthcare system. In contrast to this, poor-quality healthcare poses a negative burden on health services, reflected in its ineffectiveness, inefficiency, limited access, and user dissatisfaction.

Although the reality is that often personalized treatment depends more on personal aspects than on institutional interests.

E1PS Enf, P1, R 1-4 I feel that we do give them good quality care ... Care will always vary depending a lot on the mood of the people and in this case doctors and nurses.

E3PS Med, P1, R20-27 The doctor has to see a certain number of patients. With the older adult, from the moment they enter the office they do it with certain limitations because of their loss of agility in movement, and as soon as they enter the office people start asking them, what’s wrong, what hurts, scolding them because they are not caring for themselves, and that makes their time in the medical office decrease, the doctor focusing only on treating the complaint, not knowing that maybe in their home they also suffer discrimination, mistreatment, and here we are doing the same thing to them.

When analyzing the category of institutionalized, classifier of care provided, with negative connotation, there are five discourses in which the medical and nursing staff have accepted differential treatment to the elderly, which demonstrates the "ageism" (maintenance of stereotypes and prejudicial attitudes towards a person solely because of being older) presented by Losada as the third major form of discrimination. With this, Losada refers to stereotypes toward the elderly about their cognitive skills or abilities.¹⁶ This discrimination comes from the very fear of death instilled in society, as mentioned by Todd Nelson in his analysis of the institutionalization of ageism in America from TV and even children’s books.¹⁷ Discourses analyzed in this part of the analysis mention that it is the doctors who are exercising greater discrimination against the elderly, due in part to the lack of health staff. As noted from the first pages of this work, the elderly are the population group with the fastest growth and the most health problems and needs. In this regard, some interviews note the lack of resources available to doctors and nurses to provide patients with proper care.

Category II: institutionalized. Classifier: care received. Positive connotation.

The institutional analysis considers that every analyzer is a social analyzer. From this follows, first, the spontaneity of the natural analyzer and the artificiality of the strategic spatial-temporal analyzer device built for the intervention. Both are secondary to the social character of the analyzer. Lourau says "the deinstitutionalized analyzer reveals the instituting crushed under the instituted, and, in doing so, messes up the instituted". The analyzer simultaneously interrogates knowledge and power, and analyzes them both, the desire to know and our position in social relations. In this sense we can consider that "by analyzer is meant the elements of social reality manifesting more virulent contradictions of the system."

In this vein, in Mexico within the objectives of the Programa Sectorial de Salud 2013-2014,¹⁸ actions and strategies arise to be carried out to ensure effective access to quality health services. This includes strategy 2.2, focused on improving the quality of health services of the Sistema Nacional de Salud, and strategy 2.3, focused on the creation of integrated inter-agency networks of health services, whose lines of action intend to consolidate improvements in quality medical services, which include the strengthening of medical units, the implementation of prehospital care modules, the promotion of compliance with standards of quality and patient safety in health institutions, as well as updating mechanisms to regularize the technical and interpersonal quality of health services.

E2AM, P9, R5-12 Fortunately I still found a doctor. They checked me, gave me a piece of paper, and told me to go urgently to the Hospital de Milpa Alta ... In the hospital I had surgery and thankfully everyone treated me very well ... I left.

E3AM, P1, R2 and 4 So far they have treated me well and I have no complaints. The staff is very attentive, the nurse ladies, the ones that I have had so far, are very friendly.

As for the category of institutionalized, classifier of care received, with positive connotation, when analyzing the 13 speeches obtained, we noted that elderly patients or their relatives speak of the good treatment they received from nurses, doctors, and social workers. Respondents reported that they have observed improvement in the quality of care they receive. Research on the satisfaction of older adults,¹⁹ with respect to the quality of family medicine services found that 80% of respondents believe that the care they received was good both in family medicine units and specialty hospitals; however, another study reported 64% satisfaction about in the kindness of their treatment, 21.7% reported improvement of the condition, 9.1% cut waiting time, and 93% of respondents said that medical care was good on the day of the interview. The reason for this perception in 74.9% was good treatment by the doctor.

Category II: institutionalized. Classifier: care received. Negative connotation.

Production of analyzers in any given situation is the prerequisite for the way the actors perceive the situation, and it allows both the multiple crossovers of the institution to become visible, and a repositioning of the actors in front of their own institutional places, i.e. the group regains the instituting possibility to move from the place of instituted alienation.

In Mexico, the Commission on Human Rights of the Federal District (CNHDDF) in the Manual on human rights and non-discrimination of the elderly mention that non-discrimination is a human right. Furthermore, discriminatory practices are prohibited by the legal framework; however, they accept that discrimination is still part of the social routine both in the country and worldwide.²⁰ As regards discrimination against the elderly, they specify ...

Discrimination against older adults means those negative attitudes or behaviors towards members of a different group [...] that seek to restrict or deny equal treatment, services or rights ... Individuals who discriminate have a distorted view of human beings, and they ascribe to themselves characteristics or virtues that put them a step above certain groups ...

Here the evidence found during the course of this investigation on the existence of discrimination in the treatment of older adults is presented.

E2AM, P11, R1-3 The difference is remarkable: with older adults they are more rude and have no patience. Some of us do not listen well and doctors get annoyed repeating things.

E1Fam, P6, R1-6 Yes they attend them differently ... My grandfather was very grumpy. When they approached him, he did not want them to touch him or give him medicine. He would throw everything, so nurses hardly wanted get near or care for him ... I understood that they didn’t want to care for him, but also they had to understand because he is an older person.

Most of the discourse analyzed in the classifier care received, category institutionalized, with negative connotation relate to breach of quality expectations that patients have about their treatment. We found that the major items of dissatisfaction are found in the period before and during the consultation, i.e. issues ranging from waiting time to the service received in the office. Most of the complaints concerned the treatment provided by doctors. Guadalupe Maldonado¹⁹ in a similar investigation, "Quality of care of the elderly," reports that waiting time is not a priority for older adults when assessing the quality of medical care provided; however, factors such as kindness in the treatment or improvement of the disease are.

Category II: institutionalized. System consistency. Positive connotation.

Following the proposal of Juan Acha,²¹ but applying the concept to nursing care: care as a sociocultural phenomenon is subject to three basic processes: production, distribution and consumption. The former considers a professional activity that requires specific learning to produce care processes that are human in themselves. The other two processes which constitute the nursing profession concern the user audience, who is the recipient of care and demands attention, in the spaces that mediate between health care and nursing care in its essential function of providing quality care. In Mexico the practice of patient care by nurses is monitored by the Sistema Indica, which proposes the integration of evidence on improving the technical and perceived quality of health services. The Comisión Permanente de Enfermería also defines the quality of nursing services. In interviews, evidence of improvement was found in the perceived quality of care by nurses. 

E1Fam, P22, R 1-5 and 6-7 In the clinic I feel that nurses are better able to deal with seniors, because they have more patience and are never angry ... In the hospital I think is the attention is okay because they have a lot of work ... There are good nurses and rude nurses.

E3AM, P1, R4-6 Years ago, nurses were very grumpy and bossy. I don’t know if age influences this because right now they are younger or maybe already better prepared.

In this category seven discourses are found, which mostly relate to improvement found by patients in treatment provided by nurses. Respondents claim that their treatment varies according to the institution in which they were treated. Similar research reports that most of the older adults interviewed received friendly treatment by the nursing staff; 58% felt highly satisfied with the service received, 40% reported an average degree of satisfaction, while 2% felt dissatisfied with the care provided by nursing staff.²²

Category II: institutionalized. System consistency. Negative connotation.

The way of doing things, which, as mentioned earlier, corresponds to the discursive practice and, as a whole, represents the instituted part of nursing care and the care process, refers to the way professionals perform their daily practices of care (daily practice); that is, the way in which care for the elderly is institutionalized.

However, article six, paragraph one of Ley de los Derechos de las Personas Adultas Mayores states that: "Any public or private institution that provides services to older persons must have the infrastructure, installations, and appropriate equipment and human resources ... ".²³

E3AM, P3, R3-6 I've noticed that they do not have the material necessary to provide good quality service, but that does not depend on the staff but on government authorities that are in charge of the clinic.

E1Fam, P16, R 1 and 5-7 Sometimes I saw that people prefer to serve a child than a grandfather ... you understand that there are people in more serious condition than you, but the old folks can’t endure so much. We wanted to leave and come back, but we said, "we're already here, and it’s tiring."

We got 29 discourses for this section, which found that the major system inconsistencies exposed by respondents relate to waiting times for treatment, unsatisfactory treatment from doctors, and lack of resources, both material and human, to receive or provide quality medical service. Also, some subjects showed evidence of differential treatment for older adults. Research on user satisfaction in family medical units²⁴ presented 35.2% as dissatisfied. Research reported that the major items of dissatisfaction had to do with difficulty in getting the appointment and long waiting times.

Conclusions

Qualitative research is an essential tool to deepen theorizing knowledge. The approach to institutional analysis applied to the study of healthcare for older adults can address aspects of care that would be unclear with quantitative methodologies, making it convenient to continue developing this line of research.
Another potential theme of this paper is that further studies to deepen multi-factoriality involved in differentiated care will contribute to reducing the negative connotations of care in the institutionalized field.

Similarly, it could be the subject of future research, since it is a fait accompli that older adults perceive that simply by being older, health personnel "can discriminate" and also "a priori" assume that they don’t have a way to complain because the institution will always favor the staff and not support them. However, the study population sees more positives than negatives, so you could say that there is a differentiated service, but it is mostly focused on favoring older adults.

It is also clear that despite the training programs that all the nurses and doctor in health institutions are subjected to, prejudices and biases still prevail, mostly in doctors and in some nurses, for the elderly and how they are treated.

Finally, it is a reality that information and education are the best tool to reduce negative attitudes, so it is necessary to stress that the issue of differentiated services and institutional analysis be included in the curricula of nurses, in order to achieve medium-term influence on decision-makers. With this, the differentiated services will be incorporated in the political and public agenda in order to truly get the quality of healthcare assessed not only with quantitative performance indicators, as it is the daily experiential aspect which largely affects the quality of care for older adults and thus their satisfaction and trust in institutions.

References

1. Instituto Nacional de Estadística Geografía e Informática. Los adultos mayores en México. Perfil sociodemográfico al inicio del siglo XXI. México, 2005. [Cited 2014 May 8]. Available from: http://www.inegi.gob.mx/prod_serv/contenidos/espanol/bvinegi/productos/censos/poblacion/adultosmayores/Adultos_mayores_web2.pdf
2. Negrete-Salas ME. Distribución geográfica de la población mayor. México: Instituto de Investigaciones Sociales, UNAM; 2001.
3. Instituto Nacional de Estadística Geografía e Informática. Censo Nacional de Población y Vivienda 2010, México, 2012. [Cited 2013 Jun 16]. Available from: http://www3.inegi.org.mx/sistemas/TabuladosBasicos/Default.aspx?c=27302&s=est
4. Consejo Nacional de Población. El envejecimiento de la población mundial. México, 2005. [Cited 2014 Mar 30]. Available from: http://www.conapo.gob.mx/publicaciones /enveje2005/enveje01.pdf
5. Albala C, Lebrao ML, León-Díaz ME, Ham-Chande R, Hennis AJ, Palloni A et al. Encuesta Salud, Bienestar y Envejecimiento (SABE): Metodología de la encuesta y perfil de la población estudiada. Rev Panam Salud Publica / Pan Am Public Health. 2005; 17:(5/6) 307-22.
6. Molina-Sánchez MR. Panorama epidemiológico del adulto mayor en el 2005. Epidemiología. México: Dirección General de Epidemiología, Secretaría de Salud; 2006.
7. Gutiérrez-Robledo LM. Mortalidad en la población mayor. El proceso de la transición epidemiológica. México: Demos; 2001.
8. Descriptores en ciencias de la salud. Atención diferenciada. [Cited 2012 Sep 20]. Available from: http://decs.bvs.br/cgi-bin/.
9. Organización Panamericana de la Salud. La salud pública en las Américas: nuevos conceptos, análisis del desempeño y bases para la acción. Washington, DC: OPS; 2002 (Publicación científica y técnica No. 589).
10. Cámara de Diputados del H. Congreso de la Unión. Ley General de Salud. Nueva Ley publicada en el Diario Oficial de la Federación el 7 de febrero de 1984. Últimas reformas publicadas DOF el 10 de junio de 2011. p 12.
11. Lourau R. Libertad de movimientos. Una introducción al análisis institucional. Argentina: EUDEBA; 2001.
12. Minayo MC, Deslandes S, Neto O, Gomes R. Investigación social: Teoría, método y creatividad. Buenos Aires: Colección Salud Colectiva: Serie Didáctica, 1^st ed; 2003.
13. Secretaría de Salud. Ley General de Salud. Diario Oficial de la Federación. México. 19 de junio de 2003.
14. Asociación Médica Mundial, Declaración de Helsinki. Principios éticos para las investigaciones médicas en seres humanos. Seúl, Corea: AMM; 2008.
15. Secretaría de Salud. Subsecretaría de Innovación y Calidad. Programa de Acción Específico 2007-2012 de la Secretaría de Salud: Si Calidad. México: SSA; 2008.
16. Losada A. Edadismo: consecuencias de los estereotipos, del prejuicio y la discriminación en la atención a las personas mayores. Algunas pautas para la intervención. Madrid, España; 2004.
17. Nelson D. Ageism: The Strange Case of Prejudice Against the older You. California, United States of America: Department of Psychology, California State University; 2011.
18. Secretaría de Salud. Programa Sectorial de Salud 2013-2018. México: SSA; 2013.
19. Maldonado G, Orrico SE, Fragoso JS, Pérez JHM. Calidad en la atención del adulto mayor en medicina familiar. Rev Med Inst Mex Seguro Soc. 2000;38(3):125-9.
20. Comisión de Derechos Humanos del Distrito Federal. Manual de derechos humanos y no discriminación del adulto mayor. México; 2001.
21. Acha J. Teoría del dibujo, su sociología y su estética. México: Ediciones Coyoacán; 2000.
22. García MD. Satisfacción del usuario adulto mayor con la calidad de la atención de enfermería en el hospital general Cunduacán Tabasco. México: Secretaría de Salud: 2008. Available from: http://www.publicaciones.ujat.mx/publicaciones/horizonte_sanitario/ediciones/2008_sep-dic/03%20Ma%20DOLORES%20GARCIA%20HDEZ.pdf
23. Secretaría de Desarrollo Social. Instituto Nacional de las Personas Adultas Mayores. Ley de los Derechos de las Personas Adultas Mayores. México: SEDESOL; 2011.
24. Hernández Leyva B, García Peña C, Anzures Carro R, Orozco López M. Satisfacción de usuarios en Unidades de Medicina Familiar. Rev Med Inst Mex Seguro Soc. 2002;40(5):373-8.

Enlaces refback

• No hay ningún enlace refback.