Weeks 8 & 9

The final interviews: residential care in Moldova

This project is coming to an end. In order to fully understand Moldova’s elderly care, I visited a residential care home in a village in the estern part of the country. Interviews were carried out with a number of residents, aged between just under 60 and over 90.

Interview with one of the residents of the elderly care home in eastern Moldova.

Residential care is a complicated part of the Moldovan elderly care. Principally, residency is granted only to people who pay for themselves, or who have relatives that pay for them. In all other cases, the process of ageing takes place in each person’s home. There are, however, exceptions. Occasionally, residency will be granted to a person of age whose condition urgently calls for a more permanent form of support than may be offered by home care which, as has been highlighted in previous posts, typically arrives every second day. Such exceptions also require the existance of a free slot, which is becoming rarer as Moldova’s population ages far quicker than the number of residential care places increases.

Residents typically pay 60% of their pension as a fee for a place in a residential care home. Residency includes a bed in a shared room – the room may contain from two to six beds, or even more, and is gender separated. Residency also grants access to a dining room, where cooked meals are offered several times a day. At this particular home, the cook took great pride in serving well-cooked, healthy food which is also offered to staff. I had a lunch together with a group of employees and the food quality was indeed very high. Residents are said to “always put on weight”, according to staff.

Apart from a bed in a shared sleeping room and access to the dining hall, there is a communal area with books, games, a TV-set, as well as some smaller rooms with gym, bathroom and hobby area. When outdoor temperatures permit (which they do about nine months per year in Moldova), residents spend most of their daytime hours outdoors. This center has a garden, some alotment for agriculture, outdoor furniture, a grill, etc.

Interviews and observations brought forward a couple of recurring themes. Firstly, residents consider themselves happy to have arrived at this particular home, which is considered a very good one. They also expressed huge gratitude for not living alone, in their own house, anymore. Being left alone in an otherwise empty house was frequently describes in terms of a disaster, a terrible fate.
Secondly, the power balance between staff and residents appeared quite patronising. Residents were simply told to participate in interviews, although several of them showed hesitation (and I reacted by asking the staff to ask another resident). Staff described residents in terms of “child-like” individuals, persons that need a lot of attention, confirmation, moral support – but with very low own agency. It was clear that being part of the staff means to know what should be done, and being a resident means to accept things as they are, and relax and be peaceful. Staff repeatedly underlined that a large part of their job consists of showing warmth, consideration, emotional proximity, reliability, and build trust. These and similar terms have been repeated also by home care staff that I have interviewed during the previous weeks.

Since my thesis will not focus on residential care, I will not bring a comparison with Swedish residential care into this post. However, several findings during this visit align with what I have found and reflected about in the home care interviews and observation. One thing diverges quite abruptly: the sheer horror with which the residential care interviewees described the lonelyness of an old person living in their own home.

With this post, the academic part of this blogg is coming to an end. A suggestion for future collaboration between students & professors in Moldova and Sweden will be the theme of the last post – stay tuned for that, and please leave a comment below this one.

Glenn Möllergren

Weeks 5-7: Empirics & theory

Interview with home care staff in northern Moldova.

The last couple of weeks have been intense and full of fascinating input. This blog update will try to highlight some of them. The picture shows an interview with three home care workers in a village in Northern Moldova; for pandemic-related reasons the interview was performed outdoors.

While carrying out a number of interviews and observations, one thing has become a lot clearer: Elderly care workers in Moldova do spend considerable time supporting care-takers emotionally. As previously stated, talks (“convoribiri”) amount to the most commonly performed intervention during care work, but this is also regarded the most important of them all, both from care-takers and staff’s perspective. They may have considerable duration in time and occur every second day. This contrasts sharply with Swedish home care practice, characterized by short but frequent interventions.

As a Moldovan care-taker is admitted home care, a number of hours is assigned and a schedule established. Typically, the schedule (“grafic”) allows for a two-hour visit every second day, by one care-giver. Together, the care receiver (“beneficiar/a”) and the staff agrees on what needs to be done. While shopping for food, taking care of the house, helping out with preparing food, and making errands at the postal office or the pharmacy are frequently occuring task; talks & consultation takes place at almost every visit. In case a care receiver needs more time on a specific day, staff may call to the person next on the list to announce a later arrival. It’s however not feasible, or at least not sustainable, to reoccuringly spend more than the assigned number of hours, or to come at a more frequent pace – like every day or several times per day (although some staff admit to that they occasionally step out of their work schedule to make additional visits at care receivers who are in especially dire need).

This order of things differs radically from how Swedish home care is designed. There, the normality could be described as consisting of a number of very short visits per day. Care takers may be admitted help with getting out of bed, making breakfast, performing intimate care, etc – all of which may be divided into a number of short interventions. Since actions related to food, intimate hygiene, movement, and getting dressed and undressed occur in large numbers in Sweden, one may wonder why they are not mentioned in the Moldovan home care. Interviewees have given two explanations:

  1. Few people have this sort of needs. Most can get out of bed, put coffee on the table, or take care of their intime hygiene by themselves.
  2. Those that are in such an advanced state of ageing that they can not manage this any more, will anyway not have too many more months left to live, so that when those things occur, this type of interventions will not have to last for very long.

Alternatively, it may be possible that a lot of people feel uncomfortable to ask for this kind of help, because they know it’s unusual, or they’re too proud to admit to incapabilities of this kind, or out of knowledge that it may anyway not be provided.
Whichever comes closer to the truth – or if they all have some truth in them – a theory coined by James Holstein (1992; full reference below) may here be employed. Holstein applies a micro perspectiv to social interaction in public sector organisations and finds that whenever an instituion, authority or welfare organisation sets up formal criteria, such as diagnoses, it tends to “squeeze” its clients/patients into that scheme. It “produces” the clients/patients it is set up to deal with. Out of a person with certain conditions, it produces a patient with a specific diagnose – or a care receiver with a number of needs, neatly lined up in a list, corresponding with interventions lined up equally neatly.

In Swedish elderly care, the possible conditions for which an elderly person may receive home care are listed in a code guide consisting of almost 200 pages, an international functionality standard called ICF. Every possible vulnerability, urgent human need, every requirement has to be linked to one or several of the codes in the ICF. The assistance officer, investigating the conditions for home service admittance, performs an assessment interview and is required by the National Bureau of Social and Medical Services to tic all the boxes corresponding to the catalogue of codes in the ICF. Following Holstein, we may observe how the care receiver is reformed into fitting the form – the “care-taker” is thus produced. If reocurring help requirements such as getting out of bed, getting dressed or putting food on the table are expected to turn up during the interview, they’re much more likely to be asked for by the care receiver – compared to if they are not mentioned and barely possible to even pronounce. In short, while Moldova may be “producing” care-takers that are in apparent need of having a longer talk every time the care giver shows up, Sweden may be producing care receivers who require frequent visits in order to just survive each day.

The empirical study is, however, not coming to an end quite yet, and new findings may put Holstein down the list of theory providers. Please return for updates, and please do leave comments below.

Holstein, J.A. 1992. “Producing People: Descriptive Practice in Human Service Work.” Current Research on Occupations and Professions 6:23-39.

Fourth week: Corona-restrictions… but the work gets done

Social workers' office in a Moldovan village.

Halfways into the project, covid-infection rates start reaching alarming levels. Among others have all of my colleagues/informants in Chisinau city administration been ordered to self-quarantine (and many of them are ill with covid, but currently recovering). The impact is quite noticeble from the point of view of my research, since it’s impossible to collect empirical data without meeting people. Hence I decided to go to outlying villages with lower infection levels where restrictions and quarantine is not (yet) in function.

Thus I came to interview care staff and assistance officers in a village in northern Moldova. I met with them in their work office, appearing at the photo. Interviews were carried out individually and recorded, resulting in audio files that will further on be transcribed and translated into English. Following previous findings, my questions this time focused on how decision making about service provision takes the needs of each individual into consideration, since it appeared to me as if decision texts were rather vague and tended to end in a paragraph stating the admission of home service of a certain number of hours per week, without too many details as of which kind of help, how often and for how long per day had been agreed upon.

Interviewees explained that needs would typically vary from day to day, and that it’s therefore more fair, and better for everyone, to set a number hours of home service as an outcome of the assessment – without stating too detailedly exactly what sort of service or help would be provided at each visit. Thereby, money would be allocated from the regional healt & social care board to the assigned social worker in the village, and they could start working almost instantly. From that moment on, the interventions would be decided by the care-taker and the home care worker together, with a priority to what the beneficiary wishes for at each visit. As the interventions would commence, the social worker would report in a summary what had been performed at each visit, based on a 15-point-scheme of possible intervention. Of all the possible interventions, the two most common ones referred to 1) bringing groceries to the beneficiary, and 2) carrying out small talk and listen to what the beneficiary wanted to say, an activity named convorbiri. From a Swedish point of view, this last intervention appear almost unthinkable, since Swedish care staff seldomly have any time for talking to the care-taker. Reflecting on this, both interviewees stated that the need for convorbiri was more or less the corner stone of elderly care in Moldova, since beneficiearies are all too often very lonely. Looking at reports from recent weeks’ work, it was beyond doubt that the code for convorbiri appeared at almost every visit, whereas other interventions, such as bringing groceries or water, cleaning the living areas, performing personal care, or securing house heating, appeared sporadically.

Third week: a clearer picture of the assessment process

Halfways through the third week I’m happy to find that I’ve got a reasonable grip on the assessment process in Moldova’s elderly care. Findings emanate from formal documents, interviews with social assistants, care workers and their managers, as well as a sociology scholar, and, most importantly, several care-takers.

A brief summary:
When a person of age – a pensioner, basically – experiences difficulties in everyday life, they can turn to the local social care and ask for help. Initially, an assistance officer will evaluate their needs and gather the documentation required. This includes personal documents as well as medical certificates proving disabilities and, which makes Moldova very different from Sweden, a set of papers showing that the applicant lacks any form of close relative, who would otherwise be required by law to help their kid. That’s the portal paragraph in one of the documents photographed here.
When all due documents are in place, the assistance officer formulates a decision about providing help, and a schedule for its provision. The schedule, called a grafic, basically states at what days help will be provided, and what it will consist of. Formalities include registering data about the beneficiary in several different administrative systems, that appear to mean a lot of unnecessary job for the social secretary. The formal requirements – including a form with specific questions about living standard, disabilities, needs, and other personal data about the applicant – are stated in national law, which makes Moldova a different case from Sweden, where such a form (albeit a much more detailed one) is recommended, though not juridically enforced, by the National Social Board.

As soon as formalities are in place, a social worker will be assigned to start providing the help. After three months, an evaluation of the services is required by law, but in practice, this may take a lot longer, since the beneficiary is anyway free to make a phone call to the assistance officer at any moment, should the services not match expectations. Re-evaluations – including a visit to the beneficiary’s home – will then take place roughly once per year.

If the administrative process is not carried out according to the detailed regulation, the assistance officer will be held responsible. One of my informers has had their salary reduced twice because of formal mistakes. Considering the overwhelming amount of formal requirements involved in the assessment process, one may wonder if there is anyone who can actually perform this job to perfection.

From the beneficiaries’ point of view, the system seems to provide a set of security measures, aimed at preventing ignorance, poor quality care, or mistreatment. Apart from directing themselves to the care staff – which typically is one care giver specifically for one beneficiary – or to the assistance officer, a receiver of elderly care in Moldova may also address the local administration manager, or turn directly to the National Inspection of Social Care. Considering that a substantial part of the collective of beneficiaries may suffer from dementia – a majority, according to some informants – there seems to be quite a requirement for frequent check-ups. At the same time, informers are stating that the experts from the National Inspection tend to ask beneficiaries about data that they may have a hard time remembering, like on what day a certain service was provided. “They usually don’t even know what day it is”, said one care worker.

First impressions of Moldovan elderly care

During the second week of MFS I’ve had the great privilege of meeting the managers of elderly care in the central district of Moldovas capital, Chisinau. In a brief summary of what we’ve talked about, one may conclude a couple of crucial matters. Here are some of the highlights:
1 Moldovan elderly care mainly covers the need of people who don’t have a family, or whose families are unable of caring for them when they reach their old age. By law, family is obliged to care for their kin, and the assessment authority – the Directia Generala Asistenta Sociala si Sanatate, the administration for social assistance and health care – will duly investigate an applicant’s possibility to obtain help from their children or spouse. Hence, in this district, numbering about 100 000 inhabitants, a mere 300 are beneficiaries from elderly care, meaning 0,3% of the population receive elderly care. In Sweden, this figure is about ten times higher.
2 Once the assessment process has considered the applicant’s right to receive social help, a formal decision stating the amount of help admitted is issued. This amount may range from one to several hours a couple of days per week, and the help is delivered by a social worker which, as a general rule, will be the same person from day to day. In other words, a beneficiary of Moldovan elderly care will normally have to get aquainted with just one single person from the care provider. A Swedish home care receiver sees on average 15 different people per week.
3 The contents of the home care is decided upon by the care receiver and their social worker for each day. In this aspect, Moldovan elderly care differs widely from the Swedish one, where care provision is formulated in a set of interventions, scheduled in a detailed plan for each home care staff’s visit. Flexibility is minimal in Swedish home care, and appears to be rather wide in Moldova.
4 Public elderly care in Moldova takes place in the beneficiarie’s home. There are no publicly funded asylums, residential care homes or other units of that kind. Only those who can pay for residential care may recieve it. Regardless of how ill the care receiver is, help will only be provided in their home. In Sweden, approximately one out of five care receiver lives in a residential care home, and those that do, have been found to have explicitly severe disabilities or health conditions, motivating their move into a residential care unit.

During the upcoming week, my hope is to meet some of the social workers who provide care, and carry out at least one formal interview.

First week in Moldova

Dr Tatiana Gribincea and Glenn Möllergren

On Monday, October 5, I met my Moldovan mentor, Dr Tatiana Gribincea. Dr Gribincea is the leader of the department for social work at her university, the Free International University of Moldova. At our first meeting Dr Gribincea was running an online lecture for a class of students in social assistance, and I was kindly offered to share my research topic with them. The topic of the lecture was social work among old people, which is also my focus. Already on the next day, October 6, Dr Gribincea invited me to meet with social assistants, social workers and beneficiaries of elderly care in a village in the northern part of Moldova, Ochiul Alb. The experience from the visit to Ochiul Alb will be refered in an upcoming post.

MFS research project: Needs assessment in Moldovan elderly care

What happens when an old person in need of social care gets in touch with society’s institutions? What is the nature of the assessment interview, where the old person expresses their needs, and the assistance officer carries out an inquiry and decides upon provision of help?

These are the questions that originated a trip to Moldova in the autumn of 2021. As the research unfolds, this blog will report on some of the impressions. This, the first chapter, will provide a summary of the background and the setting of the scene for the eight following weeks.

1 The study
This research originated in a bachelor’s thesis in 2019 (Möllergren: Ålderism i riktlinjer för äldreomsorgen, link below) where care provision in Swedish elderly care was explored through an analysis of guideline documents from the municipal level. The main finding was that care provision is influenced by ageist prejudice about old peope. It is therefore much easier to receive help covering basic needs, like food, hygiene, security and home service, than to obtain support for “non-old-related” problems connected to psychical suffering, substance abuse, violence, and sexuality. The municipal guidelines explicitly state things like “going for a walk” as examples of what old persons are expected to need society’s help with. The crucial point is the assessment interview, where the assistance officer talks the applicant into accepting a certain set of care interventions, rather than openly listening to every expression of need that the old person might communicate. A “reversed assessment” evolves, where the care provision aligned with municipal guidelines replaces the actual needs, and the applicant is convinced to apply only for the type of care that the guidlines actually state.

But is this a purely Swedish phenomena? How would the assessment interview function in a less-ageist, less-guideline-oriented society? These reflections led to the establishment of a research plan for a master’s thesis in social work. As the MFS scholarship listed Moldova among eligible countries, this country became the location of choice. While Sweden has a decades-old tradition of manual-based assessment processes, this is a novelty in Moldova. And while the general Swedish perception of “old age” is among the most negative in the world, Moldovan culture is more appreciative.
The application for an MFS scholarship was handed in. A positive decision was concluded in the spring of 2021, but the Ministry of Foreign Affairs didn’t put Moldova off the corona restricted list until July 2021, meaning the research could take place only in the autumn of 2021.

2 The preparation
Initial discussions involving the mentor Linda Lill at MaU and the local Moldavian supervisor professor Tatiana Gribincea at the The Free International University of Moldova, ULIM, started out in the autumn of 2020. It was therefore possible to fast-forward the pracitalities once the scholarship was granted. In order to maximize flexibility during the research, I chose to use a car to get to Moldova. Departure date was September 29 from Malmö and the trip went through Poland and Ukraine entering Moldova in the north-west. The 1750 kilometers took four days to complete and today, October 3, I arrived in the capital of Moldova – Chisinau.

Chisinau is a city of 700 000 people, counting a number of universities as well as an array of economical, educational and political institutions. Official language is Moldovan, which is practically identical to Romanian, but broad layers of the population – especially in Chisinau – speak Russian. The territory currently known as the Republic of Moldova was under Russian and Soviet rule for the lion part of the last two centuries, and in Soviet time, russians were encouraged to relocate to Moldova. The country also has a significant Ukrainian minority as well as Roma and a number of smaller nationalities. Up until the Holocaust, it was also home to a large Jewish population, most of which was murdered by Romanian and German fascists.
After independence following the demise of the Soviet Union in 1991, Moldova has encountered a dramatic decline in living standards, resulting in migration to both Western Europe and Russia. Combined with a drastic decline in nativity, Moldova is, after 30 years of independence, a country that, to some estimates, has lost half its population while the remaining half is considerably older, compared to 1991. In other words, the present-day Moldovan state struggles with finding a way to support its increasingly larger old-age-population, with less working people around to contribute. The situation is challenging. As if this was not enough, a significant part of the contry’s territory is a de-facto independant state over which the central gouvernment exercises no control – Transnistria. It is a frozen conflict, where the Transnistrian leadership in its capital Tiraspol enjoys Russian support, meaning that Moldova is unable to win a military show-off. Lacking control over parts of its territory effectively blocks Moldova from entering the EU. In 2020/21 the Moldovan electorate, however, vote for a pro-EU, liberal leadership, throwing out the former communist gouvernment.

Since Moldova has primarily been ruled by pro-communists since 1991, it has defied the introduction of neo-liberal mechanisms that characterizes most Western states. At the same time, funding of welfare services is painfully insufficient. It therefore offers an interesting research environment for studies in social work, and the logic along which welfare services are provided – which brings us to the present moment, where this research is about to begin.

I’m looking forward to sharing findings along the way. I also welcome feedback and questions.

Glenn Möllergren, master student of social work at MaU