“You Think We are in the Stone Age, but We Have Already Made Progress—Where are You?”: A Qualitative Study of Ultra-orthodox Women’s Telemedicine Service Usage in Israel

The implementation of video consultations instead of in-clinic consultations in routine primary care settings has demonstrated substantial benefits: increased accessibility, improved chronic disease management and clinical outcomes, decreased hospitalizations and emergency visits, increased satisfaction with provided services, improved patient waiting times, and reduced costs (Bashshur et al., 2016; Calvo et al., 2014; Chintala, 2023; Izquierdo et al., 2015; Mozes et al., 2022; Reed et al., 2023; Schuttner et al., 2019; Schweiberger et al., 2024; Temesgen et al., 2022; Vosburg & Robinson, 2022). Furthermore, there is an emerging understanding of how different telemedicine modalities can address healthcare disparities among racial and ethnic minority populations, thereby reducing inequities and providing greater access to healthcare (Gibbons & Casale, 2020; Paige et al., 2022; Qureshi et al., 2020; Roghani & Panahi, 2021).

Within Israel’s healthcare system, telemedicine has become increasingly integrated into routine care delivery. Primary care telemedicine is implemented in a hybrid model, combining traditional face-to-face visits with video consultations and other modalities such as store-and-forward correspondence with physicians (Haimi et al., 2020; Hasson et al., 2021; Mozes et al., 2022, 2023; Pilosof et al., 2021). This model of care is delivered by all four Israeli Health Maintenance Organizations and Family Health Centers in communities and is offered at no additional cost to patients. Implementation data indicate successful adoption among the general population, with usage patterns varying across different demographic groups. Current studies indicate that telemedicine adoption in Israel has been particularly strong in urban areas and among younger, technologically proficient populations. However, certain communities, including ethnic and religious minorities, exhibit different patterns of uptake and utilization, highlighting the need for targeted approaches to ensure equitable access to these services.

While the Israeli Ultra-Orthodox community, which comprises 13.6% of the population in Israel (Malach, 2023), could potentially benefit from telemedicine services in general and video consultations in particular, their current usage remains negligible. This disparity stems from different patterns in technology and smart phones usage among the Ultra-Orthodox population compared to general population. While the use of telemedicine in the general population was impacted by the growing usage of smart mobile devices and raised significantly (Israel Internet Association, 2020; Mozes et al., 2022), in the Ultra-Orthodox population has historically prohibited cellular phone use, due to a general suspicion toward technology that characterizes orthodox religious groups (Blondheim & Katz, 2016; Campbell, 2007) and rabbinic prohibition.

The Ultra-Orthodox or Haredi Jews in Israel constitute a minority group in society that adheres strictly to Halacha rules (Friedman, 1993) and comprises approximately 1,280,000 people. Since the 1950s, this community has perceived itself as a minority at risk of cultural dissolution through assimilation into mainstream Israeli society. Consequently, they have developed various boundary-maintenance mechanisms, including restrictions on technology use, which they perceived as a potential threat to cultural autonomy and religious continuity (Stadler, 2009). Halacha instructions govern most aspects of private and public life for Ultra-Orthodox families, significantly influencing technology usage and health consumption habits. With the proliferation of smartphones, Ultra-Orthodox leaders have intensified efforts to protect the community from what they perceive as threats to the spiritual integrity of community members (Campbell, 2010; Cohen, 2011; Rosenberg & Blondheim, 2021). In response to the infiltration of open internet and smartphones into Ultra-Orthodox society, a group of rabbis, representing several Ultra-Orthodox sub-communities, developed regulatory mechanism to monitor cellular phones use through the Rabbinical Affairs Committee of Communication, an association established in 2005 (Wikipedia, n.d.). This committee prohibited smartphone use and approved only “kosher” phones that lack Internet connectivity. Specifically, a kosher cell phone excludes features commonly found in smartphones such as internet access, web-based applications, camera, radio, music, games, and text messaging capabilities via applications like WhatsApp (Rosenberg & Blondheim, 2021; Rosenberg & Rashi, 2015) [See Fig. 1].

Initially, this ban proved successful, and most devices in Ultra-Orthodox society were either kosher or filtered for content. During this period, as telemedicine programs began emerging in the Israeli public health system, the Ultra-Orthodox community remained unable to access these services due to their use of kosher phones and limited use of internet-enabled computers relative to the general population. However, as stated in the Talmudic law, “Decrees should not be passed if the majority of the people cannot comply with it” (Talmud Bavli Avodah Zara, folio 36a), Ultra-Orthodox people began seeking solutions to reconcile rabbinic prohibitions regarding smartphone use with the demands of everyday life, as smartphones, internet, and computers had become basic platforms for communication and information. Additionally, recent years have seen significantly increased participation of Ultra-Orthodox individuals in the labor market and higher education enrollment (Malach & Cahaner, 2023), while the internet and smartphones have demonstrated value in a wide range of daily applications (Rosenberg & Blondheim, 2021).

In recent years, the Rabbinic Committee has approved a modified “kosher smartphone” with content filtering capabilities. This smartphone bears a symbol indicating kosher supervision [See Fig. 2], enabling not only voice communication but also access to camera and limited apps such as GPS, calendar, email, and filtered internet access specifically for work-related needs. This development facilitates a balance between religious observance and modern technological requirements.

Currently, more than 68% of the Ultra-Orthodox population has access to the internet through workplace connections, home networks, and paid internet shops and stations (Malach & Cahaner, 2023). However, smartphone use largely remains unspoken and undisclosed publicly, so there is a lack of formal published statistics regarding smartphone adoption in the Ultra-Orthodox population. Available published data suggest that approximately half of the Ultra-Orthodox public possesses a cell phone (Rosenberg & Blondheim, 2021; Shahar et al., 2023). Despite these technological adaptations, video consultations remain underused, and research examining telemedicine adoption in Ultra-Orthodox society is lacking.

Ultra-Orthodox women typically lead busy lives, balancing multiple roles and responsibilities within their families and communities. They commonly marry young and have large families, with an average of 6.6 children per woman (El-Or, 1994; Malach & Cahaner, 2023). These women serve as primary caregivers, managing child-rearing, household duties, and often providing financial support for their families, while their husbands engage in religious studies. This demanding lifestyle creates challenges in accessing health care (Edelstein, 2020; Gershuni et al., 2023) and telemedicine services could particularly benefit these women by providing convenient, time-efficient access to primary healthcare from their homes, enabling video consultation with healthcare providers without the need for traveling or arranging childcare.

While this study focuses on Ultra-Orthodox women in Israel, its implications extend far beyond this specific population. The experiences of Ultra-Orthodox women in accessing video-consultations services offer valuable insights into the needs of other culturally distinct populations worldwide, including religious communities with strict technological guidelines and immigrant communities navigating unfamiliar healthcare systems.

The primary aim of this study is to explore Ultra-Orthodox women’s attitudes and behaviors regarding video-consultation usage in primary care settings, specifically their interactions with family physicians, pediatricians, and nurses in Family Health Stations. Given the global emphasis on telemedicine research in primary care, particularly regarding issues of ethnicity and religion (Gibbons & Casale, 2020; Paige et al., 2022; Qureshi et al., 2020), this study addresses three key research questions. First, how do Ultra-Orthodox women perceive and interact with video-consultation services, particularly considering their traditional limitations on technology use? Second, what cultural, religious, and practical factors facilitate their use of these services? Third, how do communal norms and rabbinic guidance shape their attitudes toward telemedicine, and what implications does this have for service adoption?

Through these investigations, we aim to identify strategies that enhance video-consultations accessibility while respecting religious and cultural values, potentially informing healthcare delivery for both Ultra-Orthodox communities and other cultural minority groups globally.

This exploratory study employed an qualitative research design, following current qualitative-methods studies guidelines (Creswell & Poth, 2016) for designing, conducting, and analyzing the data were followed in the study. The study employs a Heideggerian interpretative phenomenological approach (Heidegger, 1962; Lopez & Willis, 2004), chosen for three key considerations. First, it enables understanding of shared attitudes and experiences of a phenomenon among groups of individuals, which is particularly relevant for studying video consultations use in cultural contexts. Second, following Heidegger’s concept of “being-in-the-world” (Dasein), this approach acknowledges that Ultra-Orthodox women’s experiences are inherently shaped by their religious beliefs and community norms. Third, this framework facilitates the development of culturally sensitive practices and policies based on participants’ lived experiences (Creswell & Poth, 2016; Van Manen, 2003). Creswell’s methodological approach was applied within this philosophical framework to systematically analyze and interpret the data. The study received approval from the Institutional Ethics Committee of the University of Haifa. All participants signed the consent form.

Our study population consisted of twenty-two Ultra-Orthodox women with children under 18 years old who had visited their family physician or pediatrician or Family Health Station nurses at least once during the previous year. A purposive snowball non-probabilistic sampling approach was chosen (Creswell & Poth, 2016). Women participating in the study represented diverse Ultra-Orthodox sects, including Lithuanian, Hassidic, and Sephardic groups; various living areas (periphery and center, Ultra-Orthodox and mixed cities); different geographical communities (Jerusalem, Bnei Brak, Zfat, and regions in South and North Israel); and included women who had participated in the tshuva movement (Sharabi, 2015), having transitioned from secular life to religious observance. Data saturation was reached after interviewing 19 participants, as no new themes or significant insights emerged in subsequent interviews. Three additional interviews were conducted to ensure complete saturation across different Ultra-Orthodox subgroups, resulting in our final sample size of 22 participants. This sample size aligns with recommended ranges for phenomenological studies (Guest et al., 2006) and proved sufficient to capture the diversity of experiences within the Ultra-Orthodox community.

A multidisciplinary team developed the interview guides, comprising a pediatrician, a nurse, two social and behavioral science researchers, and a female Ultra-Orthodox research assistant. The guides were designed to facilitate investigation of attitudes toward video consultations while addressing various aspects of technology and telemedicine usage. Question sampling is presented in Table 1 with full interview guides available in supplementary materials. The first five interviews were transcribed and analyzed to confirm that the protocol was capturing usable data. Additionally, the interview guides explored several topics beyond the scope of this article, mapping attributes and levels of Ultra-Orthodox women’s video-consultation preferences for incorporation into a future Discrete Choice Experiment quantitative study.

Conducting research within the Ultra-Orthodox community presents unique challenges (Rier et al., 2008), particularly when investigating smartphone ownership and usage, which remains forbidden in some communities and is strictly regulated by rabbinic and societal norms. Consequently, we implemented special methodological considerations: the questionnaire employed formal language, avoiding slang or expressions considered immodest, and an Ultra-Orthodox female research assistant conducted the interviews. The study adhered to guidelines for sensitive topic research (Silverio et al., 2022) including appropriate places for sensitive data collection, indirect questions (Qu & Dumay, 2011), personal diary maintenance and research assistant attending supervision meetings.

The research team employed Creswell phenomenological analysis method (Creswell & Poth, 2016), which represents a simplified version of the Steviek-Colaizzi-Keen method (Moustakas, 1994). In alignment with our Heideggerian phenomenological framework, the analysis sought to understand both individual experiences and their broader cultural-religious context. The analytical process proceeded in several stages. First, researchers engaged in reflective discussions regarding their personal attitudes toward Ultra-Orthodox women’s use of telemedicine. This step aimed to set aside the researchers’ preconceptions, ensuring results emerged directly from participants’ responses. Subsequently, researchers independently conducted initial readings of interview transcripts. During the second reading, they performed horizontalization of the data, identifying significant nonrepetitive, non-overlapping statements regarding Ultra-Orthodox women’s perceptions of video consultations.

Significant statements were grouped into larger “meaning units”—themes, accompanied by textual descriptions and supporting quotations. Following independent analysis, researchers convened to compare and discuss their findings ultimately reaching consensus on themes and their textual descriptions. Structural description for each theme was added to enrich the “essence” (El-Or, 1994) of telemedicine experience, encompassing how they used, which types of telemedicine service they accessed, and the context in which video consultations might be utilized.