Israeli Adults’ Non-take-up of Social Benefits: A Study Using the Socio-ecological Model

Abstract

Even though welfare states aim to address citizens’ social care needs, disparities in benefit distribution persist, leading to “non-take-up.” Non-take-up is the phenomenon in which people who may be eligible for a benefit fail to apply for it or forgo it after applying. Based on a qualitative approach, this study explores reasons for the non-take-up of social-security benefits and services in a convenience sample of 34 Israeli adults. The findings show that the reasons for non-take-up of social benefits and services may be divided into several interrelated levels. Four of the levels identified were identical to those suggested by the socio-ecological model: intrapersonal, interpersonal, organizational, and cultural, with multiple subthemes included in most of them. The policy level, which is integral to the theoretical model, does not emerge in this study. Theoretically, the findings show that the economic “rational trade-off model” does not suffice to explain the non-take-up phenomenon. Future research should expand the study of non-take-up of social benefits and services to potential, rather than actual, claimants of particular benefits or services.

Keywords:

• Social care
• social needs
• social security
• welfare services
• welfare rights

Introduction

Providing assistance in Activities of Daily Living such as feeding, washing, dressing, and mobility, and in maintaining independence, social interaction, and protection for members of vulnerable groups, is core functions of welfare states. States attain these functions by providing equal access to personal care and assistance to people who are disabled or ill as well as social benefits and welfare services to those in need of them (Morlino & Raniolo, 2017). For various reasons, some benefits or services do not reach some people who need them. This phenomenon, termed “non-take-up,” reflects the extent to which people in need, who may be eligible for a benefit if they meet all the requirements, do not apply for the benefit or forgo it after applying (Goedemé & Janssens, 2020). The qualitative study that follows combines a phenomenological design with a thematic analysis to explore people’s reasons for non-take-up.

Literature Review

Non-Take-up of Social Benefits and Welfare Services: Definition and Types

Non-take-up occurs when people who may be eligible for a benefit do not apply for it or forgo it after applying (Nelson & Nieuwenhuis, 2019). Although the terms “non-take-up,” “non-receipt,” and “non-provision” are sometimes used interchangeably, the first-mentioned is the most common in the literature (Janssens & van Mechelen, 2022). Three types of non-take-up have been identified: (a) primary, in which people qualify for a benefit but intentionally or unintentionally do not claim it; (b) secondary, in which people claim (or start to claim) a benefit but do not receive it; and (c) tertiary, in which claimants are not eligible for the benefits (Van Mechelen & Janssens, 2017).

Regardless of the type, non-take-up is a phenomenon of considerable scope and consequences (Ko & Moffitt, 2023). Using survey data from EU countries, Lucas et al. (2021) report that the ratio of those who qualify for a benefit or a service and do not take it up, to the total number of people who qualify for the benefit or service in question, ranges from 20% to 80% depending on the benefit and the country. Linking survey data with administrative records in Germany, Brookmeyer et al. found a non-take up rate of 37%. Finally, based on administrative records from the Italian welfare system, Boscolo and Gallo (2023) showed that the number of people potentially eligible for a social benefit exceeds the number of those who take the benefit by over a million. Despite this high prevalence, the effects of and reasons for non-take-up have been insufficiently studied and discussed.

Non-take-up of Social Benefits and Welfare Services: Consequences and Reasons

Although some scholars and decision-makers discuss the benefits of non-take-up, mainly due to its association with short-term saving on budget expenses, the majority debate only the negative short- and long-term consequences of the phenomenon (Janssens et al., 2021). At the societal level, some of the most common detrimental effects of non-take-up of benefits include increased rates of poverty and inequality. At the individual level, non-take-up is associated with increased feelings of helplessness and depression as well as higher levels of economic hardship and lack of trust in the welfare system (de Schutter, 2022).

Given these negative effects, researchers and policymakers have sought to understand the determinants or reasons for non-take-up. Following van Oorschot (1991) early work, various investigators (Daigneault & Macé, 2020; Janssens & van Mechelen, 2022; Lucas et al., 2021) suggest the need for a multiple-level framework to understand the reasons for non-take-up. This framework, they say, should include a macro level (social norms, policy, and legal system), a meso level (organizational and administrative level), and a micro level (client level and street-level bureaucrats, i.e. frontline staff or employees who interact directly with the public and serve as the connection between government policy-makers and citizens).

Despite the importance of this body of knowledge, the study of non-take-up of social benefits and welfare services is still described as a “developing research agenda” (Lucas et al., 2021, p. 162). Accordingly, the aim of the present study is to expand knowledge of the topic by exploring the reasons for non-take-up of social-security benefits and welfare services in Israel.

The Israeli Setting

Israel is a natural setting for exploring the topic of this study for several reasons. First, its welfare and social-security policies have switched from social-democratic to neoliberal in recent decades. Over the years, government spending as a percent of GDP has decreased, as has the rate of universal allowances that are not contingent on an income test. In recent years, the ability of the welfare state in Israel to deal with main challenges of social security and welfare has been limited. This is manifested in stability in the rate of spending on welfare as a percentage of GDP—close to 10%—and little change in levels of poverty and economic inequality. The prevalence of poverty and inequality remains high: In 2021, 21% of the population was below the poverty line and the Gini index of net income inequality stood at 0.3750. The few positive changes that have occurred probably trace to a combination of an increase in the labor-force participation of different population groups (albeit at low wage levels) and changes in social-security programs that target particular populations, through which the ratio of those living below the poverty line may easily be raised to above this line. (The elderly living in poverty are a case in point.) These changes, however, have not affected the neediest population in Israel, families living in poverty; their proportion and their level of inequality remain among the highest in the OECD (Gal & Madhela, 2018).

Second, Israel is a multicultural society comprised of a Jewish majority and a minority that is mostly Arab. The Jewish majority is not monolithic and varies in religiosity, culture, language, and socioeconomic status. Most Jewish citizens are traditional or secular (JNO); a minority is ultra-Orthodox (JO). The ultra-Orthodox group constitutes 12% of the total population and is the most religious sector in Israeli society. Members of this group exhibit very high fertility rates, a younger-than-average age composition relative to the general population, and low socioeconomic status. They also have a sense of community, extending mutual help through charities and other organizations or by individuals in their social environment (Klonover et al., 2023). The Jewish group also includes various immigrant groups, with those from the former Soviet Union (FSU) being the largest. Most of these immigrants came to Israel in the early 1990s and had a high level of education, small households, and a strong tendency to preserve the language and cultural norms of their country of origin (Kushnirovich, 2018). Finally, Israeli Arabs (AR) constitute about a fifth of the population. They are mostly Muslim (75%); the rest are Christian and Druze. They differ from the Jewish majority in language and ethno-cultural values as well as in health indicators (Baron-Epel et al., 2022). In terms of socioeconomic status, JO and AR constitute 54% of poor households countrywide (Bleikh, 2018) and may be defined as the group most vulnerable to non-take-up of social benefits and welfare services.

Although several studies conducted in Israel sought to understand the non-take-up problem, they were restricted to claimants or beneficiaries of a given means-tested benefit or service, such as disability benefits (Holler, 2020; Tarshish, 2023) and homelessness services (Szeintuch, 2022), or focused on professionals and street-level bureaucrats (Holler & Benish, 2022; Weiss-Gal & Gal, 2009). Furthermore, these studies were not guided by a theoretical model, as is the current study.

The Socio-ecological Model

To better understand the complexity of the non-take-up phenomenon, this study used the socio-ecological model as its theoretical framework. Developed by Bronfenbrenner (1989) and extensively invoked to explain factors and barriers associated with health behavior, this multifaceted model identifies five interacting levels of influence on behavior. The first level—the individual one—stands at the core of the model and includes personal knowledge, beliefs, and attitudes. The second level—interpersonal—comprises formal and informal social networks, including social support. The third level—organizational—aggregates organizational systems, their characteristics, norms, and rules. The fourth level—socio-cultural—integrates social and cultural norms. The fifth and final level—that of policy—adds legislation and policies.

The Current Study

Pursuant to the literature described above, this study uses the socio-ecological approach to explore the perceived reasons for non-take-up of social-security benefits and welfare services. Its overarching research question is: What are the reasons for the non-take-up of social-security benefits and welfare services among a heterogeneous sample of Israeli adults?

Methods

Study Design

A qualitative design based on semi-structured in-depth interviews was used. Qualitative methods are well suited for gaining a deep and thorough understanding of complex and sensitive phenomena such as non-take-up of benefits and services. Moreover, by permitting participants to express their perceptions and experiences in their own voices, qualitative methods enable researchers to grasp a broad variety of themes without being tainted by methodological biases such as social desirability.

Sample

A purposive sample of 34 Israeli adults was used. Potential participants were recruited through the researchers’ professional and personal connections. Inclusion criteria were age 20 years or above; being cognitively intact and able to understand the questions (as assessed by the interviewers), and affiliation with one of the following: the majority group in Israel (non-ultra-Orthodox Jews), the Jewish ultra-Orthodox group, or one of the largest cultural minority groups (Jews from the FSU and Arabs).

Instrument

The interviews were based on an interview guide (Appendix 1) developed on the basis of an analysis of the literature, as described above. The interview guide covered the following areas: experiences of consuming welfare services in the last year, the need to forgo welfare services or allowances, reasons for forgoing welfare services, consequences of forgoing needed welfare services, and identification of factors responsible for preventing the waiver of welfare services. Participants were asked to relate to their experience of claiming social-security benefits or welfare services and to the experiences of others in their social environment. The interviews lasted 45 min on average and were audio-recorded and transcribed verbatim (or translated into Hebrew if needed).

Procedure and Data Collection

Semi-structured in-depth interviews were conducted between November 2021 and December 2021. During this period, Israel was in the midst of its fourth wave of Covid-19, therefore, the interviews were conducted by telephone. Potential participants were contacted by interviewers who were fluent in Hebrew, Arabic, or Russian, as the case may be, and trained in qualitative research methods. They explained the aims of the study, obtained oral consent to participate, and arranged a convenient time for the telephone interview to take place. Participants were recruited and data were collected until data saturation was achieved, that is, until no new information was gained and the comments repeated themselves.

Data Analysis

Thematic analysis was used. As suggested by Braun and Clarke (2016), the investigators first familiarized themselves with the transcribed data and then used manual inductive coding to generate meaningful units, identify categories and codes, define and name main themes, and write the manuscript. Coding sheets (compiled in table form) were used to organize participants’ remarks by themes, categories, and codes. Detailed coding guidelines were developed and discussed by the research group until a consensus was reached. Trustworthiness was attained by including pseudonymized quotes and meeting regularly to discuss the interpretability of the results. In sum, data collection and data analysis were guided by a reflexive approach.

Rigor of the Study

To secure the study’s rigor, Lincoln et al. (1985) criteria were addressed during the qualitative process. To achieve credibility, the investigators had the required knowledge and research skills, as well as a prolonged engagement and familiarity with the different groups examined. To ensure dependability, this study aimed to verify that the findings are consistent with the raw data collected. Moreover, the study’s purpose, methods, and data collection procedures were clearly defined and documented. Dependability was reached by closely following data analysis procedures to obtain in-depth descriptions and transcription of participants’ experiences. Confirmability was achieved by making sure that no biases are introduced by the research team. The investigator in charge of data collection had a Ph.D. in sociology and no previous experience with the topic under investigation. The other members of the research team had academic backgrounds in gerontology and public health but no involvement in the topic; thus, they may be considered as having neutral expectations.

Ethical Considerations

Ethical approval for the study protocol was obtained from the University of Haifa Ethics Committee (Ref. Nr 410/21). Before being interviewed, all participants signed an informed consent form explaining the aim of the study, their right to refuse or discontinue participation, and the confidentiality of the data.

Findings

Participant Characteristics

Thirty-four Israeli adults were included in the study: 12 Jewish non-ultra-Orthodox (mean age 49.0, 58.3% female), seven ultra-Orthodox Jews (mean age 38.1, 57.1% female), seven Jewish immigrants from the FSU (mean age 54.7, 71.4% female), and eight Arabs (mean age 37.1, 62.5% female). Fourteen participants had personal experience claiming or receiving social benefits or services. The sample characteristics are presented in Table 1.

Table 1. Sample characteristics (N = 34).

		All (N = 34)	Female (N = 21, 61.8%)	Male (N = 13, 38.2%)
Age (mean, S.D.)		45.1 (11.6)	44.5 (10.8)	46.2 (13.1)
Marital status (percent)	Single	8.8	4.8	15.4
	Married	61.8	57.1	69.2
	Divorced	29.4	38.1	15.4
Number of children (mean, S.D.)		2.3 (1.7)	2.0 (1.6)	2.8 (1.9)
Years of education (mean, S.D.)		15.1 (2.6)	15.4 (2.5)	14.7 (2.7)
Nationality (percent)	Jewish	76.5	76.2	76.9
	Arab	23.5	23.8	23.1
Religiosity (percent)	Secular	52.9	57.1	46.1
	Traditional	20.6	14.3	30.8
	Religious	5.9	9.5	0
	Ultra-Orthodox	20.6	19.1	23.1
Self-rated health (percent)	Very Poor	2.9	4.7	0
	Poor	2.9	0	7.7
	Fair	17.7	14.3	23.1
	Good	44.1	38.1	53.8
	Very good	32.4	42.9	15.4
Economic situation assessment (mean, S.D.)	Very Poor	0	0	0
	Poor	2.9	4.8	0
	Fair	26.5	23.8	30.8
	Good	52.9	52.4	53.8
	Very good	17.7	19.0	15.4
Having personal experience claiming or receiving welfare benefits or services (percent)		41.1	42.9	38.5

Reasons for Deciding to Take up Welfare Rights

Although all participants had witnessed situations in which social-care needs were not met, only a few cases were based on the participants’ personal needs: two in the JNO group, two in the JO group, and two in the AR group. The main reason for not forgoing social benefits or services was the feeling of deservingness, as expressed by one of the participants:

When do you need [help from the welfare or social security system]? Usually when you are in distress—like after a serious accident or serious illness, God forbid. Or when you are reaching old age. And if you’re someone who has contributed to your country and has paid your taxes properly all your life, then why not [receive help from the system]? It’s something you deserve… to grow old with dignity or to live with dignity, and if that’s what the state should give you, let it give you. (Sh, male, 53 years old, JNO)

Reasons for Non-take-up of Welfare Rights

All participants provided ample details of the reasons leading to their own or others’ decision to not exercise their entitlement to welfare services or benefits. Following the socio-ecological model, these reasons were grouped into four themes that reflected the most common levels of the model: (1) individual reasons, (2) street-level bureaucrats’ reasons, (3) organizational reasons, and (4) ethno-cultural reasons. Figure 1 illustrates the themes and subthemes that emerged from the interviews. A list of these themes together with sample excerpts from the interviews, followed by a unique identifier indicating the participant’s number, gender, age, and group membership, is shown below.

Figure 1. Thematic map of forgoing of social care.

Theme 1—Individual, Intrapersonal-Level Reasons

Three reasons for forgoing [rights]: despair of the bureaucracy, lack of knowledge, and shame.

Despite socio-demographic differences, participants consistently reported individual-level reasons for their decisions to forgo social benefits or services. The main personal barriers mentioned were lack of knowledge and feelings of shame and humiliation in the face of welfare stigma.

Subtheme 1.1—Lack of Knowledge and Awareness

Some people are not aware of the services they are entitled to.

Lack of knowledge and low awareness of the services and benefits provided by the National Insurance Institute (NII) or the Ministry of Welfare were key reasons for non-take-up. Most participants attributed individuals’ limited knowledge to the complexities of navigating and understanding the organizational process and its rules and regulations.

No, to get something from the National Insurance you have to know the laws and know what to get and where to get it.… That’s right. If they owe you something, they won’t approach you and give it to you; you have to work your head off for it. (Y, 60 years old, male, JNO)

Some participants believed that lack of knowledge of what they had coming to them was harmful, especially in times of crisis and emergency such as during the Covid-19 pandemic, when many people needed help from the welfare system to survive and did not know how or to whom to turn to receive what they needed.

In addition, during the coronavirus time, they gave out food cards. People didn’t know how to get this card, so they turned to the welfare bureau to find out. Also, there are people who didn’t know how to file for unemployment with the National Insurance; they also turned to the welfare bureau to help them do it. (M, 31 years old, female, AR)

Participants suggested two ways to prevent the unnecessary and detrimental consequences of non-take-up caused by lack of knowledge and awareness. The first was for the welfare bureaucracies to provide more knowledge about available services and benefits to citizens, especially to vulnerable populations, on an ongoing basis. One of the participants even recommended establishing a special department within the NII that would provide knowledge and information.

National Insurance has to appoint someone who’ll be in charge of this thing, population groups that are more problematic in that sense. To give them information and to understand where the problem is. Where it comes from and how to solve it. Don’t leave it pending. There really has to be someone responsible for it at National Insurance [this was stated generally and hypothetically; the interviewee was in no need of services and had not forgone any herself]. (E, 41 years old, female, JNO)

The second suggestion voiced by some of the participants was to improve collaboration and interaction between the different entities that provide social care in Israel.

So that they’ll know their rights and the benefits they’re entitled to and the money they’re entitled to and the allowances they’re entitled to, everything that’s being decided about them, National Insurance together with the social aid and welfare agencies, together with neighborhood activists, to get to such a situation that in the end everyone will know exactly what they’re entitled to and based on what criteria, clear and unequivocal criteria, so you shouldn’t have to pull all kinds of strings and get lawyers and spend money to get what you’re entitled to. (Sh, 35 years old, male, JNO)

Subtheme 1.2—Stigma and Associated Negative Emotions

I’d rather give up [the benefits] than be stigmatized by others.

The stigma associated with receiving social benefits or services, otherwise known as welfare stigma, has been conceptualized as the set of negative stereotypes and emotional reactions that are associated with seeking help from welfare organizations (Strier & Werner, 2016). Participants described mainly negative emotions as a central reason for renouncing or delaying seeking help from welfare institutions.

I know there are lots of families that are financially bad off … unable to raise their children. But they didn’t turn to the welfare bureau for help, and it’s because of the stigma. (N, 32, male, JO)

Welfare stigma was especially strong in the Arab sector, to the point that some participants reported knowing people who refused to even enter the building or contact welfare institutions by telephone.

I personally know lots of people who should receive welfare services like financial aid because of their economic situation. But they’re totally unwilling to do it.… That’s our society—Arab society, I mean—when they ask for assistance or help from the welfare services it shows that the family is poor and needs help.… People are ashamed to say that they’ve got a record with the welfare services. People are even ashamed to be physically present in the building where they provide welfare services. Sometimes they’re also ashamed to call the welfare services on the phone. (R, 33 years old, female, AR)

Many participants expressed concern about being humiliated or undervalued if they seek social benefits. This emotion was voiced especially with regard to the NII medical committees’ eligibility assessment process. Appearing before the committees that make decisions based on the applicant’s ability to perform Activities of Daily Living and Instrumental Activities of Daily Living was described as a demeaning situation, in which claimants felt that they were perceived as dishonest or malingerers for claiming their rights.

I also had to get a disability allowance. I broke my leg, I had a difficult operation on my leg.… I put in a claim for a disability allowance.… They summoned me to the committee… In the committee, they treated me badly… with disrespect.… I walked out in the middle of the [meeting] and didn’t go back anymore… I don’t want anything from them…. (Mu, 60, male, AR)

Feelings of humiliation were based not only on personal experience. Even participants who had not been personally involved in the process of claiming social benefits reported hearing “through the grapevine” about extremely negative experiences with the NII medical committees.

Yes … you can hear a lot [about the medical committees] on Facebook; many people write posts about it. I don’t know who appoints these doctors [on the medical committee] but they’re not doctors. They mistreat sick people and send them away for ten checkups each time.… They [the claimants] are subjected to humiliation to get anything. (Y, 52, female, FSU)

Shame was another negative emotion reported frequently by participants who experienced feelings of embarrassment and of doing something immoral or improper when claiming their rights for social benefits.

I know about families in distress who don’t admit publicly that they are in distress, they’re miserable, and it’s unpleasant that they need this; for them it’s shame. (Shl, 53, male, JNO)

Other things that cause people to forgo welfare services are shame, unwillingness to share personal matters with others, and concern about confidentiality. And the most important thing where public mental-health services are concerned: we’re afraid that it’ll be documented. I know a psychologist who works in this field.… Once he told me that when people approach him… the first question they ask is whether it’s going to be documented in their medical file! (F, 36 years old, female, AR)

Theme 2—Interpersonal, Street-Level Bureaucrats Level Reasons

Welfare employees don’t know anything and sometimes don’t want to hear anything.

The second reason for forgoing social care services and benefits is related to interaction with the welfare organizations’ street-level bureaucrats. Participants perceived these public employees, who work directly with claimants (Trappenburg et al., 2020), as treating claimants with insensitivity, apathy, and objectification. These characteristics, which, according to the participants, elicited negative and painful experiences, were associated with street-level bureaucrats’ need to work “by the book” and their inability to show flexibility, understanding, or consideration for the individual claimant.

I get a disability benefit from the NII. A few months ago, I appealed because they gave me only 65% disability…. At the NII, they treat people with disabilities like items on a list of cars. But to buy a car of this or that model year, you don’t take into account only its price, you also check its quality.… You also check its condition.… National Insurance doesn’t do this.… They go only by the book.… What I’m trying to say is that National Insurance works on the basis of some guidebook; they stick to it so closely that they don’t take people’s other personal characteristics into account. (F, male, 35, AR)

Sometimes [claimants] don’t know how to express themselves and in my opinion there are also times when the officials aren’t really willing to listen, to be there for the person, there’s a feeling that they come to work but aren’t really coming to work. (O, 40, female, JO)

A few participants expressed some understanding or acceptance of the behavior of those handling their claims. They explained that street-level bureaucrats’ lack of patience and empathy trace to their working conditions—especially the limited resources available to them, the limited discretion they have, and to the need to “stick to the book.”

Some of the responsibility for people doing without medical or welfare services belongs to the employees within the system itself. I think there are people who are working in the wrong places.… These workers are burned out all the time.… Therefore, at work they give the minimum they can get away with, or less, so when people turn to them, they don’t explain to them the rights and services they’re entitled to. Therefore, people don’t know a thing about the services. The institutions also don’t support the workers; for example, they don’t send them away for training … don’t give them promotions, and so on.… The whole thing makes them even more burned out.… It affects the worker’s mental state … and makes him give less than the minimum that he can give. So I think one of the solutions to the problem is that the system should support its workers.… It would improve their service to the public. (R, 33 years old, female, AR)

Theme 3—Organization-Level Reasons

I think something about the system isn’t okay…

This theme concerns participants’ perceptions of the characteristics of the agencies providing social care that hinder or prevent citizens from receiving the services and benefits they are entitled to. Two subthemes pertaining to organizational reasons emerged in the data analysis: the welfare system as a complex bureaucratic and untrustworthy system.

Subtheme 3.1—Welfare Bureaucracy

It’s a crazy bureaucracy, an indifferent and impenetrable system.

All participants, in all groups, described the NII and the Ministry of Welfare as bureaucracies characterized by administrative complexities and cumbersome processes. Participants reported difficulties in navigating the system, particularly in complying with the burdensome paperwork they were required to submit.

Sometimes I feel that the bureaucracy is not easy. Because once someone comes to welfare to receive a particular service, there are a lot of forms he has to submit and fill out … and again people are having a hard time with this whole thing. (R, female, 33 years old, AR)

The process was perceived as convoluted, obstructive, indifferent to individuals’ needs, and requiring extensive knowledge of rules and regulations. Participants complained about the need to prepare and submit numerous forms, sometimes repeatedly, in order to receive the benefits they deserve. These difficulties resulted in decisions to forgo their rights.

Man … they [social welfare entities] tell you to sit down and get this and that, in the end you have to bring forms from here and bring forms from there and take care of forms from here and go for it. To get something from the NII you need to know the rules and know what to get and where to get it…. If you’re entitled to something, they won’t come to you and give it to you, you’ll have to figure it out alone. (Y, male, 60 years old, JNO)

Participants described not only the difficulties of the process but also its length as a reason for giving up much-needed social benefits. This happened mostly because when the approval for the benefit finally arrived, the person was no longer eligible for it due to death or change of status.

Grandma was totally dependent on others to live her life. [We] contacted the NII for help. When the benefit was approved, it was too late. The answer came after she died (YN, 43 years old, JNO)

[There were] delays in my father’s pension, and there were delays in all sorts of one-time payments that are owed to pensioners and survivors of the Holocaust or something like that, and there are always delays. It takes a month, two months, half a year, a year, and pure and simple, that’s how it is. (E, 56, female, FSU)

Although the main outcomes of the excessive bureaucracy were anxiety and resentment, for some participants it had serious consequences for their economic situation and quality of life.

I had to give up a huge amount of money. I got divorced in a private rabbinical court that isn’t recognized by the state. And there was a really serious delay in the court’s giving its approval. For this reason, they [the NII] held up the income support that I was entitled to. I was literally down to my last slice of bread, very, very badly off. (T, 35, female, JO)

Subtheme 3.2—An Untrustworthy System

I don’t trust [the welfare bureaucracies] to care about the citizens.

Almost all participants expressed lack of trust and confidence that welfare entities would provide them with the benefits they need and are entitled to. Some expressed the feeling that applying for benefits or services from the NII or the Ministry of Welfare was “a lost game” or “a waste of time” to begin with and therefore preferred to relinquish their rights rather than deal with the administrative burden of claiming their benefits.

Ask for something from the welfare system? Absolutely not. I’m telling you, absolutely not. This is a really troubled system, I don’t know, I’ve never seen anything that they really did for the community. (O, 40 years old, female, JO)

Theme 4—Ethno-Cultural Reasons

There are two reasons [for forgoing social care]: the first is bureaucracy, the second—language and culture.

This theme reflects the ethno-cultural aspects behind the participants’ reasons for forgoing their right to social care. These factors reflect how cultural or religious beliefs influence people’s motivations and behavior. In the current study, these factors were primarily evident in relation to minority groups—the Arab, the Jewish ultra-Orthodox, and the FSU. Two main subthemes emerged: beliefs and attitudes toward technological digitization and being characterized as a culture of honor, adhering to the value.

Subtheme 4.1—Language Barriers

Language is a barrier; it makes the difficulties worse.

For participants who belonged to the Arab and FSU groups, language barriers exacerbated the burden of the bureaucratic process. Poor proficiency in Hebrew made the process tedious and irritating, prompting people to forgo their rights just to avoid the psychological costs associated with it.

There’s the language thing, too. Most of the forms are in Hebrew and they’re too long. People find them hard to fill out. It makes things very difficult. The bureaucratic process is really tiresome. These institutions and centers should have a volunteer to help people fill out the forms and present claims. (R, 33 years old, female, AR)

Participants reported that language difficulties had negative effects not only on the claimant but also on others in their social network who had to help them complete the forms.

There are people who don’t know how to read and write Hebrew.… Sometimes they can’t read Arabic, either.… The moment they apply to the NII, they have to fill out forms.… But they can’t fill out the forms on their own.… And then they start to chase after [street-level bureaucrats] to help them do it.… That makes things much harder for these people. (F, 35 years old, male, AR)

Participants also voiced concerns about street-level bureaucrats’ insensitivity and impatience in dealing with claimants’ language problems.

I said I’m her sister-in-law; she’s here next to me and she can’t speak. Get a Russian speaker and she’ll gladly talk. There’s none. There’s none after 1:30. I waited on hold for them to answer me. There’s no service by telephone; everything is by computer in Hebrew. People just give up. (B, 46 years old, female, FSU)

Subtheme 4.2—Digital Barriers

For some people, working online is the end of the world.

The digitalization of welfare institutions has caused participants from minority groups to forgo social benefits. Following the COVID-19 crisis, Israeli welfare entities have been relying increasingly on digital technology and making almost exclusive use of online methods of communication in applying for benefits, contacting street-level bureaucrats, completing paperwork, and more. These changes require some level of computer literacy and have detrimental effects on vulnerable groups that enjoy less access to online services and technology in general, including the ultra-Orthodox, Arab, and FSU groups.

The reasons offered by participants for the digital divide varied by minority group. For those in the ultra-Orthodox group, aversion to technological devices was a part of their belief system; their problems arose as a consequence of not having access to computers.

In social services, too, lots of things have switched to media, gone virtual.… I have friends who sometimes say: I don’t have the strength now.… Where will I get a computer … internet, I won’t apply for this service, and that’s that. (N, 32 years old, male, JO)

For those in the FSU group, digitalization problems were associated with language difficulties.

If I work with the computer today and I can’t figure it out, I say forget it, I don’t want it. To send something by mail, there’s no such thing. Everything has to be done online, so no. Someone who’s seventy, eight-five, what computer? There’s no such thing.… Everything’s on the computer. I said, okay, thank you. That’s that, we just gave up. (B, 46 years old, female, FSU)

Subtheme 4.3—Honor Culture

His name and his honor don’t allow him to ask for help.

This subtheme was voiced frequently by participants from the Arab sector. In the honor-oriented culture of this minority, especially its Muslim members, maintaining reputation and social image is of paramount importance (Shuraydi, 2020). Concerns about losing individual and family standing and integrity were among the main reasons mentioned by participants in the Arab group for forgoing social care.

In other words, people think a person who asks welfare institutions for help is poor.… They think that he has no relatives or friends who can help him. (M, 31 years old, female, AR)

One participant suggested that to help people in the Arab sector overcome the honor barrier, welfare institutions should play a more proactive role by contacting families in need of help and making more information and knowledge available in Arabic.

I know people who really need help … but don’t ask for it because of their honor … because if they ask for help, especially economic help, it’ll damage their honor. Therefore, the welfare [system] ought to establish a relationship with these families, explain things to them … and help them. (N, 39 years old, female, AR)

Arab participants reported concealing their need for help from the welfare system as a way of retaining their self-esteem and their family reputation. The fear of disclosing their need was based on the conviction that seeking help from welfare entities may result in a breach of confidentiality. They feared that receiving or claiming social benefits would become evident immediately to those socially close to them, who would perceive them as unable to meet the expectations and norms of the culture of honor.

I’ve never asked the welfare [system] for help and I never will because I think nothing is secret in the welfare [system]…. If I receive help of any kind, the whole village will know about it the next day. There’s no secrecy at all, especially when the welfare workers come from the same village…. For example, I know exactly who in our village received help from the welfare [system]; I even know how many bags of rice they got! (M, 31, female, AR)

Subtheme 4.4—Distrust in the Fairness of the System

They know to take your money but they don’t like to pay.

Some participants, especially those belonging to the Arab and FSU minorities, perceived the welfare system as unfair and unjust.

There’s an unfair distribution of services. Like food cards. I know lots of people who are rich and receive food cards … and I know other people who really need those cards but haven’t received them.… And no one even got in touch with them to tell them they’re entitled to such a thing.… (N, 39, female, AR)

Subtheme 4.5—Sense of Community

I believe we have a sense of responsibility toward the community.

Participants in the ultra-Orthodox group described unique characteristics of their community, such as closeness among members and the characteristic concept of mutual help, allowing them to forgo the help provided by formal bodies while still meeting their needs.

It’s just that there are lots of charitable organizations, lots of people, really good people. People can afford to do without [entitlements] because the community gives support. Someone who doesn’t live in a community-like place would have to go straight to the authorities. Here maybe you can approach the neighborhood rabbi or someone like that, a synagogue treasurer or someone like that, and they can really help you. You can ask for economic aid, you can turn to people who will arrange a loan for you, and even more.… (Y, 35 years old, male, JO)

These participants stated that when faced with the need for social care, they knew that they could always get help from charity organizations and members of their social network.

First of all, the ultra-Orthodox public gets assistance from the state in all sorts of ways. Generally, too, if we’re talking about the ultra-Orthodox public internally, there’s this matter of free-loan funds, mutual aid, charity, it’s a really big thing. Not to speak of organizations like United Hatzalah and Yedidim and Yad Sarah, and the like. And when you give birth you know you’ll be getting help from other women. They help, they do the cooking, they even take care of the children. In our population, there’s mutual aid in all respects. (N, 32 years old, male, JO).

In the subsequesnt sections we provide an in-depth discussion of the findings and their implications.

Discussion

This qualitative study explored the non-take-up of social benefits and services in a convenience sample of 34 Israeli adults using the socio-ecological model as its framework. Although all the participants heard about non-take-up cases, only seven (26%) reported being personally affected. This percentage is at the lower end of the range (20%–80%) reported in studies conducted in OECD countries (Lucas et al., 2021), and in a recent study conducted in Israel (50%—Gottlieb, 2021). This difference may originate in inconsistencies in the conceptualization of non-take-up. For example, whereas other studies examined non-take-up in relation to a particular benefit or service such as disability benefits, in this study no specific benefit, service, or means-tested program was mentioned (Daigneault & Macé, 2020).

The findings show that the reasons for the non-take-up of social benefits and services may be divided into several interrelated levels as conceptualized by the socio-ecological model. Four of the five levels of this model were identified in the data: intrapersonal, interpersonal, organizational, and ethno-cultural, with multiple subthemes included in most of them. The policy level, which is integral to the theoretical model, did not emerge in the interviews, most likely because not only is the non-take-up phenomenon understudied (Goedemé & Janssens, 2020) but also because participants had scant knowledge of matters of policy.

The Individual/Intrapersonal Level

Two subthemes emerged at this level: low awareness or knowledge of available social benefits and services, and welfare stigma. These reasons were also identified as significant in a survey assessing the motives of people eligible for social benefits but not receiving them in 16 European Union countries (Eurofound, 2015). Awareness of the availability of social benefits and some extent of knowledge about their objectives, eligibility criteria, and rules are essential for putting in a claim (Daigneault & Macé, 2020). For some individuals, however—especially those belonging to vulnerable groups or having cultural barriers—acquiring this information may be so costly that they relinquish their claims. Poor awareness and misinformation, referred to as “learning costs” by Moynihan et al. (2015), have been recognized as among the main reasons for non-take-up.

Participants in the present study attributed the individual-level difficulties to organizational complexities and lack of coordination among social-care systems. They suggested increasing and simplifying the information provided and improving communication and interaction among different social institutions as a strategy for increasing awareness and knowledge, thereby mitigating the incidence and consequences of non-take-up.

Welfare stigma was the second subtheme identified at the individual level. Although lack of awareness or knowledge are the prime causes of non-take-up, usually dissuading individuals from trying to start the claiming process even if they make no deliberate decision to this effect, welfare stigma is also associated with people’s decisions not to claim benefits of which they are aware (De Angelis & van Wolleghem, 2023) in order to avoid the psychological costs associated with stigma (Moynihan et al., 2015; Kühner & Chou, 2023). Previous research in Israel reported welfare stigma as a common phenomenon among claimants and beneficiaries of long-term care (Strier & Werner, 2016) and disability benefits (Holler, 2019; Tarshish & Holler, 2021). Negative stigmatic feelings were manifested especially among those who appeared before the National Insurance medical committees (Gilad & Assouline, 2022). These findings show that feelings of shame and humiliation not only reflect the self-stigma experienced by claimants or beneficiaries of social benefits and services but also mirror the vicarious stigma felt by people who have no personal experience with the process but have heard or read about others’ involvement with welfare institutions.

The Interpersonal Level

The quality of interaction with street-level bureaucrats is crucial for the experience of people in need of social benefits and services. Street-level bureaucrats are the first whom the claimant encounters and they greatly influence eligibility decisions and policy implementation (Lavee et al., 2018; Nielsen et al., 2021). Perceptions of these employees as insensitive, unresponsive, and inflexible were reported as one of the main reasons for relinquishing welfare claims. Viewing welfare bureaucrats as indifferent and lacking empathy toward the needs of those seeking help elicited resentment, frustration, and anger. Although research on the emotional or affective aspects of encounters with street-level bureaucrats is limited, it is clear that such encounters take a high emotional toll on claimants (Hattke et al., 2020).

As in other qualitative studies (Barnes & Henly, 2018; Holler & Tarshish, 2022), not all participants blamed the employees for these negative interactions. A few attributed the behavior of street-level bureaucrats to their disadvantageous and stressful working conditions, which they defined as the organizational characteristics of the system in general, and to scarce financial and human resources.

The Organizational Level

Organizational-level factors were the most prominent reason mentioned for the non-take-up of social benefits. The bureaucratic structure of the processes used to determine eligibility and claim benefits in welfare institutions in general (Simanainen, 2021) and in the Israeli welfare system in particular (Tarshish & Holler, 2021) have been widely discussed in the literature. Similarly, the participants perceived welfare institutions in general and the National Insurance Institute in particular as red-tape bureaucracies (Hattke et al., 2020) characterized by rigid and complex procedures leading to unnecessary and detrimentally delayed decisions and feelings of frustration and anger.

In response to these complaints, Israeli welfare institutions have introduced changes to reduce bureaucratization—for example, digitalizating the claiming process (Tarshish & Holler, 2021). For some of the most vulnerable groups, however, these changes have amplified rather than mitigated the difficulties, reinforcing willingness to discontinue the application process.

The Ethno-Cultural Level

Consistent with the socio-ecological model, participants in this study not only reported individual, interpersonal, and organizational reasons for forgoing social benefits but also recognized the importance of ethno-culturally embedded norms, beliefs, and practices in making decisions about relinquishing them. The first subthemes at this level reflected the difficulties some of the participants experienced when claiming welfare services and benefits owing to language and digitalization limitations. These problems, conceptualized by Hernanz et al. (2004) as information costs, were reported as being especially challenging to vulnerable groups (Janssens & van Mechelen, 2022). Language barriers were of particular concern among participants in the Arab and FSU groups, who reported problems in understanding and completing the multiple forms required and communicating with street-level bureaucrats.

Although the adoption of digital technology by welfare institutions worldwide and in Israel is aimed at improving service quality (Hansen et al., 2018), the results showed that some participants found it immensely challenging. Digital literacy is particularly low in the FSU and ultra-Orthodox groups because of problems of access. For ultra-Orthodox Jews, the limitations are exacerbated by an ideology that opposes the use of digital technology (David & Baden, 2020). These problems created a digital divide between these groups and the majority group. Similarly, a recent quantitative survey of a representative sample of Israeli people aged 60 and above showed a statistically significant difference between minority and majority groups in e-government use (Rosenberg, 2022). It is also found that the use of digital technology for obtaining government services may be difficult for younger people as well, possibly leading to a decision to forgo the quest for help in the future.

The last two subthemes that were identified at the ethno-cultural level also reflect core values and beliefs among the Arab and ultra-Orthodox groups. As members of an honor culture, participants in the Arab group expressed reluctance to seek help from welfare sources due to concerns about losing their reputation and good name. Belonging to such a culture has been associated with interpersonal violence, as in the case of honor killings (Ne’eman-Haviv, 2021) and also, recently, with unwillingness to seek help from mental-health services (Foster et al., 2021). The results of this study show that this unwillingness recurs in relation to welfare services.

Finally, the highly developed sense of community that characterizes members of the ultra-Orthodox group is a core value that affects their decisions on whether or not to seek social benefits or services despite the costs associated with the process. Participants in this minority group explained that if they are in need, they can always obtain a response from other members of the community or from any of the numerous NGOs and voluntary bodies that support members of their group without necessarily having to apply to the welfare system for it. Indeed, a 2013 survey of the Israeli population aged 20 and above showed that 21% of the ultra-Orthodox Jewish population received help from a variety of voluntary sources as against 4% of the Jewish non-ultra-Orthodox population (CBS, 2015).

When talking about a sense of community that allows them to forgo their welfare rights, participants referred mainly to the group level, at which ultra-Orthodox society is characterized by cohesion, mutual support, and solidarity (Stewart & Townley, 2020). However, they also expressed a sense of community at the individual level, that is, a psychological sense of community defined as the individual feeling that members of their community will help meet one another’s needs (Stewart & Townley, 2020). Consistent with the socio-ecological model, the two levels were intertwined, especially when stigmatic beliefs limited the sense of belonging and willingness to turn to family members for help.

In sum, the ethno-cultural reasons for non-take-up are complex and seem to be endemic to all three minority groups. To overcome them, measures to provide needed services and benefits appropriately should be taken at the organizational level.

Limitations

Several limitations of the study should be noted. First, the generalizability of the findings may be limited by the small and non-representative sample. Second, the sample did not include people over retirement age, limiting the possibility of applying the conclusions to potential applicants for the long-term-care allowance, a very important component of caregiving systems in many countries (Pennerstorfer & Österle, 2023). Thus, future studies should replicate the present study with a sample including participants over ages 62 for women and 67 for men. Third, the study was conducted during the Covid pandemic. Recently, non-take-up has been conceptualized as affected by the time dimension (Lucas et al., 2021); therefore, participants’ responses may reflect the unique characteristics of the period. Future research should replicate the study during another period of time. Third, although recent works stress the importance of placing the (potential) individual claimant or beneficiary at the center of the analysis (Warin & Lucas, 2020), the current study would have benefited from including street-level bureaucrats and decision makers as well. Finally, the interviews were conducted by phone, limiting the possibility of establishing rapport with participants and interpreting their non-verbal language. Despite these limitations, the findings of this qualitative study expand knowledge in this evolving area (Bennett, 2024) and have important theoretical and policy implications.

Theoretical Implications

This study adds important theoretical insights. First, it demonstrates that the traditional economic “rational trade-off model” does not suffice to explain non-take-up of social benefits and services (Janssens & van Mechelen, 2022). A comprehensive multilevel model such as the socio-ecological framework used here helps to yield a better understanding of the phenomenon and the intricate relationships among its different levels. Second, similar to the conceptualization of help-seeking (Saint Arnault, 2018), the results of this study highlight the importance of ethno-cultural determinants of non-take-up of social benefits and services. Finally, it is found that the study of non-take-up of social benefits and services should not be limited to the examination of claimants and beneficiaries of particular benefits or services. Potential claimants may provide important information about the motivations guiding decisions about take-up.

Policy Implications

From a practical or policy point of view, the findings of this qualitative study have important implications at different levels of analysis. At the individual level, in order to lower non-take-up rates, information about available social-security and welfare programs, eligibility requirements, and the claiming process should be distributed proactively and routinely. This may be attained via various means of communication adapted to groups from different cultures, levels of education and literacy, language proficiency, and more. Some of these measures may include simple steps such as translating application forms into different languages or taking on additional multilingual staff members. Moreover, education and intervention programs aimed at reducing stigmatic beliefs and negative emotions associated with receiving social benefits and services should be provided to the general public and to vulnerable groups in particular.

At the interpersonal level, street-level bureaucrats should receive training in methods of communication, especially with culturally-sensitive groups. Efforts should be made to improve their working conditions, including budgetary and human resources. At the organizational level, recent works suggest that a more pro-active approach toward reducing non-take-up of social benefits should be taken, including contacting and providing information to potential claimants (Elek-Ben & Rafaeli, 2023; Pennerstorfer & Österle, 2023; Van Gestel et al., 2023).

At the community level, community leaders should be contacted and asked to approach members of groups at risk of non-take-up in order to explain the importance of applying for needed social services and benefits.

Ethics Approval

This article does not contain any studies with human participants performed by any of the authors. Ethical approval was granted by the University of Haifa, Israel (reference number 410/21).

Acknowledgments

The authors thank Miriam Greenstein, Hanan AboJabel, and Natalie Ulitsa for their support in conducting the in-depth interviews.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Data Availability Statement

The data that support the findings of this study are available from the corresponding author per reasonable request.

Additional information

Funding

This work was supported by the research foundation of the Israel National Insurance Institute (Grant No. 18328).

Appendix 1.

Interview guide

Facilitation Questions for Interviews on Forgoing Services

1. Getting acquainted: In the first stage, the interviewer shall introduce him/herself and present the goals of the study. The study concerns the characteristics of the consumption of healthcare services by older adults. It is conducted by by Prof. Perla Werner (University of Haifa) and Prof. Aviad Tur-Sinai (Max Stern Yezreel Valley College) and is funded by the research foundation of the National Insurance Institute.

2. The interviewer shall address the ethical issues that the study raises: nothing said in the interview will be associated with the interviewee’s name; only the main insights that emerge from the interviews will be disclosed. If the interviewee feels uncomfortable in the course of the interview, he or she is asked to inform the interviewer about the fact.

3. There is no requirement of answering specific questions and there is no single correct answer to the questions and issues that will be discussed in the interview.

4. The interviewer shall explain to the interviewee that the discussion is being recorded for transcription purposes.

5. At the beginning of the interview, the interviewer shall ask the interviewee to introduce him/herself (name, marital status, age, and place of residence).

Questions for discussion:

First, Let’s Talk about the Consumption of Social Services. The Services Include National Insurance Allowances, Assistance from the Welfare System, etc

1. Now I would like to ask you to share your experiences in consuming social services in the past year. How frequently have you met with someone from the welfare services or visited a welfare bureau/the National Insurance Institute? Why? Has there been a difference of some kind in these patterns relative to previous periods? In the frequency of consuming the services? In their quality? In the way you received the service (a welfare bureau, by telephone/virtually, in some other way)?

2. Have you ever had (or do you know anyone who has had) to forgo a social service (National Insurance allowances, assistance from the welfare system) at least once? Did this happen during the pandemic? What service was it?

3. If the interviewee answered that he or she did not have to forgo social services (allowances/assistance from the welfare system): You said that you have not had to forgo social services (National Insurance allowances/assistance from the welfare system) to date. In your opinion, could you find yourself in a situation that would induce you to forgo a certain social service? Why would this be? What service do you think it would be?

4. In your opinion, is it worth telling others when you are about to forgo a social service that is needed? To whom? Why?

5. What, in your opinion, are the main reasons for forgoing social services?

6. In your opinion, are there personal factors that prevent one from receiving a service in a timely manner? What are they? How can they be addressed?

7. In your opinion, are there factors associated with the service provider that prevent one from receiving a service in a timely manner? What are they? How can they be addressed?

8. In your opinion, are there factors associated with the social-service system that prevent one from receiving service in a timely manner? What are they? How can they be addressed?

9. Which social services are you willing to forgo if necessary? Which services are you unwilling to forgo under any circumstances?

10. What, in your opinion, are the implications of forgoing a social service that is needed?

11. Who, in your opinion, is responsible for ensuring that people do not forgo the social services that they need? Is there anything you would like to add?

Thank you for your cooperation!