Introduction

With rapid economic development and social progress, people's living standards have gradually improved, and the incidence of subhealth or diseases such as over-nutrition in the diet structure, "three highs", sleep problems, and gastrointestinal digestion has increased significantly, and people are paying more and more attention to health issues. In addition, the outbreak of the coronavirus pandemic has further increased residents' concern for health, and also greatly increased the nation's concern for medical protection and commercial health insurance.

In addition, the epidemiological pattern has completed the transformation from infectious diseases to chronic non-communicable diseases due to the changes in residents' economic income, dietary habits, and lifestyles brought about by economic development and social progress. And chronic disease, as a lifelong condition, has become the most significant disease burden worldwide. At present, a considerable number of chronic diseases are caused by environmental problems. Existing studies have shown that air pollution can affect an individual’s sleep and induce chronic respiratory diseases such as bronchitis and asthma (Guan et al. 2016; Heyes and Zhu 2019; Zhang et al. 2022). In addition, some scholars have also found that sewage discharge or water pollution will increase the incidence of digestive tract diseases (Wang and Nie 2016). Air and water pollution impose substantial health costs on exposed populations (Williams 2019). People will be willing to invest in their own health in order to avoid the additional costs associated with poor environmental quality (An and Heshmati 2019). Insurance is a way to mitigate the health burden caused by pollution (Chen and Chen 2020). Therefore, residents will be willing to purchase commercial health insurance to avoid health costs in advance.

However, although China's medical security system is constantly improving, social medical insurance still suffers from problems such as low standards, difficult balance of payments, limited coverage, and limited risk protection, and can only provide basic medical security for residents (Dong 2009). Commercial health insurance, a supplement to social medical insurance in China, can effectively compensate for the insufficiency of social medical insurance and reduce the economic pressure on residents in terms of high medical costs. Therefore, along with the increase of residents' health protection needs, business health insurance has shown a high growth trend in recent years, and the scale of the industry has been expanding. To solve the contradiction between the growing health security needs of residents and the imperfect medical security system, China's State Council has successively issued the "Several Opinions on Accelerating the Development of Commercial Health Insurance" and the "Notice on Printing and Distributing the '14th Five-Year' National Medical Security Plan" and other relevant policies to encourage the development of commercial health insurance and support the connection between insurance institutions and basic medical insurance (Choi et al. 2018). As a pilot demonstration area for China's social and economic development, the Yangtze River Delta is also at the forefront of commercial health insurance development. Many cities in this area have introduced customized commercial medical insurance programs.

Therefore, in the context of the increased pressure on the social health insurance system, to further implement the national medical insurance reform policy and promote the high-quality development of commercial health insurance, it is necessary to clarify the factors affecting residents' intention to purchase commercial health insurance and those mechanisms which influence them.

Literature review

As an important part of the multi-level medical security system, how to effectively promote the demand for commercial health insurance has become a top priority. Residents' purchasing decisions for commercial health insurance are affected by their purchasing intention and purchasing ability. Given a certain level of purchasing power, increasing residents' intention to purchase commercial health insurance becomes the primary task.

Existing research has conducted a rich discussion on consumer purchase intention. In terms of theoretical models, the SOR (Stimulus–Organism–Response) and TRA (Theory of Reasoned Action) models are widely used in consumer behavior research in medical care, health, clothing, environmental protection, and other fields to explain the consumer's intention to buy the product (Hu et al. 2016; Moon et al. 2017; Paul et al. 2016; Prakash and Pathak 2017; Sohaib and Kang 2015). The strong predictive ability of SOR and TRA models on consumer behavioral inclinations has been well verified. In terms of influencing factors of purchase intention, some studies have found that cognition, emotional attitude, subjective norm, group identity, perceived behavior control, and corporate social responsibility word of mouth will significantly influence purchase intention (Bantie et al. 2020; Prakash and Pathak 2017). Using the TRA model, (Prakash and Pathak 2017) found that personal norms, attitudes, environmental concerns, and willingness to pay significantly affect consumers' intention to buy environmentally friendly packaging. With regard to cognition, it has been argued in the literature that marketing communication strategies, mass media information, reference group influence, and social interaction will all significantly affect cognition (Kai et al. 2021). With regard to attitudes, some scholars have found that trust, online video advertising, the influence of reference groups, brand concept, the interaction between social crowding and advertising orientation, Internet word-of-mouth, situational influences, firms' ethical and unethical actionscorporate social responsibility, and service climate significantly impact consumers' attitudes towards products (Dietz et al. 2004; Ferrell et al. 2018; Folkes and Kamins 1999; Foxall and Yani-de-Soriano 2005).

Residents’ purchase of commercial health insurance is a type of consumer purchasing decision, and there is an influence mechanism similar to that for general purchase behavior. Many studies have explored the influencing factors of commercial health insurance demand (Atinga et al. 2015; Mamun et al. 2021; Abdel Fattah et al. 2021). The existing literature mainly focuses on three aspects: demographic characteristics, and subjective and objective influencing factors. In the study of demographic characteristics, some scholars believe that age, gender, marital status, family size, family income, and education level will significantly affect the demand for commercial health insurance (Denise et al. 2008; Fang et al. 2008; Giesbert et al. 2011; Hopkins and Kidd 1996). In the study of subjective influencing factors, some scholars have concluded that clan mutual assistance, risk preference, risk cognition, risk perception, cognitive ability, peer effects, and extended family network effect (Han and Tan 2021; Jaspersen et al. 2022; Kai et al. 2021) will affect residents' commercial health insurance demand. In the study of objective influencing factors, some scholars have concluded that air pollution, income and wealth, preferential tax policies, population aging and residents' health status, and population mobility will significantly affect the demand for commercial health insurance (Pinilla and López-Valcárcel 2020; Wang et al. 2021a; Zhao 2020).

People have unilaterally pursued rapid economic development ,and environmental problems have become increasingly prominent in recent years. To avoid the health risks caused by environmental pollution, the demand for medical insurance has increased, and scholars have begun to pay attention to the relationship between environmental pollution and health insurance. Some studies have concluded that environmental factors are commonly identified to positively affect residents' intention to purchase health insurance (Mistry and Vyas 2021; Wang et al. 2021b). In terms of macro data, (Wu et al. 2019) proved that air pollution could directly or indirectly promote the consumption of commercial health insurance by affecting residents' risk perception by constructing a spatial Durbin model and generalized moment estimation. Chen and Chen 2021 used data from the China Health and Nutrition Survey to investigate the causal effects of air pollution on health spending and identified a non-linear relationship between them. Liu and Ao 2021 adopted daily air-pollution data and insurance claim records, and pointed out that the cost of controlling air-pollutant emissions could be offset by curtailing health care expenditure. An and Heshmati 2019 used the costs paid by NHI (National Health Insurance) policyholders for specific diseases to define healthcare expenditure, and found that air pollutants (NO2, O3, PM10) can positively affect healthcare expenditures. Zhao 2020 indicated that there was heterogeneity in the effects of air pollution on home insurance purchases, with health insurance being sensitive to air pollution levels. Chang et al. 2018 also confirm that daily air-pollution levels have a significant impact on the decision to purchase health insurance. In terms of micro data, Chen and Chen 2021 found that worsening air pollution increases the demand for career health insurance, with chronic illness and depression as two pathways. A study by Liu 2020 found that the shock of air- and water-pollution information had a significant positive driving effect on the consumption of residential commercial health insurance. **a et al. 2022 explored the relationship between PM2.5 concentrations and medical expenditures using individual insurance data from Bei**g. Cui et al. 2016 and Wu 2018 indicated that air pollution problems can damage the health status of residents, who choose to diversify their risk by purchasing commercial health insurance. It was also found that the air-pollution index was positively correlated with the sales of commercial health insurance (Chang et al. 2018).

To sum up, the existing literature has carried out rich research and discussion on commercial health insurance from different perspectives, providing strong theoretical and methodological support for this research. However, the existing literature on commercial health insurance mostly stays at the macro data level, and the relationship between environmental pollution perception and commercial health insurance purchase intention is seldom studied at the individual level. The main innovations of this paper are as follows:

  1. (1)

    This study constructs the theoretical framework of the research based on the SOR and TRA models and uses the structural equation model to test the influence mechanism of different factors on residents' commercial health insurance purchase intention.

  2. (2)

    Based on theoretical cognition and practice experience, this study innovatively introduces two factors, water pollution perception and air pollution perception, as moderator variables to examine the moderating effect of environmental pollution perception.

  3. (3)

    Different from the existing literature that uses demographic variables as independent variables, this study innovatively designs a multigroup SEM analysis framework based on demographic variables to examine the moderating effects of demographic variables.

Theoretical analysis and research hypothesis

Theoretical analysis

The SOR model was proposed by Mehrabian and Russel in 1974 based on stimulus–response theory. The model comprises stimulus variables, one or more groups of mediator variables, and response variables, and the relationship between stimulus and response is expressed through mediator variables.

The TRA model was proposed by Fishbein and Ajzen in 1975. The model has four dimensions: individual attitudes, subjective norms, behavioral intentions, and behaviors. It believes that intentions cause behaviors, and intentions are, in turn, determined by the individual's attitude and subjective norm.

In psychology, motivation is a state of mind reflected in a person before they adopt a particular behavior. Motivation is an information processing system that allows organisms to reduce uncertainty (Anselme 2010). Motivation is about why people think, feel, and act the way they do under a given scenario (Dweck 2017). This suggests that motivation can be foregrounded as a person's cognition or attitude towards something. Moreover, people develop an attitude towards something because they are stimulated by something outside. In the SOR model, the variable of motivation is not refined, and the TRA model believes that behavioral intentions depend on attitudes and subjective norms. So this study attempts to combine the TRA and SOR models by integrating the attitudes and things learned from the TRA model into motivation variables in the SOR. This combination can make the transmission between variables in the model more logical and improve the model's explanatory power.

Research hypothesis

Based on the above discussion, in terms of variable selection, this study chose advertising marketing and family and friend behavior for the stimulus dimension, attitude and cognition for the organism dimension, and purchase intention for the response dimension. Furthermore, this study introduces two moderating variables, water- and air-pollution perception, to explore the influence mechanism of residents' commercial health insurance purchase intention. The research framework is shown in Fig. 1.

Fig. 1
figure 1

Research framework

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Advertising marketing refers to the various publicity actions that insurance companies carry out to promote commercial health insurance. Insurance companies can use various marketing methods to establish a positive image of commercial health insurance in resident's minds so that residents have positive attitudes about commercial health insurance. Based on this, a hypothesis is proposed:

  • H1: Advertising marketing positively affects residents' attitudes towards commercial health insurance.

Behavior of friends and family refers to commercial health insurance behaviors of those closer to the resident. Residents tend to reflect and modify their behaviors with regard to the value judgments and behavioral standards about commercial health insurance of other members in their group. Based on this, a hypothesis is proposed:

  • H2: The behavior of relatives and friends positively affects residents' attitudes towards commercial health insurance.

Cognition is the subject's knowing, learning, and understanding of related things, and residents' value cognition of commercial health insurance helps to form the correct purchasing attitude towards commercial health insurance. Based on this, a hypothesis is proposed:

  • H3: Residents' cognition of commercial health insurance positively affects their attitudes.

Through advertising marketing, insurance companies can raise residents' cognition of commercial health insurance's definition, types, roles, and claims. Based on this, a hypothesis is proposed:

  • H4: Advertising marketing positively affects residents' cognition of commercial health insurance.

Resident's cognition of commercial health insurance will be affected by relatives and friends. The more relatives and friends know about commercial health insurance and the more friendly they are towards it, the more likely residents are to gain more knowledge about it through word-of-mouth communication. Based on this, a hypothesis is proposed:

  • H5: The behavior of relatives and friends positively affects residents' cognition of commercial health insurance.

The more positive a resident's attitude towards commercial health insurance is, the more likely they are to make a decision to purchase commercial health insurance. Based on this, a hypothesis is proposed:

  • H6: Residents' attitude towards commercial health insurance positively impacts purchase intention.

The more comprehensive a resident's cognition of commercial health insurance is, the more likely they are to decide to purchase commercial health insurance. Based on this, a hypothesis is proposed:

  • H7: Residents' cognition of commercial health insurance positively affects purchase intention.

The positive relationship between attitude and purchase intention is strengthened when residents perceive higher water- and air-pollution levels, because higher environmental pollution perception can boost the transformation of attitudes into intentions by considering health risks. Based on this, two hypotheses are proposed:

  • H8: Water-pollution perception positively modulates attitudes—the action path of purchase intention.

  • H9: Air-pollution perception positively modulates attitudes—the action path of purchase intention.

The positive relationship between cognition and purchase intention is strengthened when residents perceive higher water- and air-pollution levels, because higher environmental pollution perception can make residents worry about their health and seek workarounds through their existing cognition on policies. Based on this, two hypotheses are proposed:

  • H10: Water-pollution perception positively moderates the path from cognition to purchase intention.

  • H11: Air-pollution perception positively moderates the path from cognition to purchase intention.

Study design

Questionnaire design

Except for the first part of the demographic variables, the rest of the measurement items are all measured on a 7-point Likert scale, with "1" indicating strongly disagree and "7" strongly agree. The demographic variables include gender, residence, etc. The remaining variables are divided into seven dimensions according to the constructed research framework — water-pollution perception, air-pollution perception, advertising marketing, behavior of relatives and friends, cognition, attitude and purchase intention — totaling 39 scale items. The main measurement contents corresponding to each dimension are shown in Table 1.

Table 1 Scale design
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Data collection and sample characterization

This study conducted an online questionnaire survey through buying services from Wenjuan (http://www.wenjuan.com), a leading online research service provider. This survey uses a stratified sampling method, stratified sequentially according to the province and city where the survey unit is located, followed by sample size allocation in proportion to the number of current resident population. The survey respondents are permanent residents from four provinces of Jiangsu, Zhejiang, Shanghai, and Anhui in the Yangtze River Delta. The period for this survey was from January to March 2022. A total of 3342 questionnaires were returned, of which 2952 were valid questionnaires, an effective recovery rate of 88.33%.

In the sample, the proportion of men and women is 40.62% and 59.38% respectively. Residents aged 20–39 are the main ones, accounting for 78.69%. In the distribution of jobs, the general staff account for a large proportion, reaching 32.96%, followed by university students, reaching 19.07%, and enterprise managers accounting for 15.41%. Residents with a bachelor degree and college degree are the majority, accounting for 79%. In terms of residence distribution, urban residents account for 81.84% and rural residents account for 18.16%.

Empirical analysis

SPSS21.0 and AMOS22.0 were used to analyze the survey data. Firstly, the reliability and validity of the questionnaire were tested by reliability analysis and factor analysis. Secondly, the correlation analysis of variables and hierarchical regression was built to analyze the mechanism among advertising marketing, behavior of friends and relatives, cognition, attitude, and purchase intention. Finally, the moderating effect of air-pollution perception and water-pollution perception on the path from cognition to purchase intention, attitude to purchase intention was tested.

Reliability and validity test

Before constructing the SEM, the quality of the questionnaire was checked. First, Harman's single factor test was used to examine the common method bias. The total variance explained by the first factor was 45.619%, which was below 50%, proving that this study had no serious common method bias problem. The Cronbach's alpha coefficients of the questionnaire and each dimension were 0.968, 0.958, 0.961, 0.860, 0.894, 0.937, 0.928 and 0.915, all higher than 0.8, indicating that the questionnaire has strong internal consistency. The KMO (Kaiser–Meyer–Olkin) value was 0.981, which was greater than 0.6, indicating that the questionnaire is suitable for exploratory factor analysis. And the total variance explained by the four factors with eigenvalues greater than 1 extracted using principal component analysis was 72.423%, which was greater than 50%, indicating that the existing structure of the questionnaire can explain the research content well.

Then, the confirmatory factor analysis was conducted with the help of AMOS. When the confirmatory factor analysis was carried out using the initial measurement model, all the other measurement paths were significant except for the path “cognition to purchase intention”. Moreover, the standardized load coefficient values of all measurement paths are above 0.6, the SMC (squared multiple correlation) is above 0.3, the AVE (average variance extracted) is above 0.5, and the CR (construct reliability) value reaches above 0.7, revealing that our model has high reliability and convergent validity. All the above analyses indicated that the questionnaire has good reliability and scientific validity, and that the data obtained can be used for statistical analysis. The results are shown in Table 2.

Table 2 Reliability and validity of the scale
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Goodness of fit

After passing the reliability and validity test, validation factor analysis was performed using Amos 22.0, and the results are shown in Table 3. The seven-factor model had the best data fit among all models, indicating that the discriminant validity of air-pollution perception, water-pollution perception, advertising and marketing, family and friend behavior, perception, attitude, and purchase intention was high. Notably, the CMIN/DF value of the model is greater than 5. To exclude the influence of the sample size, 1447 samples from the total 2953 samples were randomly selected for cross validity test (He et al. 2017; Lin et al. 2022; Nan and Wang 2022), and the results showed that CMIN/DF value dropped to 4.117, within the acceptable range. Moreover, other test indicators were consistent with the full sample's test results, showing that the model was robust. Some literature also pointed out that when the sample size is too large, it is not appropriate to use the chi-square value as the test index of the model fit, and the RMSEA index, which is less affected by the sample size, can be used. In this study, RMSEA is 0.044, which is in line with the acceptable range. Overall, the model fit results with the full sample are good (see Table 3), and further analysis can be implemented.

Table 3 Goodness of fit
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Descriptive statistical analysis

Before hypothesis testing, descriptive statistics were conducted for each variable, and the results are shown in Table 4, which provide preliminary support for the hypothesis.

Table 4 Descriptive statistics and correlations (N = 2952)
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Hypothesis analysis

Main effect test

This study constructed several cross-level models and used SPSS 21.0 software for analysis. The results of analysis are shown in Table 5. We can draw the following conclusions:

  1. (1)

    In the influence path of purchase intention, both attitude and cognition are significant. It can be seen that improving residents' cognition and guiding their attitudes are of great significance to improving their intention to purchase commercial health insurance.

  2. (2)

    In the influence path of cognition, both advertising marketing and behavior of relatives and friends show a significant impact. Therefore, the promotion and publicity carried out by insurance companies in various media will help improve residents' cognition with regard to commercial health insurance. At the same time, related supportive behaviors of surrounding relatives and friends on commercial health insurance promote residents' cognition.

  3. (3)

    In the influence path of attitude, advertising marketing, behavior of relatives and friends, and cognition all show significant influence. It is evident that advertising marketing and behaviors of relatives and friends can directly change the attitude of residents, and can also indirectly increase residents' acceptance and recognition of commercial health insurance by improving cognition.

Table 5 Path analysis results
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Therefore, hypotheses H1, H2, H3, H4, H5, H6, and H7 are all verified.

Multigroup analysis

To test whether there is a moderating effect of demographic variables in the model, AMOS was adopted to conduct a multigroup analysis of gender and residence. The results are shown in Table 6. We can draw the following conclusions:

  1. (1)

    Gender significantly moderates the influence path of residents' intention to purchase commercial health insurance. The effect of the behavior of family and friends on women's perceptions was more significant than that for men. Men performed better than women in terms of the behavior of family and friends influencing attitudes. In terms of advertising marketing influencing attitudes, males and females showed opposite effects. In the male group, the relationship between advertising marketing and attitudes showed a negative influence, while the female group showed a positive promotion.

  2. (2)

    Residence location also plays a significant moderating role in residents' intention to purchase commercial health insurance. For rural residents, the positive influence of advertising and marketing on their perceptions and the positive influence of family and friends' behavior on their attitudes are more significant than those of urban residents; and in the path of perceptions influencing attitudes, there is a more significant promotion effect on urban residents than on rural residents.

Table 6 Multigroup analysis results
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Moderating effects

The moderating effect is whether the independent variable x will be affected by the moderating variable m when studying the influence of the independent variable x on the dependent variable y. The specific process is shown in formula (1). Here, y is the dependent variable, x is the independent variable, m is the moderator variable, mx is the interaction term between the moderator variable and the independent variable, and the coefficients are a, b, c and c’, respectively.

$${\displaystyle \begin{array}{l}y=a+ bx+ cm+e\\ {}y=a+ bx+ cm+{c}^{\prime } mx+e\end{array}}$$
(1)

To test whether there is a moderating effect of water- and air-pollution perception on the relationship between attitude, cognition, and purchase intention, SPSS was used to analyze the moderating effect. The results are shown in Table 7.

Table 7 Results of moderating effect
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Only the air-pollution perception * attitude interaction term is significant. Moreover, the path coefficient is a positive value, meaning that the more serious the air pollution perceived by residents, the greater the degree of influence of attitude on purchase intention.

The interaction items of water-pollution perception * attitude, air-pollution perception * attitude interaction and water-pollution perception * cognition do not show significance, which indicates that water- and air-pollution perception do not play a moderating role in the path from cognituon to purchase intention and water-pollution perception does not play a moderating role in the path from attitude to purchase intention.

Discussion

From the above analysis, it can be seen that all the hypotheses are supported except for hypotheses H8, H10, and H11, indicating that the constructed theoretical model has good explanatory power. The similarity between this study and the existing literature is that the influence mechanism of advertising marketing and behavior of relatives and friends on residents' intention to purchase commercial health insurance has been confirmed. For example, there are many studies that have found that advertising marketing and behavior of relatives and friends can promote consumer attitudes (Knoll 2016; Liñán et al. 2011; Neema and Navin 2022). Moreover, Dehghani and Tumer 2015 identified the positive effect of advertising on consumers' purchasing intention, and Gunawan and Huarng 2015 indicated that influence from relatives and friends, as an expression of subjective norm, can positively affect users’ purchase intention.

At the same time, this study also proved that "advertising marketing - attitude - purchasing intention", "behavior of relatives and friends - attitude - purchasing intention", "advertising marketing - cognition - purchasing intention", "behavior of relatives and friends - cognition - purchasing intention" and "advertising marketing/behavior of relatives and friends - cognition - attitude - purchase intention" are effective paths. Similar path relationships were also confirmed in previous studies (Liñán et al. 2011).

Additionally, unlike other studies that use demographic characteristics and environmental pollution perception as predictors, this study creatively employs demographic variables as moderators to observe their moderating effects. It shows that there exists a significant path difference with respect to gender and residence. This finding can provide business insights for commercial insurance companies to optimize their product portfolio. Moreover, the moderating effect of water- and air-pollution perception was explored. The results showed that air pollution perception only significantly positively moderates the path from attitude to purchase intention, without affecting the path from cognition to purchase intention. This effect is in line with the findings from Zhao et al. 2021, who found that perceived pollution intensity could significantly positively promote health care expenditure.

Conclusions and recommendations

Conclusions

This study selected resident residents in the Yangtze River Delta as the survey subjects, used questionnaires for empirical analysis, constructed a structural equation model based on TRA and SOR theories, and investigated the influence mechanisms of different factors on the intention to purchase commercial health insurance through multigroup analysis and moderating effect test. The results are as follows:

  1. (1)

    The purchase intention of residents is significantly and positively affected by attitude and cognition. The more positive the attitude and the more comprehensive the cognition with regard to commercial health insurance, the stronger the residents' intention to purchase commercial health insurance.

  2. (2)

    Residents' cognition is significantly and positively affected by advertising marketing and behavior of relatives and friends. Advertising marketing and behavior of relatives and friends will promote residents' understanding of commercial health insurance and improve the comprehensiveness of cognition.

  3. (3)

    Residents' attitudes are significantly and positively affected by advertising marketing, behavior of relatives and friends, and cognition. Advertising marketing and behaviors of relatives and friends will promote a positive change in residents' attitudes and improve residents' recognition of commercial health insurance.

  4. (4)

    In the analysis of the moderating effect, demographic variables (gender and residence) play a significant moderating role in the influence of residents' commercial health insurance purchase intention. Air-pollution perception significantly moderate the path from attitude to purchase intention.

Recommendations

Based on the above results, targeted recommendations are put forward from the following five aspects:

  • First, advertising marketing can promote residents' cognition of commercial health insurance and a positive change in attitude. Raising cognition will also promote a change in residents' attitude and further increase their intention to purchase commercial health insurance. Based on this, insurance enterprises can strengthen content publicity, improve residents' recognition of commercial health insurance, pay attention to the diversity of publicity channels and improve publicity coverage. Also, it is necessary to increase the construction of medical infrastructure, and improve the convenience of medical treatment to make people willing to be treated. Furthermore, purchasing commercial health insurance to reduce the medical burden (Tavares, 2020) will promote the construction and improvement of China's medical security system.

  • Second, behavior of relatives and friends affects residents' cognition and attitude towards commercial health insurance, which in turn affects their intention to purchase commercial health insurance. There is a mutually reinforcing relationship between advertising marketing and behavior of relatives and friends. Enterprises can use word-of-mouth communication and hold publicity seminars to firstly change the cognition and attitude of a small number of people, especially collective leaders, towards commercial health insurance. And then, they can gradually increase the cognition and attitude of a larger group of residents towards commercial health insurance to increase their intention to purchase it.

  • Third, according to Leon Festinger's theory of cognitive dissonance, purchase intention can be approximately equal to purchase behavior. When residents' cognition and behavior are inconsistent, they will lead to a sense of dissonance. Moreover, changing attitudes to achieve consistency is the primary way to reduce dissonance. Based on this, enterprises can promote a change of attitude and purchase intention by frequently deepening residents' cognition of commercial health insurance.

  • Fourth, the positive effect of advertising marketing on cognition and the positive effect of family and friends' behavior on attitude are more significant for rural residents than for urban residents. Based on this, enterprises should pay attention to the huge potential users of rural residents, and choose publicity methods that rural residents can reach to improve their cognition and attitude. While develo** high-end commercial health insurance products to cater to the less price-sensitive group, it is also necessary to launch "high-cost-effective" products for rural residents. The government should also improve the infrastructure construction in rural areas, expand the channels by which rural residents can learn about commercial health insurance information, and guide them to view commercial health insurance-related products rationally.

  • Fifth, in the case of high levels of air-pollution perception, the degree of influence of attitude on purchase intention will be more significant. So, local governments should release more information about environmental pollution. Meanwhile, enterprises can increase publicity in areas with more serious environmental pollution, emphasizing the importance of preparing for health risks in advance by purchasing commercial health insurance, to help achieve the strategic goal of a healthy China and further promote the construction and improvement of China's medical security system.