Health insurance purchase intentions in the past decade: a systematic review and future research directions

BACKGROUND: Health insurance plays a critical role in reducing financial burdens and improving healthcare access. However, misconceptions about risks and costs often lead to poor decision-making and low coverage, even in major economies. Understanding the factors influencing health insurance purchase intentions is essential for expanding coverage and addressing healthcare disparities. This study systematically reviews these factors to identify key patterns and research gaps. METHODS: A systematic review was conducted using the TCM (theory-context-methodology) and ADO (antecedent-decision-outcome) frameworks. Forty-eight studies published from 2014 to 2023 were analyzed to categorize influential factors based on theoretical models, geographic contexts, methodological approaches, and behavioral antecedents, decisions, and outcomes. RESULTS: A total of 141 influential factors were identified across the reviewed studies, with a steady increase in publications over the decade. The TCM framework revealed the predominant use of the Theory of Planned Behavior, while research focused mainly on China, the United States, and India. The ADO framework highlighted behavioral antecedents as the most significant, followed by individual and financial factors, with purchase intention being the primary decision variable. CONCLUSIONS: This review synthesizes current research on health insurance purchase intentions, identifying significant theoretical fragmentation and geographic disparities. It also provides recommendations for future research to explore underrepresented regions and emerging trends, with implications for expanding health insurance coverage and promoting healthcare equity.