Objective To understand the intention and behavior of rural residents in Changzhou city, Jiangsu province, to improve their health literacy and its influencing factors, so as to provide a reference for improving the health literacy level of rural residents in this area.

Methods From May to June 2024, a multi-stage random sampling method was used to select 605 rural residents in Wujin district and Jintan district of Changzhou city for a questionnaire survey, and 27 rural residents were randomly selected for in-depth interviews. Based on the theory of planned behavior (TPB), a mixed quantitative and qualitative methodology was used to analyze the intention and behavior of rural residents in Changzhou city to improve their health literacy and its influencing factors.

Results The average scores of health literacy self-improvement intention and behavior of 605 rural residents in Changzhou city who participated in the questionnaire survey were (14.75 ± 2.81) and (23.99 ± 7.03), respectively. The average scores of behavioral attitude, subjective norms, and perceived behavioral control in TPB theory were (11.97 ± 2.41), (11.34 ± 2.35), and (16.38 ± 2.17), respectively. The results of structural equation model analysis showed that perceived behavioral control had a positive impact on both the intention (β = 0.68, P < 0.001) and behavior (β = 0.17, P = 0.001) of rural residents to improve their health literacy. Gender moderated the path from perceived behavioral control to health literacy self-improvement intention (diff β = 0.02, P = 0.002) and behavior (diff β = 0.04, P = 0.021). Personal annual income also moderated the path from perceived behavioral control to health literacy self-improvement intention (diff β = 0.15, P = 0.001) and behavior (diff β = 0.19, P<0.001). Among the 27 rural residents in Changzhou city who participated in the interviews, 25 (92.6%) believed that improving health literacy was very important and that it was necessary to learn health knowledge and skills, but only 8 (29.6%) were willing to take actions to improve their health literacy. 16 (59.3%) said that they would only pay attention to health knowledge and skills that were helpful for the prevention and control of their own diseases due to their own health needs and rarely communicated with their family and friends. 10 (37.0%) said that although they were willing to consult doctors to improve their health literacy, the help they received from village doctors was limited. 13 (48.1%) said that they would look for opportunities to learn if there were suitable and convenient ways to improve their health literacy. 20 (74.1%) said that online methods were more convenient and that they were able and willing to search for health information online.

Conclusions Perceived behavioral control has a positive impact on the intention and behavior of health literacy self-improvement, and there are differences between different genders and personal annual incomes. Rural residents in Changzhou city generally believe that health literacy is important, but they have not yet formed the motivation to learn health-related knowledge and skills.