Urban–rural disparities in care deficit among functionally impaired older adults in China: prevalence gaps and shared determinants, 2013–2020

Global population aging highlights equitable elder care as a crucial challenge. China’s rapid aging amid a marked urban-rural divide offers a critical context to examine structural disparities in care deficits. This study aims to quantify urban-rural disparities in care-deficit prevalence among functionally impaired older adults, identify determinants shared across settings, and formally assess whether associations differed by residence. We analyzed pooled repeated cross-sectional data from the China Health and Retirement Longitudinal Study from 2013 to 2020, comprising 5,723 functionally impaired older adults contributing 12,602 person-wave observations (aged ≥ 60 years). Care deficit was defined as needing but not receiving assistance for at least one affected activity. Survey-weighted generalized linear mixed models (GLMMs) with community-level random intercepts were employed. All prespecified covariates were included; 19 rural-residence × covariate interaction terms were tested with Benjamini-Hochberg FDR correction. Participant-level cluster-robust sensitivity analyses assessed repeated-observation correlation and the year × residence interaction. Care-deficit prevalence was consistently higher in rural than urban areas (2013: 42.44% vs. 33.79%; 2020: 47.49% vs. 38.01%), although trends were non-monotonic. The fully adjusted GLMM confirmed that rural residence was associated with higher odds of care deficit (OR = 1.39, 95% CI: 1.18–1.65, P < 0.001), and this association was robust in a survey-weighted sensitivity model with participant-level cluster-robust standard errors (OR = 1.35, 95% CI: 1.15–1.58, P < 0.001). None of the 19 rural × covariate interaction terms remained significant after Benjamini–Hochberg FDR correction. Depressive symptoms and being married/cohabiting were consistently associated with care deficits in both urban and rural settings; nominal patterns for age, education, consumption, and chronic disease burden were exploratory. Care-deficit prevalence remained consistently higher among rural than urban functionally impaired older adults in China from 2013 to 2020, without statistically significant evidence that the gap changed over time. Depressive symptoms and marital status were shared correlates across settings. Policies should combine nationwide depression screening with context-sensitive strengthening of rural chronic-disease management and urban community-based care.