Unequal paths of healthy ageing: a qualitative exploration of urban-rural disparities in self-management of intrinsic capacity decline

Abstract

Declining intrinsic capacity may compromise healthy ageing, while opportunities to manage functional change are shaped by social and structural circumstances. Urban-rural differences in the conditions surrounding everyday self-management remain poorly understood. This study explored how social determinants enabled or constrained function-oriented self-management of IC decline in two contrasting communities in Zhejiang Province, China. A qualitative interview study was conducted from August to October 2025 in a metropolitan community in Hangzhou and a village-based community within economically developed Yiwu. Twenty-eight community-dwelling adults aged 70–95 years were recruited through purposive maximum-variation sampling, with 14 from each setting. Eligibility required possible IC decline identified using Step 1 of the World Health Organization Integrated Care for Older People (ICOPE) screening tool. Data from individual, face-to-face, semi-structured interviews were analysed using reflexive thematic analysis. The five-domain Social Determinants of Health (SDOH) framework informed interpretation and reporting rather than initial coding. Twelve subthemes were developed from participants’ accounts and organised within five SDOH domains. In the rural setting, participants linked lower pensions, limited insurance coverage, travel costs, distance to services, and intermittent family accompaniment to postponed assessment, rehabilitation, or follow-up. In the urban setting, participants described digital procedures, inaccessible housing, and sensory or mobility limitations as barriers to independent use of nearby services, with assistance from adult children often required. The older age profile of the urban group was considered when interpreting these patterns. Across settings, functional usability reflected affordability, accessibility, continuity, navigability, and alignment with older adults’ capacities rather than availability alone. Constraints accumulated across domains, although experiences varied within each setting. This study extends the SDOH framework to the everyday management of IC decline. It distinguishes nominal availability from functional usability and highlights the importance of aligning support with older adults’ capacities. The findings support context-sensitive, function-oriented primary care and community services responsive to local barriers and functional needs. These patterns are specific to the two study communities and are not nationally representative.