Perceived quality of home- and community-based services and urban-rural disparities in aging-in-place intentions: evidence from Chinese older adults

Abstract

Background

With approximately 90% of older adults globally preferring to age in place, this study examines how perceived Home- and Community-Based Services (HCBS) quality shapes older adults’ intentions within China’s urban-rural context. While existing research emphasizes perceptions of internal factors and service utilization, significant gaps remain regarding perceived HCBS quality’s role across different environmental contexts.

Methods

Using data from 11,601 older adults in Sichuan, China, we analyzed perceived HCBS quality across four dimensions (service quantity, service quality, provider sufficiency, and distance) through an ecological framework integrating service quality models and the Ecology Model of Aging. Stratified urban-rural differences and moderation effects of unmet care needs were tested.

Results

Perceived HCBS quality significantly predicted aging-in-place intentions, with notable urban-rural variations. Rural older adults showed resilience to service quantity limitations but sensitivity to quality deficits, provider shortages, distance, and service unavailability, while urban respondents were more affected by provider shortages and distance barriers. The negative impact of service unavailability was exacerbated when care needs were unmet among urban but not rural older adults, while rural older adults who perceived both distance barriers and unmet needs were most likely to age in place, reflecting either greater adaptation to systemic constraints or fewer alternative options in rural areas.

Conclusions

Findings underscore the need to improve HCBS accessibility and provider availability to support aging-in-place preferences. Urban areas require strategies addressing service proximity and workforce capacity, while rural regions benefit from enhanced service quantity and quality. These results highlight the importance of context-specific policies that account for both service quality perceptions and urban-rural disparities in China’s aging population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-025-06936-z.

Background

A survey from the National Poll on Healthy Aging showed that about 88% of older adults aged between 50 and 80 in the United States believed it was important to age in place for as long as possible [1], which is a significant phenomenon reflected in many countries around the world. In the foreseeable future, the family-based mode of aging-in-place will remain the mainstream mode of old-age care [2]. The situation is similar in China. According to China’s national policy documents [3, 4], over 90% of Chinese older adults prefer aging-in-place arrangements, forming the basis of the “9073” care service system for older adults (which means 90% of older adults age in place at home, 7% age with support from community-based services, and 3% reside in institutional facilities).

Moreover, influenced by the concept of filial piety, Chinese caregivers are prone to consider taking care of older adults as an important family responsibility [5, 6]. Besides traditional concepts and customs, the aging-in-place intentions are also shaped by individuals’ perception of the external environment, particularly their evaluation of community resources and service accessibility [2, 7, 8]. For example, older adults’ positive perceptions of HCBS quality, such as reliable medical care, responsive service providers, and age-friendly infrastructure, can enhance their confidence in remaining at home [1]. Conversely, dissatisfaction with service availability or quality may erode this intention, even among those culturally inclined toward family care. This interplay between external environmental perceptions and cultural preferences highlights the need to examine how perceived HCBS quality influences aging-in-place decisions, particularly in contexts like China where rapid urbanization has created stark rural-urban disparities in service provision.

Perceived HCBS quality and the aging-in-place intentions

Existing research on subjective perceptions that affect aging-in-place intentions has traditionally centered on perceptions of internal factors, such as older adults’ self-assessments of physical capabilities, psychological well-being, and personal preferences. For instance, studies have examined constructs like perceived behavioral control over daily activities [2], perceived preparedness for end-of-life decisions [7], and perceived life purpose [9]. These internal perceptions are often linked to individual agency and psychological resilience, which are critical for maintaining independence at home [10].

However, less attention has been paid to how older adults’ evaluations of external environmental factors shape their intentions to age in place. External perception encompasses aspects like community support systems, service accessibility, and the quality of care available. While some studies have explored perceived age-friendliness of neighborhoods [11] or social support networks [12], the specific role of HCBS quality remains underexplored.

This gap is particularly notable given the growing reliance on HCBS to support aging-in-place globally. The current literature on HCBS has primarily focused on utilization rates as an indicator of service effectiveness, with studies across different cultural contexts showing similar patterns of service use disparities [13]. For example, utilization rates are often used to measure service uptake [14] or as a mediating variable between socioeconomic factors and age in place outcomes [8]. Yet utilization rates do not capture the nuanced relationship between service quality and older adults’ subjective experiences. Even studies examining determinants of HCBS use, such as Døhl et al. [15], have emphasized usage patterns rather than quality evaluations. Thus, the impact of perceived HCBS quality – how older adults judge service outcomes and environmental suitability – on their aging-in-place intentions remains understudied across different cultural and policy contexts [16, 17].

Urban-rural differences

The impact of perceived HCBS quality on aging-in-place intentions may differ between urban and rural older populations due to structural disparities in service infrastructure and resource accessibility. Urban areas typically offer superior housing, transportation networks, and healthcare systems, which can shape older adults’ expectations and evaluations of HCBS. For example, studies have documented that urban regions have denser healthcare provider networks and better-equipped facilities compared to rural areas in both Asian [18] and Western contexts [19, 20]. In contrast, rural areas often face challenges like inadequate public transportation, limiting older adults’ ability to access services [19]. In the United States, rural older adults face particular challenges in accessing specialty care, with average travel distances to healthcare facilities being 3–5 times longer than in urban areas [21]. These environmental factors not only affect service utilization but also influence subjective perceptions of HCBS quality, such as convenience and reliability [10].

Despite these contextual differences, research on urban-rural variations in HCBS quality perceptions and their effects on aging-in-place intentions remain limited. Existing studies have primarily focused on physical environmental factors, such as home accessibility, places available for meeting with friends [2], house ownership, or city size [22], rather than service quality evaluations. Even studies examining HCBS utilization, such as those in Scandinavian countries [15], United States [23], and Korean [7], have centered on service utilization rates rather than subjective quality assessments. In China, with rapid urbanization, rural-urban divides in HCBS availability and quality have emerged, creating distinct environmental contexts that shape aging experiences [17].

The role of family care presents another critical dimension of urban-rural differences. Rural older adults often compensate for formal service gaps through stronger reliance on family support networks [24, 25], a pattern observed globally. In Italy and Spain, multigenerational households remain common in rural areas, serving as a buffer against limited formal services [26]. Conversely, studies in Germany and the United States show urban older adults typically have weaker family ties but greater access to community services [21, 27]. However, rural-to-urban migration of younger generations is straining traditional care systems worldwide, such as China’s “left-behind older adults” [24] and depopulated rural areas in the American Midwest [19]. When family support is unavailable, rural older adults face compounded disadvantages, being doubly vulnerable to both formal service deficits and informal care shortages [13, 28]. China’s urban-rural disparities reflect both universal challenges of rural aging and unique aspects of its rapid urbanization and family policy context [25, 29]. Therefore, understanding how older adults in urban and rural settings differentially perceive HCBS and the role of family support has significant implications for the design of equitable services to support aging-in-place across diverse contexts.

Theoretical framework and hypotheses

This study synthesizes three theoretical perspectives to examine how perceived HCBS quality may affect aging-in-place intentions across urban-rural contexts: the Customer Perceived Service Quality Model, the Model of Health Service Quality, and the Ecology Model of Aging. An integrated conceptual model can be found in Supplementary Fig. 1.

The Customer Perceived Service Quality Model, introduced by Grönroos [30], posits that customer-perceived service quality is the gap between consumers’ pre-service expectations and their post-service experience. This model emphasizes the significance of the customers’ subjective evaluation in determining service quality. In the context of HCBS for older adults, this means that their preconceived notions about the services, such as the level of care, convenience, and support they expect, will be compared to their actual experiences. Their subjective perception is likely to influence their decision-making regarding aging-in-place.

Building upon this, the Model of Health Service Quality [31] offers a four-dimensional framework for classifying these evaluations into administrative, technical, interpersonal, and environmental components. Administrative quality refers to the behind-the-scenes support mechanisms that ensure the smooth delivery of HCBS. Technical quality reflects the effectiveness and proficiency of the services provided. Interpersonal quality emphasizes the interactions between service providers and older adults. Environmental quality relates to the physical and social surroundings in which the services are delivered.

Based on Grönroos’ Customer Perceived Service Quality Model, we posit that aging-in-place intentions depend on whether HCBS meet older adults’ pre-existing expectations. These expectations are operationalized through the Model of Health Service Quality’s four dimensions. Therefore, we hypothesized that deficits in all types of HCBS quality would be negatively associated with aging-in-place intentions among Chinese older adults (H1).

Further, the above service-centric models can be imbedded into the Ecology Model of Aging [32] to understand how environmental context affect individual’s decision-making. The model regards aging process as a continued adaptation to the external environment and to the changes in internal capabilities. When environmental pressures exceed a person’s ability to compensate, alteration of the living environment should happen. According to the Ecology Model of Aging, making the decision about whether to aging-in-place can be conceptualized as a dynamic adaptation process where older adults continuously balance their personal competencies against environmental demands. When the older adults perceive that their living environment is insufficient to support their daily lives (e.g. poor HCBS quality, limited informal care), relocation may become more likely. In China’s rapidly aging together with rapidly urbanizing landscape, both urban and rural environments generate distinct adaptive challenges through high population density, lacking of service, or geographic isolation. Guided by the Ecology Model of Aging, we hypothesize that there are urban-rural differences in the impact of perceived HCBS quality on Chinese older adults’ aging-in-place intentions. These differences may vary depending on the demographic characteristics, health status, and social factors of older adults (H2).

Building on the Ecology Model of Aging, we propose that unmet care needs fundamentally alter how older adults respond to deficiencies in HCBS. The model suggests that successful aging-in-place depends on maintaining equilibrium between environmental demands and one’s adaptive capacity, with family support serving as a crucial compensatory resource. When care needs are adequately met through familial assistance, older adults may demonstrate greater resilience to HCBS quality shortcomings, as personal support networks help buffer systemic service gaps. However, when care needs go unmet, this compensatory mechanism fails, causing environmental pressures to overwhelm the individual’s adaptive capacity and making relocation more likely. Moreover, this dynamic may manifest differently across urban and rural contexts due to their distinct environmental structures and support systems. Urban older adults, typically embedded in more formalized service networks but with weaker family ties, may respond more strongly to HCBS deficiencies overall when lacking care support, as they depend more heavily on institutional systems. Conversely, rural older adults, who generally maintain stronger community bonds but face greater geographic isolation, may exhibit particular vulnerability to service gaps when family support is unavailable, as distance compounds existing resource limitations. Thus, we hypothesize that the negative effects of HCBS quality deficits on aging-in-place intentions will be magnified among older adults with unmet care needs, with the pattern more evidenced among urban than rural respondents (H3).

Together, the three models account for both micro-level service perceptions and macro-level environmental contexts, enabling analysis of how HCBS quality perception translate into residential decisions across diverse living environments. Guided by these theories, the overarching aim of this study is to comprehensively explore the impact of older adults’ perceived HCBS quality on their aging-in-place intentions. Additionally, the research aims to examine urban-rural differences in the effects of perceived HCBS quality on aging-in-place intentions, and the moderation effect of unmet care needs perceived by older adults.

Methods

Data source

Data used in this study were collected from Sichuan province of China. With the assistance of the Sichuan Provincial Health Commission, data were collected through the population monitoring points established in each district and county under its jurisdiction. This approach enabled us to efficiently reach a wide range of older adults across the province. Employees in each population monitoring point were responsible for disseminating the survey information, and identified eligible older adults aged 60 and above within their administrative regions. To participate in the survey, respondents were provided with a QR code. By scanning this QR code, respondents were directed to an online platform where they first completed an informed consent form. The informed consent form clearly stated the purpose of the study, the use of data, and the measures taken to ensure confidentiality. Only after providing consent could the respondents proceed to the online questionnaire. For older adults unfamiliar with smart devices, family members or local staff could assist with questionnaire completion to minimize digital literacy barriers.

The online questionnaire covered variables including aging-in-place intentions, perceived HCBS quality, healthcare needs, and various demographic, functional, and social factors. The data collection took place from May to June 2023. The study was approved by the ethics committee of Southwest Jiaotong University (No. SWJTU-2403-NSFC003). The data collected were encrypted during the transmission and storage processes to safeguard respondents’ privacy.

Study sample

The original sample for this study consisted of 12,954 respondents recruited through the above-mentioned data collection process. After careful check of the data, respondents who were younger than 60 years old were excluded from the data. Additionally, responses with significantly irrational responses (such as same answers to all questions) and those with severe missing values were eliminated. After these exclusions, a total of 11,061 older adults were retained as the current study sample.

Measures

The aging-in-place intention

The aging-in-place intention was measured by a single question: “What is your most preferred way of aging?“, answers to this question included aging-in-place, living in a community-based care institution, and living in a nursing home. Aging-in-place was coded as 1, and all other choices were coded as 0.

Perceived HCBS quality

Perceived HCBS quality was measured by a multiple-choice question: “do you think the HCBS in your community (village) have the following problems?”. Choices included: “the number of services is limited”, “the service quality is low”, “the number of providers is insufficient” and “the services are too far from home” to cover administrative quality, technical quality, interpersonal quality, and environment quality perspectives. We also included choice options “there are other problems” and “there is no problem”. Respondents were allowed to choose multiple options that apply to their perception. Answers to each of these choice options were coded as “yes” =1 and “no” = 0. Respondents indicating “there are other problems” provided written descriptions, with 92% citing: no local services (50%), service unawareness (30%), or non-use of available services (12%). These were collectively coded as “service unavailability” to reflect systemic access barriers beyond the predefined quality dimensions.

Residential type

Residential type was self-reported by respondents answering the question: “Which residential type does your usual place of residence belong to?” Response options were: “Urban (residing in cities or townships)” and “Rural (residing in villages)”. Responses were coded as 1 = rural and 0 = urban. This classification follows China’s official Regulations on Statistical Classification of Urban and Rural Areas [33].

Covariates

Three categories of potential indicators of aging-in-place intentions were identified in previous literature. The first category is demographic characteristics, including gender, age [7, 12, 26], and education attainment [34]; The second category is health factors, such as self-rated physical health [35], ADLs and IADLs [36]; The third category is social factors, such as social support [37], home ownership status [12], and living environment such as physical attributes and amenities in the community [37] and environmental conversion factors [2]. Referring to the literature, in this study, we also included demographic factors, health factors, and social factors. Demographic factors included gender (1 = female, 0 = male), age (in years), education attainment (elementary school or lower, middle or high school graduates, and technical college or above) and marital status (1 = married, 0 = unmarried/divorced/widowed/other). The health factors included three variables: number of chronic diseases (such as hypertension, dyslipidemia, and diabetes, etc.), coded as 0, 1, and 2 or more, fell in the past year (1 = yes, 0 = no), and green medical channel usage, asking whether the respondents have used the HCBS’s green medical channel to access medical care from hospitals in the past three years (1 = yes, 0 = no). Social factors included three variables: cohabitation status (1 = cohabitation with family members, 0 = living alone), number of healthcare insurances (0, 1, 2 or more), and need for care (0 = do not need care,1 = care needs are fully met, 2 = care needs are not fully met). For the test of moderation effect, we generated a dummy variable “unmet care needs”, with care needs are not fully met coded as 1, do not need care and care needs are fully met coded as 0.

Analytic strategy

Firstly, descriptive statistics (means and standard deviations) were performed to show the basic data structure, chi-square tests and t-tests were used to compare urban-rural differences in each item. Secondly, bivariate analysis was conducted to test the correlation between the aging-in-place intentions and the six dimensions of the perceived quality of HCBS and residential areas. Thirdly, the hierarchical logistic regression model was used to explore the impact of covariates on the aging-in-place intentions, and then the perceived HCBS quality variables were added into the model to further analyze the effects of perceived HCBS quality on aging-in-lace intention, controlling for covariates. Fourthly, logistic regression models were conducted for urban and rural samples separately to compare whether there are urban-rural differences in the association between perceived HCBS quality and aging-in-place intentions. Finally, interaction terms between HCBS quality and unmet care needs were added into the urban and rural models to test the moderation effect of unmet care needs. Data analysis was carried out using StataMP 18.

Results

Table 1 presents the descriptive statistical of study variables by residential area. The proportion of men and women was relatively balanced, with the urban sample had some more females (57% in urban vs. 51% in rural sample). The average ages for both urban and rural samplers were around 69 years old, with the rural sample 0.6 years older than the urban sample. Urban older adults were more educated comparing to rural older adults (χ² = 1614.05, p <.001). About 25% of rural older adults reported falls in the past year, comparing to 23% in urban older adults (χ² = 4.09, p =.043). Rural older adults were more likely to report use of the green medical channel to access healthcare (28% in rural vs. 21% in urban sample, χ² = 58.72, p <.001). No significant differences were found on rates of being married (about 76%) or cohabitating with family members (about 89%) between urban and rural samples. In terms of needs of care, rural older adults were more likely to report that their care needs were not met by family caregiving (χ² = 48.06, p <.001). Regarding perceived HCBS quality, more urban older adults were not satisfied with the supply of services as well as number of service providers. About 45% of urban older adults perceived limited number of services, and 19% perceived insufficient number of service providers in their community, while in rural older adults, 38% reported limited number of services, and 13% reported insufficient service providers. However, regarding distance from home, more rural older adults thought that HCBS were too far from home comparing to urban older adults. Urban older adults were also more likely to report service unavailability, and relatively more rural older adults thought there was no problem (37%) with the current HCBS in their villages than urban older adults (35%).

Table 1.

Descriptive statistics of study variables by residential areas

N=11,601

Table 2 shows the results of bivariate analysis for our main study variables. Chi-square tests indicated significant between-group different in perceived HCBS quality and aging-in-place intentions. Overall, older adults who perceived that the HCBS in their community have limited number of services, the service quality is low, the number of providers is insufficient, the service is too far from home, or service unavailability were less likely to age in place, whereas those who perceived there was no problem with the current HCBS service were more likely to age in place. There was also a significant urban-rural difference in the aging-in-place intentions, with 88% of rural older adults would like to age in place, while the percentage among urban older adults was relatively lower (80%).

Table 2.

Bivariate analysis of main study variables (n=11601)

N=11,601

Table 3 presents results from hierarchical logistic regression models predicting aging-in-place intentions. In Model 1, we only included covariates. Results showed that older adults who were older, lived in rural areas and were cohabiting with other family members were more likely to age in place, whereas older adults who had higher levels of education, had fallen in the past year, and whose care needs were not fully met were less likely to age in place. Perceived HCBS quality variables were added into Model 2. Older adults’ perceptions that the quality of service was low (OR = 0.80, p =.001), the number of providers was insufficient (OR = 0.69, p <.001), the services were too far from home (OR = 0.64, p <.001), and service unavailability in their community/village (OR = 0.69, p =.018) were significantly associated with lower aging-in-place intentions. However, the perception that number of services is limited was not significantly associated with aging-in-place intention. The “no problem” variable was not included in the model to avoid the multicollinearity issue. We conducted a separate model including only covariates and perception of “no problem”, and the results showed that older adults who thought there was no problem with the current HCBS were 84% more likely to age in place (OR = 1.84, p <.001).

Table 3.

Hierarchical logistics regression model predicting aging-in-place intentions

N=11,601. Male, non-married, urban residence, elementary and incomplete education, no chronic disease, did not fall during the past year, no green medical channel usage, living alone, having 1 healthcare insurance, and did not need care were used as reference groups

Table 4 presents the urban-rural differences. Results from logistic models showed that urban older adults who thought that the number of providers was insufficient (OR = 0.71, p =.001) or the services were too far from home (OR = 0.66, p <.001) were less likely to age in place. The perception that number of services was limited and service quality was low were only associated with lower aging-in-place intention at marginally significant levels. Among rural older adults, all perceived problems except for number of services were significantly associated older adults’ lower intention to age in place. There are also differences between urban and rural older adults in fall, HCBS’s green medical channel usage, cohabitation and needs of care. Urban older adults who had fallen in the past year and used the green medical channel to access healthcare in the past three years were less likely to age in place, while the effects were not significant among rural older adults. Moreover, rural older adults who lived alone, or whose care needs were not fully met by family caregiving were less likely to age in place; however, such associations were not significant among urban older adults.

Table 4.

Logistics models predicting aging-in-place intentions by residential areas

Male, non-married, elementary and incomplete education, no chronic disease, did not fall during the past year, no green medical channel usage, living alone, having 1 healthcare insurance, and did not need care were used as reference groups

The stratified moderation tests revealed distinct patterns in how unmet care needs moderated the relationships between HCBS quality perceptions and aging-in-place intentions across urban and rural older adults. The complete results of these moderation analyses are presented in Supplementary Table 1, with urban-rural comparisons illustrated in Fig. 1.

Fig. 1.

Moderation effects of unmet care needs on HCBS quality impacts, stratified by urban/rural residence

Among rural participants, a significant interaction effect was observed between distance barriers and unmet care needs (β = 0.805, p <.001). Paradoxically, rural residents with unmet needs showed greater determination to age in place despite distance challenges. Urban participants showed no significant moderation effect for distance barriers based on care need status. Both groups showed more positive intentions when distance was not perceived as problematic, regardless of care need status. For service unavailability, urban older adults exhibited a significant interaction effect (β = −1.48, p <.001), with stronger negative associations when care needs were unmet. This moderation effect was not observed among rural participants.

Discussion

This study examined how perceived quality of home- and community-based services (HCBS) influences aging-in-place intentions among Chinese older adults, with a particular focus on urban-rural disparities and sufficiency of family care (manifested by unmet care needs). Our findings reveal that perceived HCBS quality plays a significant role in shaping older adults’ intentions to remain in their homes, though the impact varies across service dimensions and residential contexts. Importantly, the study highlights stark differences between urban and rural older adults in how HCBS perceptions affect their preferences and how unmet care needs moderates the relationships, offering critical insights for policy and practice.

The findings generally supported Hypothesis 1, demonstrating that perceived HCBS quality significantly predicts aging-in-place intentions, though with some variations across service dimensions. This aligns with Grönroos’ Customer Perceived Service Quality Model [30], which emphasizes the expectation-confirmation paradigm. Older adults who reported service quality deficits (particularly in service quality, provider availability, and distance) experienced greater dissonance between expectations and reality, reducing aging-in-place intentions. Conversely, the absence of perceived service problems strengthened intentions, affirming that meeting or surpassing service expectations fosters commitment to remaining at home. The finding that limited number of services was not significantly associated with older adults’ aging-in-place intention challenges conventional assumptions about resource scarcity, suggesting that older adults may adapt to sparse services by leveraging informal support networks [38]. Additionally, the disproportionate impact of provider quantity over service quantity underscores that older adults prioritize relational continuity and accessible care over bureaucratic efficiency. This finding adds to Dagger et al.’s multidimensional framework [31] by suggesting that each dimension varies in its impact on the aging-in-place intentions.

Our second hypothesis regarding urban-rural differences in the impact of perceived HCBS quality was supported by the findings. The Ecology Model of Aging explains these differences by framing these as distinct environmental presses requiring different adaptive responses. Urban older adults, facing high population density but weaker family ties, showed greater sensitivity to provider shortages and long service distances, likely due to higher expectations of accessible care. Rural older adults demonstrated relative resilience to service quantity limitations, which may be an adaptation to chronically inadequate resources observed globally [15, 21]. However, Chinese rural older adults showed strong negative responses to quality deficits, provider shortages, distance barriers, and service unavailability, revealing breaking points where adaptation fails. China’s rural context intensifies these challenges through unique structural pressures: large-scale labor migration has depleted traditional family support networks, while institutional barriers and uneven service decentralization have created severe care shortages [17, 24, 29]. This produces a paradoxical situation where apparent rural resilience often signifies constrained choices rather than true adaptation, demanding systemic solutions beyond individual or familial coping strategies [17, 28].

The moderation analysis reveals urban-rural divergences in responses to unmet care needs that advances ecological theory’s understanding of environmental press. When care needs go unmet, urban older adults who were embedded in service-dependent environments with greater institutional care options showed significantly reduced aging-in-place intentions. This aligns with international patterns where urban older adults with care deficits are more likely to consider residential facilities, as observed in South Korea [7] and the U.S [12]. Conversely, rural older adults exhibited paradoxical intentions—those reporting both unmet care needs and distance barriers were more determined to age in place. This finding may reflect the cultural place attachment well-documented in China [14] and cross-culturally [39], where rural identities are deeply tied to homesteads. It is also possible that rural older adults in China have limited access to institutional care [17], therefore, they determined to remain at home even care needs are unmet. The Ecology Model may thus be expanded to account for cultural effects that override typical adaptation patterns.

Policy and practical implications

The urban-rural divide in HCBS perceptions calls for tailored policy interventions. In urban areas, strategies should focus on reducing service gaps through workforce incentives (e.g., higher wages for HCBS providers) and optimizing service distribution to minimize travel burdens. Expanding telehealth and mobile service units could further enhance accessibility for older adults with mobility limitations. For rural communities, the data demonstrate that older adults’ intentions are equally vulnerable to four key service deficiencies: service unavailability, poor quality, provider shortages, and distance barriers. This demands more HCBS in rural areas that simultaneously address quality assurance, workforce expansion, and geographic accessibility. Investments in provider training, standardized care protocols, and mobile health teams could mitigate geographic barriers while addressing rural older adults’ concerns about service reliability. Given the strong baseline preference for aging in place, policies should also strengthen informal care networks. For example, through caregiver support programs or community-based respite care. At a broader level, policymakers should prioritize participatory service design, engaging older adults in HCBS planning to ensure services align with local needs. Flexible reimbursement models for rural HCBS could incentivize provider participation, while national standards for service quality could reduce urban-rural disparities. Governments could implement geographic information systems to identify service deserts and allocate resources according to meet older residents’ needs.

Limitations and future directions

This study has several limitations. First, the data were drawn solely from Sichuan Province, which may not reflect the full diversity of China’s aging population. Future research should incorporate multi-regional samples to enhance generalizability. Second, while local staff and family members provided assistance to older adults unfamiliar with digital devices, our online survey methodology may still have excluded the most digitally isolated populations, particularly rural-dwelling older adults without access to technological support. This potential sampling bias suggests our findings may be more representative of technology-accessible older adults. Readers should consequently interpret the results as reflecting the experiences and perceptions of older adults with at least minimal digital connectivity or available assistance, rather than the entire aging population. Third, perceived HCBS quality was measured with single-item indicators. While our measures captured core dimensions of HCBS quality, findings are preliminary. Future research would benefit from validated multi-item scales to assess reliability and sub-dimensions. Finally, the cross-sectional design precludes causal inferences. Future research should employ longitudinal designs to track adaptation processes as older adults encounter service changes, incorporate geographic information system (GIS) mapping to quantify environmental resources objectively, and compare these findings across China’s diverse regional aging policies. Qualitative work exploring how older adults personally define “service quality” could further refine the ecological model’s application to HCBS contexts.

Conclusion

By demonstrating the relationship between HCBS quality perceptions and aging-in-place intentions, and how this relationship diverges across urban and rural settings, this study contributes to global efforts to create an environment that supports aging in place. The findings underscore that aging in place is not merely a personal preference but a complex interplay of service accessibility, cultural norms, and family resource disparities. Policymakers should adopt context-sensitive strategies to bridge these gaps, ensuring that all older adults, regardless of residence, can age with dignity in their chosen environments.

Abbreviations

HCBS

Home- and Community-Based Services

Authors’ contributions

S.W. planned the study and conducted the investigation, Y. L. and S.W. performed statistical analyses and prepared the manuscript, Y. Y. helped plan the study, supervised the data analyses, and revised the manuscript. All authors reviewed the manuscript.

Funding

This study is supported by the General Project of Sichuan Provincial Philosophy and Social Sciences Foundation: A Study on Policy Optimization Approaches to Promote the Balance Between Supply and Demand of Services for Older Adults and Young Children in Sichuan Province (SCJJ23ND232).

Data availability

The study is not pre-registered. The data used in this study is not open to public due to data use agreement limitations.

Declarations

Ethics approval and consent to participate

The informed consent was obtained at the beginning of the data collection process. It clearly stated the purpose of the study, the use of data, and the measures taken to ensure confidentiality. Only participants who agreed with informed consent would continue to fill out the questionnaire. The study was approved by the ethics committee of Southwest Jiaotong University (No. SWJTU-2403-NSFC003). The study strictly adhered to the Declaration of Helsinki and fully guaranteed the rights and interests of every participant.

Consent for publication

All the authors have read and agreed to the submission of the manuscript.

There is no identifying image or personal/clinical detail of participants that compromise anonymity in this study.

Competing interests

The authors declare no competing interests.