We carried out a comprehensive one phase survey of two catchment areas in Beijing province; Daxing's rural villages and Xicheng in the heart of Beijing city. There were relatively few non-responders, but the higher proportion in urban Xicheng (25.7%) compared with rural Daxing (4.3%) creates some potential for response bias. We applied the same catchment area sampling techniques and research protocol in both settings, and the same research group supervised the implementation of the research. Given the proximity, shared language and culture of the two sites, we believe that the comparison was apt and likely to be informative regarding the impact of contrasting infrastructure, policies, lifestyles and family structures on health outcomes and chronic disease care. However, clearly, findings from this comparison cannot be generalised to urban and rural settings in China as a whole. In particular, Daxing is less remote, and better resourced than the majority of rural locations in China. We set out to compare rural and urban samples with respect to the health status of older people, their use of health services, and their needs for informal care. For older people, these three elements are very much inter-related. Other studies that have addressed just one or other of these elements in isolation have not provided a comprehensive overview of chronic diseases, their consequences and their management, and how these might differ in urban and rural populations. However, the broad agenda for this paper has meant that we have not been able to address each topic in detail, for which more in-depth dedicated studies will be required.
Self-reported chronic disease diagnoses (diabetes, heart disease and stroke) were more prevalent in urban Xicheng than in rural Daxing. These findings are consistent with reports from previous Chinese surveys, [37–39] but need to be interpreted with caution. There may be systematic under-ascertainment in rural sites because of low levels of awareness and help-seeking, under-detection and under-treatment. Of note, hypertension and dementia, ascertained from clinical assessments in the survey, were similarly prevalent in both sites. Low levels of education may have contributed to ignorance of chronic diseases and under-reporting  On the other hand, the prevalence of self-reported impairments was also much lower among older people in rural Daxing, consistent with their better self-rated overall health. Also, when zero inflation was accounted for the disability score count in the rural site was 40% lower. The lesser needs for care among rural elderly, based upon global assessment by the interviewer, is again consistent with a lower prevalence of chronic disease in Daxing. However, in interpreting these differences in health perception we should bear in mind Amartya Sen's allusion to the substantial evidence that "people in states that provide more education and better medical and health facilities are in a better position to diagnose and perceive their own morbidities than the people in less advantaged states, where there is less awareness of treatable conditions (to be distinguished from "natural" states of being)" . Selective mortality may be an additional explanation for the differences in health outcomes. For rural residents a 30% excess mortality is consistently observed across several data sets, from midlife onwards. The younger age and higher proportion of widows and widowers in Daxing compared with Xicheng is consistent with a difference in midlife mortality between the two populations. Unhealthier lifestyles among the rural elderly may have contributed. Consistent with our findings, a survey in Hubei Province showed higher levels of smoking and alcohol use, and much lower levels of physical activity among older people in rural compared with urban districts . While our data suggests a decline in the prevalence of current smoking among older people compared with the Beijing Longitudinal Ageing Study conducted in 1991;  this decline was more pronounced in urban (from 48.2% to 16.6%) than in rural districts (from 43.5% to 30.4%). In summary, our data, considered in the context of other Chinese surveys, is in no way reassuring regarding the underlying health status of the Chinese rural elderly population.
The differences in our survey in the accessibility and effectiveness of the urban and rural health services were striking. In the Third Chinese National Health Services Survey, rural and urban residents with an illness in the past two weeks were equally likely to seek help from a physician; hospitalisations were less frequent among rural residents, but only among those aged 65 and over [37, 42]. However, fewer than 7% of our rural sample as opposed to nearly 40% of the urban used any health service in the three months preceding the interview. In both sites, physical health was the strongest predictor of the use of health services. Our findings were not explained by the younger age and better health of rural residents. The limited availability of local health services, [38, 43] rural poverty, [37, 44] the lack of effective insurance cover after the collapse of the rural Cooperative Medical System, and sharp increases in charges under the new fee-for-service system  are all likely to be implicated. Economic factors (household assets, receipt of pension and possessing health insurance) were all independently associated with accessing healthcare in urban Xicheng, and may have explained some of the differences in help-seeking between the two sites; limited variance of these factors probably accounts for the lack of association in rural Daxing. Detection and control of hypertension is an important index of the effectiveness of community healthcare. The control of blood-pressure-related disease is a global health priority . The prevalence of hypertension among older people in China has risen sharply over the period 1991-2006, [12, 46, 47] and prevention and control are also clear national priorities. Parameters for awareness and control in urban Xicheng were similar to those recently reported for older people in urban Chengdu,  while those for rural Daxing were a little worse than those from the national InterASIA survey of 2000-2001, described at that time as 'unacceptably low' .
Underutilisation of health services, and lack of routine medical checks may explain the low detection rates [13, 22, 50]. Lack of control among those who were detected and treated was a particular problem in rural Daxing. In Chengdu,  lack of control of hypertension was associated with infrequent blood pressure checks, under-treatment, poor treatment adherence, and ignorance of risk factors and potential complications. Hypertension in mid-life is a recognized risk factor for dementia [51–53] Therefore, the extent to which prevention and control of hypertension can be established early in the coming epidemic in China and other LAMIC may have important implications for the size of the predicted increase in numbers of people with dementia in those regions . As others have noted, there is an urgent need to promote access to healthcare in China . Adequate insurance or subsidy to cover health care costs, need to be extended to those outside of the urban cadres, particularly rural residents, those without formal employment and older people . Community healthcare services need to be strengthened. However, attention needs also to be given to increasing the demand for healthcare; health promotion and education to encourage healthy behaviours and help-seeking . Older people need to be targeted .
In Daxing, the burden of support and care, where it was required, fell mainly on family members who had often given up work to care. In Xicheng, family members rarely gave up work to care, paid caregivers being employed instead. These stark differences are understandable in the context of China's rapid economic development. Urban Beijing is experiencing a boom, while development in rural areas stagnates. Widening differentials in salary levels between the city and the country drive the trend towards the employment of women from less developed provinces to care for dependent older people in the city. Residential care is costlier, and associated with considerable stigma. Some caution is indicated in interpreting the higher levels of carer strain among urban compared with rural carers, since measurement bias between urban and rural settings may have been implicated; nevertheless, the finding seems plausible. Although the literature is inconsistent on this point,  juggling work roles with those of parent, organisational and 'hands-on' caregiver for an older relative can be stressful. In Daxing, traditional extended family living arrangements are still the norm, with neighbours and relatives available to provide additional informal care. In China, as in the Dominican Republic  and the USA  dementia is consistently associated with greater needs for care, more time spent caregiving and greater caregiver strain. Non-communicable diseases are already leading causes of mortality in China  and the pace of demographic ageing in China is such that predicted increases in numbers of dependent people , and numbers of people with dementia  will be greater in absolute and relative terms than for almost any other world region. Developing policies and investing in long-term care should be key priorities, alongside health sector reform.