To analyze the influencing factors and urban-rural differences in health impairment among empty-nest elderly in China, providing references for reducing health risks and optimizing allocation of elderly care resources.

Using data from 4 025 empty-nest elderly in the Chinese Longitudinal Healthy Longevity Survey (CLHLS 2018), binary logistic regression was employed to identify influencing factors, and Fairlie decomposition was used to analyze urban-rural differences.

The prevalence of health impairment was 10.58%.Logistic regression showed significant associations with age, physical examination, pension insurance, ≥2 chronic diseases, outdoor activities, and access to healthcare/life care services. Fairlie decomposition revealed a total urban-rural difference of -0.0606, with 44.06% explained by observable factors. The main contributors were: number of chronic diseases (28.22%), healthcare access (19.64%), outdoor activities (-14.36%), and physical examination (7.76%).

Urban empty-nest elderly show higher health impairment rates than rural counterparts. Priority should be given to addressing disparities in chronic disease management, healthcare access, outdoor activities, and health examination between urban and rural areas.