Open Access Research article

Rural area in a European country from a health care point of view: an adaption of the Rural Ranking Scale

Jost Steinhaeuser12*, Petra Otto1, Katja Goetz12, Joachim Szecsenyi12 and Stefanie Joos12

Author Affiliations

1 Department of General Practice and Health Services Research, University Hospital Heidelberg, Vossstrasse 2, Heidelberg 69115, Germany

2 Competence Centre General Practice Baden-Wuerttemberg, Vossstrasse 2, Heidelberg 69115, Germany

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BMC Health Services Research 2014, 14:147  doi:10.1186/1472-6963-14-147

Published: 2 April 2014



In many countries, rural areas are facing a shortage of general practitioners (GPs). Appropriate strategies to address this challenge are needed. From a health care delivery point of view, the term rural area is often poorly defined. However rural areas have to be adequately defined to ensure specific strategies are tailored to these environments. The aims of this study were to translate the New Zealand 6-item Rural Ranking Scale (RRS), to culturally adapt it and to implement it to identify rural areas from a health care delivery perspective. Therefore we aimed to validate the RRS by defining cut-off scores for urban, semi-rural and rural areas in Germany.


After receiving permission, two researchers independently translated the RRS. In a consensus meeting, four items were identified that had to be culturally adapted. The modified RRS-Germany (mRRS-G) was sent to 724 GPs located in urban, semi-rural and rural areas to validate the “rurality” scoring system for conditions in Germany.


Four items, “travelling time to next major hospital”, “on-call duty”, “regular peripheral clinic” and “on-call for major traumas” had to be adapted due to differences in the health care system. The survey had a response rate of 33.7%. A factor analysis showed a three dimensional structure of the mRRS-G scale with a poor internal consistency. Nevertheless, the three items regarding “on-call duty”, “next major hospital” and “most distant boundary covered by your practice” were identified as significant predictors for rurality. The adapted cut-off point for rurality in Germany was 16. From this study’s participants, 9 met the RRS cut-off point for rurality (a score of 35 or more).


Compared with New Zealand rurality scores based on this tool, German scores are far less rural from a health care delivery point of view. We consider that the construct of rurality has more aspects than those assessed by the mRRS-G. Nevertheless, rural areas from a health care delivery viewpoint can be effectively defined using mRRS-G and therefore it can support tailored strategies against GPs shortage.

Family medicine; Health service research; Knowledge transfer; Physician shortage; Rural area