van Rijssen et al. BMC Public Health 2010, 10:666 http://www.biomedcentral.com/1471-2458/10/666 psychological complaints) and the claimant’s way of coping with disabilities to be important in determining their method of communication. These categories are quite relevant and salient in medical disability assess- ments, and therefore easily linked to stereotyping [14]. The physicians stated that the cultural background of claimants is a relevant category for classification. This finding is noteworthy, because cultural stereotypes may lead to perceiving people originating from the same cul- tural background as physically and culturally uniform [4], and subsequently different care for different groups of people (e.g. ethnic disparities) [23]. In addition, there is a risk of ‘self-stereotyping’, that is: claimants evaluate themselves more in line with a negative stereotype when they belief that a person with power over them holds that stereotypic view [26]. Both consequences of stereo- typing regarding cultural background might influence the result of the medical disability assessment. Three goals for stereotyping are generally distin- guished in the literature: self-enhancement goals, com- prehension goals, and motivation to avoid prejudice [2,7], and these are reflected in our findings. Firstly, self- enhancement goals correspond with the finding that physicians’ classify claimants according to the degree of positivity of the physician-claimant relationship. Label- ling a claimant as ‘negative’ or ‘critical’ might be a rea- son for communication problems or difficulty in drawing the correct conclusions. Secondly, the physi- cians mentioned comprehension goals, in that stereo- types provide a framework for the assessment and can make preparation for the interview more effective. How- ever, they also indicated that comprehension could be hindered by stereotypes if it does not provide the com- plete picture. Thirdly, the physicians were motivated to avoid prejudice, because they found it interesting to check whether the stereotypes were correct, and also mentioned the disadvantages of stereotyping. Our find- ings therefore seem to be in agreement with the ‘goal- based framework for stereotype activation and application’ according to Kunda and Spencer [2]. In their framework, self-enhancement goals and comprehension goals, together with stereotype activation, stimulate stereotype application, and simultaneously, the motiva- tion to avoid prejudice inhibits stereotype application. Several concepts in our previously published theoreti- cal model [15] match the findings from the current study. For example, we conceptualised a passive coping attitude, a wait-and-see coping attitude, and an active coping attitude, which correspond to the dimension of a submissive (first two) versus dominating (third) claimant in the typology. Similarly, the dimension of critical ver- sus respecting/accepting relationship in the typology corresponds to the conceptualisation of a result-directed attitude versus a relationship-focussed attitude. Page 11 of 13 The other attitudes in our framework: the attitude regard- ing patient-centeredness and the attitude about expression of emotions, also match the findings, but more indirectly. These are included in characteristics such as hostility and anxiousness. Overall, the typology seems to confirm the main concepts of the theoretical framework. Strengths and limitations of this study This study has several strengths, as well as some limita- tions. The strengths are: (1) the data-analysis procedure, (2) the participants, and (3) the environment in which the focus group meetings were held. Firstly, although the data were qualitative and not quantitative, they were processed and analysed in a systematic and structured way. Secondly, the participants in the focus group meet- ings had many years of experience as social insurance physicians. Thirdly, the focus group meetings took place in a familiar and safe environment, in which the physi- cians had already had the opportunity for self-reflection, talking about sensitive issues, speaking freely, and open discussions. This made the discussions easier, and it was therefore less likely that their answers and opinions would be socially desirable. Limitations of this study are: (1) the controversy of using stereotypes in relation to the method of data-col- lection; and (2) unconscious stereotyping was studied by asking participants about their conscious awareness. Firstly, stereotyping appears to be a taboo among social insurance physicians, even though it has been shown that it is valid to differentiate between patients on the basis of characteristics such as age, social circumstances, and gender [27]. The controversy of stereotyping could cause a problem, because we relied on verbal reports from the participants, which implies that they might under-report their application of stereotypes. Secondly, there is a contradiction in asking people about an unconscious process. The social insurance physicians were probably neither aware of their stereotyping beha- viour nor the stereotypes they apply. We tried to mini- mise these limitations by asking indirect and general questions (instead of only personal questions), and by asking the physicians to give examples. Within this study no time remained to validate the results, particularly the typology, in another way than by asking the physicians about their opinions in the focus groups. However, it would be interesting to use in depth interviews or a quantitative study to further validate these findings and this typology. Implications for practice The physicians indicated that there are both disadvan- tages and advantages of stereotyping, and because of the possible negative consequences, they try to be aware of the processes of stereotyping and try to minimise the