Open Access Open Badges Research article

Explaining the disability paradox: a cross-sectional analysis of the Swiss general population

Bernd Fellinghauer12, Jan D Reinhardt13*, Gerold Stucki13 and Jerome Bickenbach13

Author affiliations

1 Swiss Paraplegic Research (SPF), Guido A. Zäch Str. 4, 6207 Nottwil, Switzerland

2 Seminar für Statistik, ETH Zurich, Rämistr. 101, 8092 Zurich, Switzerland

3 Department of Health Sciences and Health Policy, University of Lucerne and SPF, Frohburgstr. 3, 4466 Lucerne, Switzerland

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Citation and License

BMC Public Health 2012, 12:655  doi:10.1186/1471-2458-12-655

Published: 15 August 2012



Disability can be broken down into difficulties in different components of functioning such as impairments and limitations in activities and participation (A&P). Previous studies have produced the seemingly surprising result that persons with severe impairments tend to report high quality of life (QoL) including perceived health regardless of their condition; the so-called “disability paradox”. We aim to study the role of contextual factors (i.e. the personal and environmental situation) in explaining the disability paradox.


The Swiss Health Survey provides information on the perceived health of 18,760 participants from the general population. We construct a conditional independence graph applying random forests and stability selection in order to represent the structure of impairment, A&P limitation, contextual factors, and perceived health.


We find that impairment and A&P limitations are not directly related but only via a cluster of contextual factors. Similarly, impairment and perceived health are not directly related. On the other hand, perceived health is directly connected with A&P limitations. We hypothesize that contextual factors have a moderating and/or mediating effect on the relationship of impairment, A&P limitations, and perceived health.


The disability paradox seems to dissolve when contextual factors are put into consideration. Contextual factors may be responsible for some persons with impairments developing A&P limitations and others not. In turn, persons with impairments may only then perceive bad health when they experience A&P limitation. Political interventions at the level of the environment may reduce the number of persons who perceive bad health.

Disability; Human functioning; Perceived health; Impairment; ICF; Graphical models; Activity limitation; Participation restriction