Spinal cord injury (traumatic or non-traumatic) often results in motor and sensory loss below the level of the lesion, leading to various secondary health conditions and inability to participate in productive life (including employment) . Improved access to healthcare and rehabilitation has led to improved survival rates among people who sustain spinal cord injury  and are expected to have longer life expectancies and participate in all life situations, including employment. A legal framework exists that promote the employment of people with disabilities. Still, unemployment remains high, resulting in people with disabilities (including persons with spinal cord injuries) experiencing high poverty levels. Employment provides PLWSCI to achieve economic self-sufficiency, personal growth, disability adjustment, social integration, life satisfaction and improved quality of life [3,4]. Employment is also associated with higher activity levels, less medical treatment, and mental stimulation. However, it is estimated that the employment rate of PWSCI is 35% compared to 79% non-disabled individuals [5–7]. A recent worldwide employment rate among PWSCI is estimated to be 38% and in South Africa to be 25% . This number is higher in developing countries with a generally low employment rate , and it is associated with poverty. Indirect costs associated with loss of income among PWSCI leads to high reliance on government social grants . Loss of employment among PWSCI also results in their families living in extreme poverty. Poverty among PWSCI is primarily due to inadequate or poor access to interventions that aim at creating employment opportunities following rehabilitation.
Factors that affect employment amongst PLWSCI are divided into two categories: non-modifiable and modifiable factors . Non-modifiable personal factors that positively affect return to work are being a male, Caucasian, being young at injury, duration of injury (more extended period after the injury), higher education pre-injury, and type of pre-injury work. Non-modifiable personal factors that negatively affect return to work in an individual with SCI is the severity of the injury . Modifiable personal factors that positively influence return to work are education/training post-injury, high level of functional independence (including wheelchair skills), internal locus of control, and positive expectations towards work and access to transport, while secondary health conditions affected to return to work negatively . Access to appropriate assistive technology as part of vocational rehabilitation plays a positive role in promoting employment post-SCI, while employer and fellow employees' negative attitudes negatively affect [3,12]. The restoration of function can address both modifiable and non-modifiable factors through multidisciplinary interventions that promote employment outcomes.
Rehabilitation is a course of action aimed at enabling people with disabilities to reach and maintain their optimal physical, sensory, intellectual, psychological, and social functional levels (including economic participation) . One of the most important rehabilitation goals is to return PLWSCI to gainful employment so that they may become integrated into their communities through vocational rehabilitation [14,15]. Vocational rehabilitation (VR) is a multidisciplinary rehabilitation strategy that aims at enabling a disabled person to secure, retain and advance in suitable employment [16,17]. VR is concerned with supporting efforts made by a person with a disability to return to and maintain employment and includes vocational guidance and training, placement, employment, and other related services . The authors further explained that VR typically begins with evaluating the person's functional limitations, barriers to employment, transferable skills, career interests and prior achievement. It might also include an assessment of performance during simulated or actual work. The assessment might be followed by counselling and support concerning educational or vocational re-entry, job accommodation, and supported employment. Educational or vocational re-entry is often facilitated by a rehabilitation counsellor who can liaise with employers, most of whom have little experience interacting with persons with disability and can have difficulty imagining how a person with an SCI could perform a specific job.
In KwaZulu-Natal (one of the largest provinces in South Africa), two major centres render acute care for SCI management and one sub-acute care facility owned and managed by the government. There are limited interventions that seek to improve employment and education outcomes for PWSCI in all facilities. To incorporate the interventions mentioned above in SCI's overall rehabilitation in KwaZulu-Natal, researchers and policymakers should identify interventions and approaches that seek to improve employment outcomes through the synthesis of existing knowledge. Two systematic reviews were published that identified interventions that seek to improve employment outcomes among PWSCI [18,19]. However, these reviews only focused on the interventions utilised and their effectiveness. To develop a vocational rehabilitation programme in a low resource community, an in-depth analysis of the available literature that focuses on the structure, process and outcomes of the interventions is required.
The theoretical frameworks that underpin this review are based on the Donabedian model and the international classification of functioning and health (ICF). The Donabedian model provides a comprehensive framework to evaluate the quality of healthcare services systematically. It has been used in healthcare systems research and the various healthcare setting (including rehabilitation) for the past two decades [20,21].
This model distinguishes three linked categories of healthcare information: structure, process, and outcomes (SPO). It is emphasised that all three components should be examined when evaluating healthcare services and being treated equally [20,21]. Structure of rehabilitation refers to the type of facility, resources, and systems (beds, modified wards); qualified professionals including speciality (physiotherapist, occupational therapist, and vocational therapist) education, training, and experience, as well as a staff-bed ratio; and unique medical and technical equipment for patients with SCI . The process as a transactional nature of providing and receiving care involving both providers and recipient of care. In rehabilitation, the process of care involves diagnosis, treatment, therapy, prevention activities, patient education activities, social support, and discharge plan . Outcomes of rehabilitation refer to changes resulting from rehabilitation interventions (process), including patient knowledge improvements, health status and behaviour, and patient satisfaction. Patient outcomes in rehabilitation include improvements in functioning and level of support required post-discharge (community integration) . This model will be used in this review to develop the research questions and identify the structure, process, and outcomes of the interventions or approaches identified. Information related to the structure (teams involved, resources utilised) will be identified; specific interventions utilised and their contexts (process) will also be included. Outcomes of the interventions, as mentioned above, will be outlined, as well as the specific outcome measurement tools utilised. Interventions and patient outcomes can be further described using the international classification of function, disability, and Health (ICF).
The ICF is a framework used to holistically assess the impairments, activity limitations and participation restrictions in an individual with a disease or injury (WHO: 2002). This framework helps rehabilitation professionals establish the interaction of these domains with the environment to develop appropriate rehabilitation interventions. In this review, the ICF will guide the identification of variables related to the process of care and patient outcomes. The data extraction tool will collect information related to the body structures and functions affected, activity and participation limitations (with specific reference to economic participation) during rehabilitation and following rehabilitation. Furthermore, environmental and personal factors will be identified that affect the economic participation of PLWSCI. Therefore, the purpose of this scoping review is to map and identify and describe rehabilitation interventions that aim to improve employment outcomes for PWSCI using the Donabedian model and the ICF. The information gained in this review will partially inform the development of a model that intends to guide employment outcomes for PWSCI in the study setting .