{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T12:32:02Z","timestamp":1777984322104,"version":"3.51.4"},"update-to":[{"DOI":"10.12688\/f1000research.171712.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,3,4]],"date-time":"2026-03-04T00:00:00Z","timestamp":1772582400000}},{"DOI":"10.12688\/f1000research.171712.2","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,3,4]],"date-time":"2026-03-04T00:00:00Z","timestamp":1772582400000}}],"reference-count":56,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2026,3,4]],"date-time":"2026-03-04T00:00:00Z","timestamp":1772582400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["f1000research.com"],"crossmark-restriction":false},"short-container-title":["F1000Res"],"abstract":"<ns7:p>Background The global age-standardised suicide rate is estimated at 8.9\/100 000, while South Africa is at an alarming 23.5\/100 000. The prehospital Emergency Medical Services (EMS) is located within this burden of health need. Emergency Care providers have a duty to assess, treat and transport healthcare consumers with suicidality, when attending to the suicide-related caseload. Aim To appraise suicidality case frequency and suicide typology for the EMS. Objectives To estimate the scope of the suicidality challenge faced by a jurisdictional EMS and its care providers. Methods Using a retrospective cross-sectional design and a novel data collection instrument, a census of three years of Ambulance Incident Management Records was undertaken in a rural district of the Western Cape, South Africa. Results Of 413,712 records, 2,976 (N) mental health-related incidents were sampled. Fourteen percent (n = 412) were assessed to have descriptors of suicidal ideation (n = 227), attempted suicide (n = 83) or death by suicide (n = 102). There were, on average, 2.8 deaths by suicide per month over the 3-year study period in the Garden Route District. Women were reported to mostly ingest poison and overdose on medication, while men used asphyxiation\/hanging and were 5 times more likely to die by suicide than women. Conclusion This study estimates the prehospital suicide and suicidality burden for the Western Cape public Emergency Medical Services, elucidating an under-researched health concern within South African prehospital care. Further study is required on the risk of emergency care provider stigmatisation towards suicide and suicidality cases, while auditing the need to assess policy, praxis, medical surveillance, EC provider clinical capacity and victim needs and experiences.<\/ns7:p>","DOI":"10.12688\/f1000research.171712.3","type":"journal-article","created":{"date-parts":[[2026,3,4]],"date-time":"2026-03-04T09:44:08Z","timestamp":1772617448000},"page":"1201","update-policy":"https:\/\/doi.org\/10.12688\/f1000research.crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Typologies of suicidality and suicide presenting to a prehospital South African Emergency Medical Service: a retrospective cross-sectional analysis"],"prefix":"10.12688","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3598-9907","authenticated-orcid":false,"given":"Daniel","family":"Tilley","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8072-7634","authenticated-orcid":false,"given":"Lloyd Denzil","family":"Christopher","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Thomas","family":"Farrar","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5261-0677","authenticated-orcid":false,"given":"Navindhra","family":"Naidoo","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2560","published-online":{"date-parts":[[2026,3,4]]},"reference":[{"key":"ref1","article-title":"One raped every 12 minutes; South Africans abandoned in war against crime.","year":"2024"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"28865","DOI":"10.3402\/gha.v8.28865","article-title":"Explaining the role of the social determinants of health on health inequality in South Africa.","volume":"8","author":"J Ataguba","year":"2015","journal-title":"Glob. 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We would like to thank the reviewer for all the positive suggestions and advice in making this article more academic sound and applicable to international standards for the journal. Thank you  2. Language, spelling, and style (minor but frequent issues) General comments The manuscript is generally readable, but there are numerous typographical, spacing, and grammatical inconsistencies. Several errors appear repeatedly and should be corrected globally. Key issues and examples Spacing and typographical errors Examples: \u201cSouthj african\u201d \u2192 South African \u201ctheAfrica region\u201d \u2192 the Africa region \u201cattemptedmurders\u201d \u2192 attempted murders \u201chealthcare\u201d vs \u201chealth care\u201d \u2192 choose one and apply consistently (journal style usually prefers health care). \u201cmultinomial\u201d misspelled as multinominal in several places.  \n<i>Thank you for this report. This has been fix and changed accordingly.<\/i>  Inconsistent capitalisation \u201cDeath by Suicide\u201d, \u201cAttempted Suicide\u201d, \u201cSuicide\u201d are capitalised inconsistently. Recommendation: only capitalise when starting a sentence or when formally defining a variable.  \n<i>This has been changed in the document and corrected accordingly<\/i>  Long and complex sentences Some paragraphs (especially Introduction and Discussion) would benefit from sentence shortening to improve clarity.  Example: paragraphs discussing social determinants and syndemic theory could be split.  \n<i>The long paragraphs have been shortened in to smaller coherent sentences and split accordingly.<\/i>  Redundancy Repetition of phrases such as \u201cprehospital Emergency Medical Services\u201d could be reduced after first definition (EMS).  \n<i>This has been corrected accordingly<\/i>  Recommendation: A professional language edit or journal copy-edit pass would substantially improve readability but is not a fatal flaw.  . Clearer research gap The research gap is implied but could be stated more explicitly: \u201cThere is limited empirical evidence describing suicidality typology within South African prehospital EMS settings.\u201d  \n<i>This has been added. Thank you for pointing this out and aiding in a contextualizing sentence, that we added to the manuscript.<\/i>  Research question clarity The question is posed mid-paragraph.  Recommend explicitly stating the aim and objectives at the end of the Introduction.  \n<i>This has been rearranged and fixed accordingly.<\/i>  4. Methodology  This limitation is acknowledged later but should be more explicitly stated upfront. Definition of outcomes \u201cDeath by suicide\u201d is defined as a prehospital service category, not forensic confirmation.  This is appropriate but must be clearly emphasised earlier, especially for international readers.  \n<i>We added this in earlier as suggested<\/i>  Use of multiple statistical tests While the analyses are appropriate, the rationale for each test could be more succinct. Consider a short summary table or paragraph explaining: Which tests answer which research questions. Multiple comparisons Given the number of tests run, there is risk of type I error. A brief statement acknowledging this limitation would strengthen the methodology.  \n<i>This is added and we explain how&nbsp;Tukey\u2019s method is designed to control the familywise type I error rate at a fixed level (e.g., 0.05) despite the large number of pairwise comparisons being made.<\/i>  Suggest: \u201cStrangulation (asphyxiation\/hanging)\u201d on first use.  \n<i>This has been changed throughout document<\/i>  Age modelling The quadratic age analysis is well executed. However, the clinical or practical significance of the peak at age 41 could be briefly contextualised. Combining attempted suicide and suicide. Combining cases for multinomial analysis is justified statistically.This decision should be explicitly justified earlier in the Results section.  \n<i>This is done accordingly<\/i>  6. Discussion Areas for strengthening  Balance Discussion occasionally leans toward advocacy. Consider tightening language to maintain a neutral scholarly tone. Causality- Avoid language that implies causation from cross-sectional data. Use phrases such as \u201cassociated with\u201d rather than \u201cleads to\u201d.  \n<i>This has been done accordingly<\/i>  Syndemic framing- Strong conceptually, but could benefit from: A short paragraph explaining how EMS policy or training could operationalise a syndemic approach.  \n<i>This has been added accordingly as suggested<\/i>  7. Limitations Strengths-Limitations are acknowledged and appropriate.  Suggested additions-Add explicit mention of: Potential misclassification bias. Reliance on dispatcher-reported categories. Lack of post-event outcome verification  \n<i>This has been done and explained in limitations and in methodology section. As suggested<\/i>  8. Referencing and citations  Issues- Inconsistency in formatting.Some references lack page numbers or consistent journal formatting.  \n<i>This is how the journal created the referencing format. APA was used as the initial reference format<\/i>  Grey literature-Media sources (e.g. Mail &amp; Guardian, Action Society) are useful but should be clearly framed as contextual sources, not epidemiological evidence.  \n<i>done accordingly<\/i>  Repetition-Some references appear multiple times in the reference list (likely formatting duplication  \n<i>This duplication is in requirements of the journal for data availability and is part of the instructions to create a DOI and add a reference to the reference list.<\/i>","URL":"https:\/\/f1000research.com\/articles\/14-1201\/v3#referee-comment-15509","order":1,"name":"referee-comment-15509","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.194504.r457459, Richard Mottershead, University of Sharjah, Sharjah, 17 Feb 2026, version 2, indexed","URL":"https:\/\/f1000research.com\/articles\/14-1201\/v2#referee-response-457459","order":2,"name":"referee-response-457459","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Daniel Tilley<\/b>; \n<i>Posted: 22 Feb 2026<\/i>; Please note responses are given in italics. We would like to thank the reviewer for the advice and suggestions in making this document more academically sound for international audiences and the journal. Thank you for your review.  \n<b>Recommendations<\/b> \n<b>1. Clarify Operational Definitions and Case Classification<\/b> The manuscript relies on EMS categorisation (e.g., \u201cSelf-Harm-other,\u201d \u201cSelf-Harm-poisoning,\u201d \u201cPsychiatric\/Behavioural Problems\u201d), which are not clinical diagnoses. To strengthen methodological clarity, the authors should:  Provide clearer operational definitions of:  Suicidal ideation Attempted suicide Death by suicide Explain how misclassification bias may influence estimates. Clarify how \u201cparasuicidal\u201d behaviour was differentiated from attempted suicide.  \n<i>Operational definition have been placed in accordingly in the appropriate places. Misclassification bias has been defined and explained in the methodology and in the limitations. Parasuicidal has been differentiated accordingly to explain this definition accurately.<\/i>  I might suggest that call-takers are not mental health professionals, this is a critical limitation and should be foregrounded more clearly in the methods and limitations sections. Perhaps the call-takers had enhanced training which was not highlighted within the article?&nbsp;  \n<i>This has been corrected and explained accordingly how dispatchers make us of caller prompts, senior medical technicians and senior paramedics to help with patient understandings. This is brought up earlier in the materials and methods sections.<\/i>  \n<b>2. Strengthen Justification of the \u201cSyndemic\u201d Framing<\/b> The syndemic concept is introduced as a major theoretical contribution; however, it is not analytically tested within the dataset. To strengthen conceptual coherence, the authors should:  Clarify whether \u201csyndemic\u201d is used as: A theoretical lens, A hypothesis-generating concept, Or a demonstrated empirical finding. Avoid implying that syndemic relationships were statistically examined unless explicitly tested. Consider moderating the claim of novelty unless the framework is analytically integrated into results.  Currently, the syndemic argument is persuasive but somewhat aspirational rather than empirically grounded in the presented analysis.  \n<i>This has been described better in the text as a theoretical lens and better explained in the discussion and moves away from the suggestion that this concept was analyzed.&nbsp;<\/i>  \n<b>3. Moderate Claims of Novelty<\/b> The manuscript states that suicide typology in the EMS has \u201cnot been previously assessed in South Africa.\u201d This should be carefully contextualised:  I note that there is prior work (including by the authors) on deliberate self-harm in EMS. The novelty lies in the typological disaggregation of suicidality and death by suicide within EMS records.  Refining the novelty claim would enhance academic credibility and whilst also highlighting the authors previous contributions.  \n<i>Thank you so much for this advice. and for providing us with a better novelty claim. This has been amended accordingly&nbsp;<\/i>","URL":"https:\/\/f1000research.com\/articles\/14-1201\/v3#referee-comment-15510","order":3,"name":"referee-comment-15510","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.194504.r458179, Wesley Craig, University of Cape Town African Gender Institute, Rondebosch, Western Cape, 19 Feb 2026, version 2, indexed","URL":"https:\/\/f1000research.com\/articles\/14-1201\/v2#referee-response-458179","order":4,"name":"referee-response-458179","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Daniel Tilley<\/b>; \n<i>Posted: 22 Feb 2026<\/i>; Please see comments in Italics. We would like to thank the reviewer for the suggestions and advice in making this article more academically sound for international audiences and the journal as a whole. Thank you  The research aim could be stated explicitly, aside from the abstract, it seems to be narratively embedded in the background. This also goes for the objectives; they don\u2019t seem to be listed clearly anywhere.  \n<i>This has been done accordingly<\/i>  It would be helpful to the readership to state earlier that the case descriptions are based on EMS call-taker and call-categories not postmortem findings. This is especially important when determining intent in terms of \u201cDeath by suicide\u201d vs accidental death and homicide. This is brought up in limitations, but should come earlier in methods and briefly in discussion (in general the misclassification bias\/call-taker judgment etc).  \n<i>This has been done accordingly and added earlier in materials and methods<\/i>  Please refrain from citing papers which are not directly relevant to the statements (e.g. \u201cThe null hypothesis (H0) states \u2018there is no association between two variables while the alternative hypothesis (Ha) states, there is an association between two variables (Bolboac\u0103 et al., 2011, p. 530; Tilley, 2021; Tilley et al., 2023).\u201d The latter two references are not papers informing methods\/analytic approaches. There are quite a few of these in the manuscript, please look out for these throughout.  \n<i>this has been fixed and changed<\/i>  I would suggest that references to previous publications using the same dataset should be moved from the Results section to the Introduction or Discussion, and the novelty of the present analysis should be stated more clearly.  \n<i>This has been done in the discussion<\/i>  A significant amount of time is spent on \u201cage\u201d (41 years being peak risk) as a variable yet there is no mention of it in the discussion. It would be useful to link this to other literature as it remains without context here.  \n<i>This has been added and discussed in discussion, thank you.<\/i>  The discussion is strong and statements suggesting that EMS adopt TIC approaches is almost certainly valid, however it does move beyond the descriptive epidemiological nature of the manuscript. These can rather be framed as implications for users, or just areas for future research.  \n<i>This has been done accordingly to this suggestion<\/i>  Syndemic is a novel point of discussion and has value here however it seems awkwardly placed in the introduction, with nothing in the discussion, then brought back into the conclusion. \u201c\u2026however, the novelty in this paper provides and removes the DSH scope and focuses on prehospital suicidality typology while suggesting a syndemic approach to suicide in the African setting.\u201c I don\u2019t believe it does this in its current form. Some more practical application could be valuable here, what would it look like if EMS training reflected this approach? The term is also inconsistently written in quotation marks.  \n<i>This has been defined better and fixed accordingly<\/i>  Trauma-informed care is also brought in at the latter end of the discussion with more explanation provided in the conclusion, this should be moved to the discussion section as no new information should be presented in the conclusion.  \n<i>This has been changed accordingly and removed from the conclusion<\/i>  Consent: The manuscript mentions \u201cWestern Cape Government National Department of Health Ethics Council (WC_201911_033)\u201d I don\u2019t believe this is the name of a single formal ethics committee. It appears to be a mislabelled or conflated reference to two different structures. That said, the ref number looks like a National Health Research Database (NHRD) number for a Western Cape Department of Health and Wellness Research site.  \n<i>This has been changed as advised. Thank you for this advice<\/i>  More minor things  Western Cape Department of Health and Wellness \u2013 I believe they\u2019ve changed from \u2018Government\u2019 to \u2018Department\u2019. \u201chealthcare\u201d vs \u201chealth care\u201d Inconsistent capitalisation of \u201cDeath by suicide\u201d Limitations section: \u201cdon\u2019t\u201d \u2013 avoid the use of contractions, try to write in full. There are quite a few grammar and spacing gremlins throughout, another proofread will be adequate to pick up on these. In particular the use of inappropriate capitalisation and the inconsistent use of abbreviations.    \n<i>Thank you for this advice. this has all been attended to and corrected as suggested.<\/i>","URL":"https:\/\/f1000research.com\/articles\/14-1201\/v3#referee-comment-15511","order":5,"name":"referee-comment-15511","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"The author(s) declared that no grants were involved in supporting this work","order":6,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}