Reviewer’s report
Title: 
“It was like nobody cared about what I said?” Iranian women committed
self- immolation: A qualitative study
Version: 
0 
Date: 
23 Jun 2020
Reviewer's report:
This is an interesting piece of work on Iranian women who attempted suicide by
self-immolation. However, the manuscript needs a lot of work before it will be
acceptable for publication. I have provided a number of points on how the paper
could be improved below. But overall the paper needs a complete language
review as there are multiple places where the text is very unclear and difficult to
understand. I also think more information should be given on the method of
analysis and the results - some points mentioned in the discussion are not
covered by the quotes given. I hope the following suggestions will help improve
the paper.
Title - is this a quote? If so I would expect to see "quotation marks" and to see
the quote where this was from in the text/results and mentioned in some way in
the discussion as it must be important, if it is in the title.
The first sentence of the abstract is unnecessary, we already know this paper is
on suicide and most people reading will already know the definition of suicide.
The second sentence is also a bit unclear. In terms of background it would be
better to say something about why self immolation is an issue, or to describe the
extent of the problem in Iran and elsewhere. You could, for example, emphasize
that suicide prevention is important because of the personal social and economic
impacts of suicide and suicide attempt.
The first sentence of the methods in the abstract is also unnecessary as you go on
to say conventional content analysis was used, therefore we already know that
this is a qualitative method. 
The last sentence of the results should really go in the conclusions as it's
speculation or a discussion point, not really a result. The conclusions should
probably be a bit more specific about how to help these women (e.g. family-
based therapy or public health initiatives) or what further research is needed to
help with suicide prevention in this group.
Introduction
Overall I would say you need to use more references, and more references that
are directly relevant to the topic at hand. 
You also need to be careful of the language for example in line 59 "suicide
attempts as the cause of mortality" should just be "suicide" as attempted suicide
is not fatal. 
Line 60 onward you mention some studies that have been carried out in other
locations. These are not very relevant unless they are specifically about self-
immolation. You need to be more specific throughout the paper that you're
talking about work done in Iran. For example on line 74 it says "self-immolation
is the most common violent and dramatic type of suicide in middle-aged adults"
it is not clear that you're referring to Iran specifically, and of course this isn't true
in other countries.
On line 79 the sentence about "low sociocultural background was the main cause
of self immolation." I don't think this is correct. Low sociocultural background
isn't a direct cause of suicide, though it might be a risk factor. 
The sentence starting on line 84 is contradicted by an earlier sentence - see line
77 - where it says that Iran has the second highest prevalence of self immolation.
On line 84 it says that self-immolation is no more prevalent than in other
countries. 
The justification for the study based is reasonable e.g. most work being
quantitative. But it would be good to have a bit more justification of why you are
looking at this group and this topic specifically. What is missing from current
knowledge that this paper addresses?
Methods
I'd like to see a bit more detail in the methods section. Could start by clarifying
who the target population were. (what were the effects of excluding participants
whose families or spouses did not agree to the interview should be picked up in
the limitations section of the discussion -- at the moment there are no limitations
covered in the discussion and this also needs to be addressed).
I'd like to know more about the recruitment and consenting procedures. Did
participants sign consent forms? Were they giving patient information sheets and
time to consider whether they wanted to take part before consenting? How were
they approached in the first place? Where was it, and are there any specific
characteristics of that area/location/hospital that should be taken into account
when thinking about the results (this is also something that can be picked up in
the discussion section).
The information about the lead researcher was unnecessary. 
The inclusion criteria stated that they were married female survivors of self-
immolation without much justification of why they had to be married, why not
include unmarried women?
I recognize the necessity of having the husbands or family's consent is a cultural
thing, however for an international audience it might be wise to explain a bit
more why this is necessary. 
I'd also like to know a bit more about how the interview guide was developed.
Was it piloted? Did it change as the interviews progressed?
The section overall could have a better structure
I'm not that familiar with content analysis, and it isn't clear to me whether the
analysis and coding were done by a single researcher, or if there was any validity
checking done by having other people independently code and look at themes
before coming to a consensus.
The section on rigour was a bit unclear. Although conformability, dependability,
and transferability may be specific to content analysis I would tend to use the
more generally accepted terms like reliability, validity, and generalisability. 
Results
Starting on line 140 you mention that female relatives also performed self-
immolation in past years. This is potentially a really significant issue. We know
from broader suicide research that people who have relatives who have died by
suicide are at higher risk of suicide themselves, but this is not picked up again
anywhere in the paper or in the analysis. Yet it is very significant for suicide
prevention -- e.g. should there be intervention with female relatives after
someone dies via suicide?
As there isn't a lot of information about how the themes were identified I can't
comment too much on them, but I do have a couple of comments on how they
presented. 
On line 151 you use the participant number 6, and after the quote in
brackets you have (P1). I assume the P1 is a page number, but I'm not sure why
we need to know the page number or the participant number. 
On line 211 you say a "participant who survived self-immolation" but by
definition all the participants in this study survived self-immolation.
Discussion
There's a bit of conflict between what is presented in the results and what is
talked about in the discussion. For example on line 240 you say findings reveal
that "cultural and social context is full of family conflict, poverty, and
maladjustment. However there isn't much evidence in the quotes that you've
presented that poverty or maladjustment are significant issues. Perhaps you need
to make sure that the language used in the results is the same as the language
used in the discussion to make it clearer
From line 241 to line 247 you compare the demographics of your sample to
previous work that has been done. I don't think this is particularly relevant to
your study. You have a very small sample and it looks like you're comparing this
to larger quantitative studies. It would be better if you restrict your discussion of
other work to publications that use qualitative methods or look specifically at the
reasons and causes of self-immolation in women. 
Line 251 about "burnt surface area" is not relevant to this work.
Another area that I don't think was really drawn out in the results section but is
mentioned here as important, is about marriages deteriorating after pregnancy.
Both for the discussion and introduction, you might be better looking at some of
the work around self-immolation/self-inflicted burns in South Asian countries
e.g. India and Bangladesh, to see if there are similarities with your results. 
Line 259 you mention some participants had no real intention to die and did not
realise that self-immolation by burning themselves is a dangerous means of
suicide. It would be interesting to know more about the suicidal intent of your
interviewees.
Line 272 you use the term "committed self-immolation". Generally in suicide
research we prefer not to use the term committed as this gives the idea of
something criminal when suicide is a mental health issue.
Conclusions
The conclusions need to be much tighter with more more specific comment on
how the results of this study can help in understanding self immolation within
this group, and what can be done to help prevent it. This could include things
like involving the husband or family members in therapeutic treatments/mental
health care, or the use of public health strategies to improve well-being in young
married women and to promote sources of support that are available. 
And finally a few refs you might want to have a look at:
https://doi.org/10.1016/j.jad.2019.07.005
https://doi.org/10.1016/j.burns.2012.05.022
https://doi.org/10.1016/j.burns.2020.04.042
https://doi.org/10.1016/j.burns.2017.01.001
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No
Are the methods appropriate and well described?
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No
Does the work include the necessary controls?
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authors.
Yes
Are the conclusions drawn adequately supported by the data shown?
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No
Are you able to assess any statistics in the manuscript or would you
recommend an additional statistical review?
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require further assessment in your comments to the editors.
Not relevant to this manuscript
Quality of written English
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Not suitable for publication unless extensively edited
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