Voices of Women Public Healthcare Workers amidst the Armed Conflict in Southern Philippines

Rambe Jr. Ramel*, Jiddo Andrei Maranda, Karen Veloso, Abdullah Junior Mangarun, Lynuel Santillana, Jessica Orias

Mindanao State University – Iligan Institute of Technology, 9200 Lanao del Norte, Philippines

*Corresponding Author’s Email: rambe.ramel@g.msuiit.edu.ph

ABSTRACT

Background: Healthcare workers face hazards and risks that are inherent in their job. However, the most tragic and perilous encounter for these professionals in the Southern Philippines occurred when Maute-ISIS insurgents took over the Islamic City of Marawi in the Province of Lanao del Sur. Methods: This study delves into the experiences of women public healthcare workers at the time of human-induced conflict using a qualitative phenomenological research design. Results: Data revealed that they experienced fear, anxiety, flashbacks, and trauma, though they were accustomed to hearing gunshots, as claimed. Furthermore, they have exhausted all means to survive, helped one another, and served their constituents despite being in a terrible situation. Conclusion: Disturbances can be seen on the physical, emotional, and mental levels as typical reactions to an unwelcome and terrifying situation. Camaraderie among Muslims and Christians became evident in times of trouble, such as the armed conflict. In addition, the respondents demonstrated their zeal to serve, notwithstanding the perilous situation. Setting up institutional policies on disaster preparedness for human-induced crises is beneficial for sound crisis management.

Keywords: Conflict; Hazards; Healthcare Workers

INTRODUCTION

Human-induced disasters, like any other form of natural disaster, also lead to the evacuation and displacement of those who are affected and, at worst, may cause the loss of human life. In the southern part of the Philippines, the historic and months-long armed conflict, specifically in the city of Marawi, happened on May 23, 2017, when the Philippine military tried to seize one of the leaders of the violent moro terrorist group Abu Sayyaf (ASG), who had pledged loyalty to the Islamic State of Iraq and Syria (ISIS). These insurgents took over many establishments and houses, freed the prisoners from the local jail, and overran the city. One of the many establishments that was charged by the terrorists on the first day of battle is a government-owned healthcare institution where they brought their wounded comrades for medical treatment.

As the conflict and terror rose in the city, the people of Marawi fled to nearby municipalities and cities to escape the overwhelming danger brought by the conflict. However, many of the constituents and healthcare providers of the government-owned healthcare institution remained at work and were able to experience the terror brought by the crisis. Many of these workers were women, who were not only vulnerable but often at risk in conflict situations. In the study by Bentz et al. (2021) on the mental health impact among hospital staff caused by a terror attack, it was found that among the emotional conflicts experienced by the respondents were anxiety, depression, and suicidal thoughts.

The unusually large and tremendous war that lasted for several months has brought devastating harm and damage to the city. And on the very first day, the institution considered the home of ailing people seeking medical treatment was disturbed by the terror brought by this unwanted event. Since everyone has the right to enjoy the highest attainable standard of physical and mental health (OHCHR, 2008), it is therefore the mandate of every healthcare worker to aid, nurse, and treat people seeking medical treatment without any distinction. Moreover, in armed conflicts, women and their families think that simply being women—often with children—will give them a higher level of protection from the warring parties. Many women frequently choose not to leave the fighting or the threat of hostilities. They think they will be protected by their gender and the role that society has created for them. Because they are less able to flee, women frequently stay to protect the family's assets and means of subsistence and to care for the young, old, and ill family members (ICRC, 2020).

Thus, this study aims to describe the experiences of women health workers in a government- owned healthcare institution during the ISIS-Maute-inspired conflict in Marawi City, Philippines, and to propose an institutionalized policy framework on emergency and disaster risk reduction management for human-induced crises.

METHODOLOGY

A qualitative descriptive phenomenology was employed in the conduct of the study. The foundation of phenomenology as a general philosophical science was laid out by Edmund Husserl. Husserl referred to this as the phenomenological reduction as its central methodological tenet. It directs the philosopher's attention toward uninterpreted fundamental experience and the pursuit of the essences of things as a result (Landgrebe, 2024).

Purposive sampling was used to recruit the six participants coming from the public hospital in the city of Marawi, Lanao del Sur. The criteria for being able to participate in the study were as follows: (1) women public healthcare workers; (2) present and working during the first day of the siege. They were determined with the assistance of the hospital administrators, who identified the eligible participants. The psychological safety and task performance of healthcare staff, as well as the moderating effect of patients' perceived respect during public health emergencies (Wang et al., 2024)

Prior to data collection, a series of coordination meetings with the research locale were held. Informed consent was obtained from each participant after a thorough explanation of the purpose and procedures of the study. The participants were assured of the confidentiality of all the data obtained throughout the course of the study. Since interviews in the healthcare industry allow researchers to identify and comprehend data from participants' lived experiences using phenomenological methodology (Tanwir, Moideen, & Habib, 2021), one-on-one interviews were utilized to collect data using a researcher-made semi-structured interview guide. The interview was done at their respective homes and offices, wherever the respondents found it comfortable and convenient. The data collection and interview were scheduled according to the availability of the participants and conducted by the lead researcher and one member.

To establish rigor and trustworthiness, each interview session, which lasted about 40 to 50 minutes, was recorded using an audio recorder along with field notes. The data was transcribed verbatim before proceeding with coding and analysis. Each transcript was read several times to obtain a general understanding of the data. Significant findings were then identified and labeled, followed by the formulation of meanings. The formulated meanings were then clustered into common themes. Peer review by an independent third-party researcher and validation by an expert, along with member checking, were applied to increase study credibility and confirmability. In addition, triangulation was used to identify convergence of data obtained through multiple data sources and methods like field notes and interview transcripts (Johnson, Adkins, & Chauvin, 2020). The researchers made sure that the participants did not experience any kind of harm, discrimination, or stigmatization during the course of the study. Respect for human dignity was also given top priority, and participants were given the freedom to participate in the study at will without feeling compelled to do so or to refuse to answer questions or discuss specific subjects. They were also given the freedom to withdraw from it if they so desired.

Ethical Considerations

Ethical clearance for this study was obtained from Ethics Review Committee of Mindanao State University, Iligan Institute of Technology, College of Health Sciences (MSU-IIT CHSERC), Philippines with reference no. E2019-01 on 8th January, 2019.

RESULTS

The lived experiences of women public healthcare workers amidst the armed conflict are categorized into 4 themes, namely: experiences during the siege, actions that should have been taken during the siege, changes and learnings from the experience, and hopes of the workers after the siege. Table 1 summarizes the themes and sub-themes.

Table 1: Summary of Emergent Themes and Sub-themes.

The respondents of the study all expressed the fear they felt during the attack, recalling the panic and shock they primarily felt as well. As anxiety rose in those hours, they said their imaginations were already conjuring up images of what could possibly happen to them. There was confusion in the pandemonium that ensued, they reported. Alongside these thoughts, the respondents voiced concern for their family, friends, and patients. However, safety and survival were the foremost priorities.

The respondents were able to observe their own responses to the attack and those of their colleagues. Furthermore, they noted the hospital environment at that time and the behavior of the insurgents towards the hospital workers. They also became conscious of how the people around them handled perceived safety issues in relation to religious differences.

When they heard gunshots in the vicinity of the hospital that day, the respondents had the same initial impression of the incident as the usual rido (clan war), which they recounted as a regular occurrence in the city. They did not realize the large scale of the incident until later on. One of the respondents, however, expressed having had a premonition of something going awry that day.

As hospital staff, they looked to the hospital administration for instructions. This was an unprecedented event, and it was believed that places like medical facilities would be spared from such assaults. No protocols had been put in place as of that time, they recounted. One of the immediate responses was to try to contact the security sector.

In the aftermath of the attack, they continued to experience fear and anxiety. Among the manifestations of these were lack of sleep and getting easily startled by noises, which are similar to gunshots. They disclosed experiencing flashbacks and feeling traumatized by the skirmish.

Nevertheless, the respondents articulated that despite the experience, they still have the passion to serve. They also conveyed that receiving help and concern from others helped motivate them to continue public service.

DISCUSSION

Table 2: Theme 1: Experiences During the Siege

Women healthcare providers have varying experiences during the first day of conflict when the insurgents invaded their medical facility. Their responses relate to fear and anxiety, where they experience panic, wild imagination, shock, fear of soldiers, aggravation of fear, confusion, lack of sleep, and concern from family, friends, and patients. One of them said, “I couldn't understand it, because in my mind I felt strong but my body was trembling." Another respondent claimed, “I started to cry when [I heard] the firing become heavy. It was really audible, even above the sound of the air conditioner, because it meant there really was a war in Malutlot. So there, I sat and started crying." Another one said, “When it was said that the ISIS were already there, then all of a sudden there was banging on our door; there wasknocking that was so loud, and so my imagination was that there was someone carrying a gun." On the other hand, one pointed out that she feared the soldiers more than the Maute-ISIS; she said, “I am more scared of them than the ISIS; it’s not that they had a different treatment because they are soldiers and police; they have heavy voices, don’t they?”. They also expressed that fear is aggravated by posts read on social media: “So imagine the fear we felt whenever we read on Facebook that there were beheadings." Others were confused on what to do; one of them said, “Now what will happen to us? Just like that? Would I be able to go home, and what will happen to our patients? Where would we go? I said, Where would we escape?”. Others claimed a lack of sleep: “We didn't have enough sleep because of the gunshots." They were also anxious about their families and patients. One said, “So when she left, that is when I cried. It was only on the outside when I said, “Go home, I’m safe,” but deep inside me, I felt afraid”. “The first thing that came to mind was to transport all the patients. But there were soldiers and police outside, and they could engage in a shootout with the ISIS, so I then thought that they could be safer inside the hospital.”.

In the study by Junaid, Haar, and Parker (2018) about local employees working in a terrorist region, one of the emerging themes is terrorism stressors, which include loss, fear, trauma, risk to life, and resilience/habituation. Moreover, anxiety and somatization (fatigue, general malaise, headaches) are common responses to disaster, according to Brunner (2010).

They also expressed their observations of their colleagues, the hospital environment, insurgents, and religious issues regarding safety. “While all the way from the dietary [section] going to the pharmacy, the guards on duty changed into black [clothes] so they could not be identified [by the ISIS]," said one of the respondents”. The others pointed out their observation with the insurgents: “They were the ones wearing black, but usually, those that passed by us were young; some of them were covered; the others were not; they were even handsome, but they were young, around 14 years old." Having observed the hospital environment upon going out, one exclaimed, “Oh, when we reached the flagpole area, when we went out, it was really deserted, and it felt different; there was really a different aura." There were also issues observed with safety related to religious affiliation, wherein those who were Maranao Muslims were deemed safer compared to Christians. One of them said, “It was initially believed that they were against Christians, so all of the Christians were made to evacuate, especially the frontliners in the ER, some from the pharmacy; the Maranao Muslims were told to return [to their stations], and all the Christian frontliners were removed from their assigned areas." While others exclaimed, “Just do not let a Christian go out [from hiding]"; “there was one that was allegedly shot because he was not able to recite the Shahada when asked by an ISIS member.”.

Although there was no mention of harassment from the respondents when the Maute-ISIS militants occupied the hospital, their statements concerning their observations are supported by the following reports: Davies (2017) reported that ISIS teenagers were among the insurgents shooting people dead for failing to quote the Koran. In a report posted by Amnesty International (2017), Tirana Hassan (Crisis Response Director at Amnesty International) said that the months-long battle in Marawi took a heavy toll on civilians, with Christians in particular being attacked by Islamic State (IS) militants.

At first, they thought that what happened was just the usual incident of gunshots or “rido” (clan feuds). Accordingly, this incident is ubiquitous in the country, particularly in the southern Philippines (Cabalza, 2017). Later, they realized that it was not the usual clan feud but a more tragic and serious incident. "Actually, it is normal in Marawi to hear gunshots. I grew up here, so I have become accustomed to that, so we thought it would be resolved because there are clan wars here; it is normal to hear gunshots from that. We did not think that there would reallybe a group that would come in. Those Mautes, we had no idea that they were ISIS Maute; “I thought it was just a rido or [military] operation; later I was able to say, perhaps there was some kind of misunderstanding”; “Chaos started to ensue. And the people of Marawi have gotten used to the sound of gunshots”; “Well, at first we said it was just rido, but it turns out it was not because it has lasted for several months”; “I only started to worry when there was a policeman wearing black; uhm, I said, Oh my! It seems we now need to hide.”.

Furthermore, they also expressed their experience concerning how their administrators responded to the incident at that time in terms of instructions to the staff, protocol, and contact with the Armed Forces of the Philippines (AFP). According to one of them, “The first instruction to us was to go to the gym. Of course, it was all so sudden, and the gym was closed; we were not able to get inside, so we then went to the dietary." It can also be noted that the hospital has no standard protocol for responding to armed conflict such as this. There was no organization in evacuating the patients from their rooms. As stated by the staff, “All the patients were carrying their belongings, crowding the aisles; there were those on wheelchairs and on stretchers; then there would be an announcement that the ISIS were coming back! The patients had to turn back to where they came from; it was so sad. “It was just like in a movie, an exodus, or something like that; you will feel it because aside from the employees, there were patients and watchers. Imagine the hospital. You have seen that it is so big; there are thirteen nursing stations, and there is the OPD, and the people were going in all directions with the stretchers, wheelchairs, and everything else they were carrying with them from APMC just to be able to go out from there. They were carrying with them their IVs." Also, the AFP had difficulty contacting the hospital administrators at that time; one of them said, “They could not contact anyone [from the administration] inside.”.

No man or institution is ever prepared when confronted with unexpected encounters. Often, such situations lead to chaos and confusion among people. Accordingly, war is unpredictable, as are its consequences (Lindley-French & Boyer, 2012).

Furthermore, they shared that saving themselves is their immediate concern, along with their safety and survival strategy. During armed conflicts, civilians’ resort to strategies to protect themselves (Jose & Medie, 2015). "Then, in fact, I was not even able to think of my family. I said I have to save myself first," said one of them. The other one exclaimed, “It seems that you really feel that you are on your own on how you would be able to go out from there because our other fellow workers from Amai said what they did was just to do the best they could on their own on how to get out [of the hospital]." They also felt safer inside the hospital than to escape. They said, “We just stayed inside”; “I felt safer being inside”; “When it happened that the insurgents came in, we really closed the door [in our department] and locked it, including the fire exit." Aside from keeping themselves locked in their departments, others took the initiative of preserving their cell phone batteries and finding their own source of food the next day. When asked what they did while locked in, a respondent said, "Oh, nothing; we just waited. After that, the power was shut down, we didn’t have any light, and we were trying to reserve the batteries on our cell phones. Of course [our means of] contact from outside, telling them we were just there”. While another one explained, “The next day, sir, we looted because we did not have anything to eat because in the kitchen, no one was cooking there. We went to the refrigerators in the private rooms.”

Women healthcare providers also experienced trauma and flashbacks after the incident. “When I heard the ambulance siren, I could not breathe, sir. I had a panic attack.” Here at home, at first I could not sleep because I felt that whenever there was a sound off of the roof, like the wind [blowing on it], I felt like these were sounds of gun shots." “It is fear again, like yes, oneto three shots, it is nothing. but when I hear more of those, it is like the familiar shots I heard during the siege, wherein you lose poise anywhere I am. I do not know what is happening to my body; it becomes akin to a ball, like the bones give in." According to the WHO (2003), mental health and social problems are risk factors for people who are exposed to extreme stressors. Being exposed to an extraordinarily stressful event leads to psychological and emotional trauma (Robinson, Smith, & Segal, 2023). Further, women who had experienced armed conflict and forced migration brought psychological distress, violence, and discrimination (Jolof et al., 2022). Also, the degree of trauma and the availability of physical and emotional support were connected to women’s heightened susceptibility to developing conflict-associated mental health sequelae (Carpiniello, 2023).

They also affirm their passion to serve despite being in a tragic situation. “You don’t have to complain; just accept it. For me, what I felt was that it was like the end of the world because it’s a total war, so I just need to survive. That is, it. I said, If I die, I die in line of duty." “Our role as nurses is that we do not leave our patients; we were able to do that. That we did not leave each other; we were also able to do that." “Yes, maybe that was what we really swore oath to, that yes, you want to go but you cannot get out." Self-sacrifice is exemplified by true service. Women in armed conflict show remarkable endurance and resilience in the face of severe trauma, drawing strength from both internal resources and social support (Jolof et al., 2022).

There were statements of help and concerns from other people, their colleagues, and especially the Maranaos. “It is a good thing that when we reached Saguiaran, we were received at the municipal hall and fed. After that, we walked right away to Pantar." “They were on their way down to Iligan, but then she remembered me. They had another vehicle, and she did not let her younger siblings go down yet and had me fetched at Amai Pakpak. Oh, and she then said, “Maam, my siblings are on their way. They will just be at the gate near TB DOTS (office); just go out." These claims are supported by a report saying that Muslims have been helping Christians during that time (Ross, 2017).

They also shared their premonitions and trust in soldiers. One of them said, “I could really feel there was something wrong that was going to happen that day because even in the morning, the environment felt different. We had so many patients that I don’t know if there might be something that could happen. Maybe it is because I am a woman?”. While one of them expressed her trust in soldiers, “I don’t think; I really told my companions that I did not think they would neglect us, I mean the military.”.

Table 3: Theme 2: Actions that Should Have Been Done during the Siege

When asked about the things or actions that they should have taken during the siege, they said that they have no regrets and that they have done their best. “It seems that there is nothing we could have done more; we did all that we could”; “during that time, I am very glad I did my best; “What was done was that we did our best.”.

On the other hand, others said they should have stayed for their colleagues and to experience adventure. “I wish I did not go down [to Iligan] because we should have been together. I made a promise. Maybe that is what I should have done, sir, that I should not have gone down, saidone of them”. Another one said, “I should have stayed. But why? My adventurous side kicked in. I want to be able to experience being in the middle of where the action is."

On good quality care processes, healthcare professionals like nurses often mentioned factors like "team collaboration," "good medical-nursing collaboration," "interpreter involvement," and "a relationship of trust" in particular as markers of effective interpersonal care procedures (Hannawa et al., 2022).

Table 4: Theme 3: Changes and Learning out of the Experience

There are changes and learnings brought about by the incident experienced by the women healthcare providers: stronger faith in God, a better self-esteem, and a stronger bond with Muslim colleagues. One of them said, “First of all, about seeking God. If you have the faith, whatever happens, you can get through it," while others said, “I have also learned that the relationship, whether Maranao or Christian, At that time, we were able to laugh, but then when we all cried, it was like we did not leave each other, and despite the fear, one said, “It’s okay. You are here [with us], ma'am, so we are together." Armed conflict increases an individual's religiosity and strengthens their faith in God (Shai, 2022). People become more resilient by overcoming tragic events and obstacles in life (Walansky, 2023). Furthermore, being with familiar people and places is a common response to a variety of threats and disasters (Mawson, 2005).

Being more vigilant and alert was also among their learnings. One of them said, “Being alert when you go up [to Marawi], one must be prepared because anytime, anything can happen." Another participant said, "We became more vigilant." Likewise, in an interview with Dr. Ernest Lualuali Ibongu regarding the series of incidents in Bangassou, Central African Republic, he said, “We simply can’t let these people down. But we remain vigilant, because CAR remains one of the most dangerous contexts in the world” (MSF, 2018).

Table 5: Hopes of the Workers after the Siege

They also expressed their hopes after the siege that pertain to the safety, peace, and rehabilitation of the city. They said, “I hope it will be peaceful and that Ground Zero will be rehabilitated because it really is a pity for those who lived there that they could not go home to their houses because even if they live in the tents of the tent cities, they are not comfortable there." In an interview with the people of Marawi, the majority of them said that they want the city to be reconstructed, especially their homes (Ngarm et al., 2019).

Further, one of them said, “They should also look into the nurse’s welfare." Proper working conditions, enough staffing and flexible shifts, job security, and psychological and mental support are just some of the important factors, along with salary, that should be given importance in considering a nurse's welfare. Furthermore, the welfare of nurses should be viewed in a more comprehensive way (Otewa, 2020). On the other hand, people affected by conflict, especially the youth, have a strong desire for peace and wish for a peaceful and sustainable future (Ruppel & Steinbach, 2023).

As other government agencies outline the overall strategy for ensuring the safety and security of learners, personnel, and schools and the continuity of education in situations of armed conflict (Llego, 2019), the above results suggest prompt and pertinent action from all the constituents of a healthcare institution during armed conflicts; therefore, it is vital to have a policy framework for such a human-induced disaster.

CONCLUSION

The people and public healthcare workers of Marawi are used to the culture of violence, like hearing gunshots brought by “rido” or clan war. However, when faced with unusual events such as sieges, they experienced anxiety, fear, panic, and trauma, which are normal reactions during abnormal events like armed conflict. Though faced with enormous danger, they still remained true to their service. People affected by human-induced crises will certainly exhaust all means to survive for themselves and their families and will cry for physical and psychosocial security and safety.

Existing animosity between groups based on religion can be set aside in the face of a crisis. The respondents attested to the cooperation among Muslims and Christians, wherein humanity prevailed as they went through the crisis together. Lastly, institutional preparedness is vital for a sound response during any form of disaster. Frontline personnel provide the basic human right of health care to the general public. Institutional preparedness will guide workers to effectively manage the situation and to perform their primary function of providing safe and quality health care to clients.

Recommendations

This study focused on the experiences of women health workers in a public hospital during a human-induced crisis. For future researchers, they may expand the scope by looking at the active role women can play in the midst of conflict as crisis managers and agents of peace. Additionally, respondents may include other genders as well for a more holistic approach. It is further recommended to look into disaster preparedness and mitigation policies in institutions that are located in critical areas of conflict.

Conflict of Interest

The authors declare that there are no competing interests in the conduct of the study.

ACKNOWLEDGEMENT

The researchers would like to express their deepest gratitude to the Center for Gender and Development (GAD) of the Mindanao State University-Iligan Institute of Technology,Philippines for funding the entire study. The researchers would also like to express heartfelt thanks and appreciation to Dr. Alma G. Maranda, RP, RPm, RGC, for devoting her time and expertise to the validation of the study results. The researchers wish to thank Mr. Jan Henry Dacua and Mr. Ronn Mietchelle Andam for their assistance. Lastly, the research team would like to thank Associate Professor Khandy Lorraine G. Apsay for extending her support during the series of meetings prior to the commencement of the project.

REFERENCES

Amnesty International. (2017, November 17). Philippines: ‘Battle of Marawi’ leaves trail of death and destruction. https://www.amnesty.org/en/latest/press-release/2017/11/philippines- battle-of-marawi-leaves-trail-of-death-and-destruction/ . Accessed on 13th April, 2023.

Bentz, L., Vandentorren, S., Fabre, R., Bride, J., Pirard, P., Doulet, N., ... & Pradier, C. (2021). Mental health impact among hospital staff in the aftermath of the Nice 2016 terror attack: the ECHOS de Nice study. BMC Public Health, 21, 1-17. https://doi.org/10.1186/s12889-021- 11438-9

Brunner, L. S. (2010). Brunner & Suddarth's textbook of medical-surgical nursing (Vol. 1). Lippincott Williams & Wilkins. https://efaidnbmnnnibpcajpcglclefindmkaj/https://rspmanguharjo.jatimprov.go.id/wp- content/uploads/2020/02/11.-Handbook-for-Brunner-and-Suddarths-Textbook-of-Medical- Surgical-Nursing-12th-Edition-Suzann.pdf

Cabalza, C. (2017, July 6). How clan feuds and Ethnic tensions breed terrorism in the Philippines. The Diplomat. https://thediplomat.com/2017/07/how-clan-feuds-and-ethnic- tensions-breed-terrorism-in-the-philippines/ . Accessed on 17th April, 2023.

Carpiniello, B. (2023). The mental health costs of armed conflicts—a review of systematic reviews conducted on refugees, asylum-seekers and people living in war zones. International Journal of Environmental Research and Public Health, 20(4), 2840. https://doi.org/10.3390/ijerph20042840

Davies, G. (2017, May 30). ISIS teenage fighters are 'shooting people dead for failing to quote the Koran' in besieged Philippines city as Duterte's military warns jihadis to 'surrender or die'. Mail online. https://www.dailymail.co.uk/news/article-4553998/Philippines-lawmakers- want-debate-martial-law-amid-siege.html . Accessed on 13th April, 2023.

Hannawa, A. F., Wu, A. W., Kolyada, A., Potemkina, A., & Donaldson, L. J. (2022). The aspects of healthcare quality that are important to health professionals and patients: A qualitative study. Patient Education and Counseling, 105(6), 1561-1570. https://doi.org/10.1016/j.pec.2021.10.016

International Committee of the Red Cross. (2020, June 10). Women and War. https://www.icrc.org/en/publication/0944-women- andwar#:~:text=This%20publication%20looks%20at%20the,protection%20for%20women% 20in%20war. Accessed on 20thMarch, 2023.

Johnson, J. L., Adkins, D., & Chauvin, S. (2020). A review of the quality indicators of rigor in qualitative research. American Journal of Pharmaceutical Education, 84(1), 7120. https://doi.org/10.5688/ajpe7120

Jolof, L., Rocca, P., Mazaheri, M., Okenwa Emegwa, L., & Carlsson, T. (2022). Experiences of armed conflicts and forced migration among women from countries in the Middle East, Balkans, and Africa: a systematic review of qualitative studies. Conflict and Health, 16(1), 46. https://doi.org/10.1186/s13031-022-00481-x

Jose, B., & Medie, P. A. (2015). Understanding why and how civilians resort to self-protection in armed conflict. International Studies Review, 17(4), 515-535.https://doi.org/10.1111/misr.12254

Junaid, F. A., Haar, J., & Parker, J. (2018). Local employees working in a terrorist region: HR managers’ perceptions. Labour & Industry: A Journal of The Social and Economic Relations of Work, 28(4), 279-302. https://doi.org/10.1080/10301763.2018.1558692

Landgrebe, Ludwig M. "Edmund Husserl". Encyclopedia Britannica, 9 Feb. 2024. https://www.britannica.com/biography/Edmund-Husserl Accessed on 23th March, 2023.

Lindley-French, J., & Boyer, Y. (2012). conclusions: The Unpredictability of War and Its Consequences. https://doi.org/10.1093/oxfordhb/9780199562930.013.0046

Llego. M.A. (2019). DepEd National Policy Framework on Learners and Schools as Zones of Peace. TEACHERPH. https://www.teacherph.com/deped-national-policy-framework-on- learners-and-schools-as-zones-of-peace/ . Accessed on 11th March, 2023.

Mawson, A. R. (2005). Understanding mass panic and other collective responses to threat and disaster. Psychiatry, 68(2), 95-113. https://doi.org/10.1521/psyc.2005.68.2.95

Mediecins Sans Frontiers. (2018, September 18). “We simply can’t let these people down. But we remain vigilant”: MSF Returns to Bangassou. https://www.msf.org/we-simply- can%E2%80%99t-let-these-people-down-we-remain-vigilant-msf-returns-bangassou Accessed on 14th March, 2023

Ngarm, S. P., Padilla, B., Schletzbaum, M., & Shahpur, T. (2019, February 6). Marawi rebuilding from ashes to a city of faith, hope and peace. https://efaidnbmnnnibpcajpcglclefindmkaj/https://www.centrepeaceconflictstudies.org/wp- content/uploads/Marawi-Rebuilding-from-ashes-to-a-city-of-faith-hope-and-peace.pdf

Office of the United Nations Higher Commissioner for Human Rights (2008, June). The Right to Health.https://efaidnbmnnnibpcajpcglclefindmkaj/https://www.ohchr.org/sites/default/files/Documen ts/Publications/Factsheet31.pdf

Otewa, M. (2020, August 10). Nurses’ welfare goes beyond pay rise. https://meshrn.com/2020/08/10/nurses-welfare-goes-beyond-pay-rise/ . Accessed on 10th March, 2023.

Robinson, L., Smith, M., & Segal, J. (2023, June). Emotional and Psychological Trauma. HelpGuide. https://www.helpguide.org/articles/ptsd-trauma/coping-with-emotional-and- psychological-trauma.html. Accessed on 10th April, 2023.

Ross, E. (2017, June 15). Christians are given hijabs by Muslims in Marawi to help them escape ISIS militants. Newsweek. https://www.newsweek.com/christians-fleeing-isis-are-given- hijabs-muslims-marawi-help-them-escape-625953 Accessed on 22th March, 2023

Ruppel, S., & Steinbach, L. (2023). Hopes and dreams: youth activities in civil society organizations in post-conflict countries. Journal of Youth Studies, 1-16. https://doi.org/10.1080/13676261.2023.2279629

Shai, O. (2022). Does armed conflict increase individuals’ religiosity as a means for coping with the adverse psychological effects of wars? Social Science & Medicine, 296, 114769. https://doi.org/10.1016/j.socscimed.2022.114769

Tanwir, F., Moideen, S., & Habib, R. (2021). Interviews in healthcare: A phenomenological approach a qualitative research methodology. Journal of Public Health International, 4(2), 10- 15. https://doi.org/10.14302/issn.2641-4538.jphi-21-3881

Walansky, A. (2023, May 09). 5 ways tragedy makes you a hella-strong person, says psychologists. Your Tango. https://www.yourtango.com/self/how-tragedy-makes-you- stronger . Accessed on 23th March, 2023.

Wang, Y., Zhang, S., Gong, L., & Huang, Q. (2024). Making it safe: linking healthcare workers' social media use to task performance during public health crises. Industrial Management & Data Systems, 124(2), 761-785. https://doi.org/10.1108/IMDS-11-2022-0711

World Health Organization (2003). Mental and social aspects of health of populations exposed to extreme stressors. Geneva WHO. https://iris.who.int/bitstream/handle/10665/67866/WHO_MSD_MER_03.01.pdf