The Supporting Literature and Methods of the Civilian Prisoner of War Study

Little is known of the lived experience of civilians who were Prisoners of War as children. This manuscript describes a review of relevant literature and the hermeneutic phenomenology methods used in a study of World War II Prisoner of War survivors from a civilian prison camp in Manila Philippines. Because of the food, safety and other environmental concerns associated with this group, Maslow’s Hierarchy of needs is reviewed to provide a relevant theoretical perspective. Existing research pertaining to resilience, PTSD, and Prisoners of War are discussed. Study methods along with their theoretical underpinnings are described and information is presented as to how the research team sought to avoid bias when conducting the study. The Supporting Literature and Methods of the Civilian Prisoner of War


Introduction
This manuscript describes a review of relevant literature and the hermeneutic phenomenology methods used in a study of World War II Prisoner of War survivors from a civilian prison camp in Manila Philippines. The participants of this study were all interned in Santo Tomas Internment Camp during World War II. During that war, about 7,300 U.S. civilians along with other allied citizens were held as Prisoners of War in Japanese internment camps located in the Philippines [1]. Most of these internees were located at Santo Tomas University in Manila Philippines (henceforth Santo Tomas Internment Camp). The internment camp was in operation for just over 3 years, from January 4, 1942 to February 3, 1945 [2]. The camp population was not static, but quickly exceeded 3,000 prisoners, many of whom were children. In May 1943 the camp population was 3,691 [2]. Internees received inadequate nutrition over a prolonged period resulting in severe malnourishment, especially during the final 8 to 12 months of internment. The mortality rate among U.S. civilian Prisoners of War in the Philippines during World War II was 7.9%. This is twice what would be normally expected within a population of similar age and demographic characteristics; the greatest proportion of these deaths occurred during the final 4 months of internment, primarily due to malnutrition [1].
The aim of the study was to examine the lived experience of allied citizen survivors of World War II Internment Camps in the Philippines with a focus on health behaviors, beliefs, and practices including coping mechanisms and the development of resilience. While the intent of hermeneutic phenomenology is to experience a descriptive account of an event before interpreting and assigning meaning to it, it is recognized that in order to be sensitive to the subtleties and nuances in these individuals' reports, researchers should be aware of the theoretical and interpretive viewpoints they may have brought to their effort [3]. Because the participants were children at the time of their internment, information obtained are likely to provide insights about how these internees persevered after having experienced a traumatic event at a formative time in their lives. Therefore, this paper will describe the population and some details associated with their internment, theoretical frameworks that inform the research, what is known about the development of coping strategies and resilience in children (especially among Prisoners of War), and Post-Traumatic Stress Disorder.

Literature Review
Background: The allied Japanese captives of World War II During World War II, approximately 145,000 U. S. citizens (military and civilian) spent time as Prisoners of War [1]. However, the conditions and outcomes associated with this experience varied greatly. Factors influencing internees' experiences included whether they were in Europe or Asia and what the individual's military status was. Generally speaking, U. S. military Prisoners of War held by the Japanese in Asia received the harshest treatment; forced labor, corporal punishment, and malnutrition were common and there was a 37% mortality rate (Table 1). U.S. Civilians held captive by the Japanese in the Philippines tended to be malnourished, with crowded, unsanitary conditions, and had a mortality rate of 7.9%. On average, both military and civilian Prisoners of War in Asia during World War II were held captive for more than 3 years [1,4]. In contrast, European military Prisoners of War had a mortality rate of approximately 1.4% and, on average, were interned for less than 1 year [1].
When World War II begans, the Philippines were a protectorate of the United States. When Pearl Harbor was bombed by the Japanese on December 7, 1941, there were thousands of U.S. civilians living in the Philippines. After Pearl Harbor, these U.S. citizens had no viable way to return home. Within 30 days of Pearl Harbor, U.S. General Douglas MacArthur had withdrawn U.S. troops from Manila Philippines and declared Manila an opened city, meaning that the U.S. would not contest militarily a Japanese invasion into Manila [5]. In January 1942, the Japanese began using Santo Tomas University in Manila Philippines as a location to intern allied citizens ( Table  2). Elsewhere in the Philippines the Japanese established smaller internment camps for allied citizens.
Internees of Santo Tomas Internment Camp suffered near starvation conditions during their last year of internment. On February 3, 1945, the camp was liberated by U.S. military personnel [2]. Although liberated, internees stayed on site for about 2 months while Manila was secured by the U.S. military in the battle for Manila. During the battle for Manila, approximately 100,000 Philippine citizens died [6]. In April of the same year the allied citizens at Santo Tomas were ordered back to the U.S. by the U.S. military and were returned to the United States.
Internees of Santo Tomas Internment Camp suffered near starvation conditions during their last year of internment. On February 3, 1945, the camp was liberated by U.S. military personnel [2]. Although liberated, internees stayed on site for about 2 months while Manila was secured by the U.S. military in the battle for Manila. During the battle for Manila, approximately 100,000 Philippine citizens died [6]. In April of the same year the allied citizens at Santo Tomas were ordered back to the U.S. by the U.S. military and were returned to the United States.

Maslow's Hierarchy of Needs
Civilian internees of Santo Tomas internment camp lived with inadequate access to nutrition, unsanitary living conditions, and poor protection from the hot tropical climate. As a war zone, fear of physical harm associated with war was a substantial concern. That being the case, Maslow's Hierarchy of Needs ( Figure 1) is an appropriate model to consider when examining the experience of former internees of Santo Tomas Internment Camp. According to Maslow's Hierarchy of needs [7], personal needs are ranked from those most imperative for survival in the following order: physiological needs, safety (and security) needs, love and belonging, self-esteem, and selfactualization. Having higher level needs met is facilitated by lower level needs already having been accomplished and/or addressed. From the standpoint of Maslow's Hierarchy of Needs, current survivors of Santo Tomas Internment Camp exhibited long term survival after a prolonged period of living in a war zone with inadequate nutrition, uncertainties as to their long term physical safety, and crowded living conditions. This suggests the development of resilience among this group of individuals and further examination of their lived experience may provide new insights to inform the resilience literature.

Resilience
Survivors of Santo Tomas Internment Camp who participated in this study experienced traumatic events, and were willing to discuss their experiences [8]. This in and of itself indicates that participants' resilience where resiliency is defined as the development of "… protective factors that positively influence [one's] ability to adjust and move forward following a traumatic event" [9]. According to Henley, resilience involves adapting and/or developmentally progressing despite severe adversity [10]. The American Psychological Association has identifiedseveral factors associated with resilient behaviors including being able to make and execute realistic goals, having self confidence in personal abilities, good problem solving and communication skills, and an ability to deal with strong emotions [11].
The 1956 report by the U.S. Department of Health, Education, and Welfare (page 9) recommended, "…that further special studies be carried out in former Pacific Prisoners of War: (a) psychologic and psychiatric studies should be made to determine the extent to which mental adjustment, physical efficiency, present and past physical illness can be explained on a psychologic basis, and to separate organic and functional complaints…" A review of the literature shows that there is no research specifically looking at the resiliency of adults who were Prisoners of War as children; however, research relevant to  This invitation included materials prepared by the research team including: a description of the study, a consent form, a demographic questionnaire, and a 1 page letter from the Primary Investigator. Inclusion criteria required that participants be former allied citizen internees of a World War II Philippines Internment Camp. Individuals with reported impaired cognitive status and/ or poor English language abilities were excluded from the study. Cognitive status and English language ability were determined in person (except 1 phone interview) based on the Primary Investigator's expertise without any formal instrument used. The Primary Investigator's father was also excluded from being interviewed for reasons associated with potential bias. Participants mailed their signed consent form and completed demographic questionnaire to the Primary Investigator.

Data Collection
The Primary Investigator arranged interviews with those mailing in consent forms. All interviews occurred from February through April of 2015. In total 11 former internees were interviewed.The group formally recruited for interview was the approximately 20 former Prisoners of War attending the 70 year liberation event in the Philippines. One interview involved a non-attendee of that event who heard about the study through the BACEPOW organization and provided informed consent to participate in the study. Seven interviews were conducted in the Santo Tomas Hotel, in Manila Philippines, around the time of the 70 year anniversary of the camp's liberation. Three interviews occurred in participants' homes in California during spring of 2015, and one interview was conducted by telephone for a former internee living outside the state of California. Interviews followed a semi-structured format, with some thematic questions listed in Table 3.

Data Analysis
Hermeneutic phenomenology, as a research method, involves the analysis of transcripts to ascertain themes and meanings associated with a lived experience [18]. This approach values the importance of the lived experience, since human behaviors are intrinsically tied to human experience. Examining the lived experience of these internment camp survivors will provide information absent from this study includes studies examining children exposed to war, child cancer patients, child burns victims, and general information about Post-Traumatic Stress Disorder (PTSD).
Werner [12] looked at a series of studies involving children exposed to war. Various mental health problems are common with this population. Higher exposure to war and being older at time of exposure was associated with more psychological problems associated with the war. Level of trauma is also a major factor. Protective factors against trauma were a strong bond with primary caregiver, social support, and a shared sense of values with community. The review identified a need to listen to children exposed to war in order to better identify their psychological status and needs.
Because the Prisoner of War literature contains little about childhood resilience, other pediatric literature pertaining to resilience may provide relevant background information. A study of pediatric cancer patients found that factors promoting resilience included positive emotions, perceived support, and good coping strategies [13]. Other research suggests that having a ridged family cohesion [14], meaningful family and peer relations, strong problem solving skills and good engagement with one's community [10] is predictive of resilient behaviors in children. Children's ability to be resilient will likely be more limited if the traumatic event continues over time (as opposed to an isolated incident) and if the trauma is severe in nature [15].
A study by Powers examined pediatric burn patients and found a variety of factors as protective against post-traumatic symptoms [9]. Parental income was associated with resiliency, as was support access, high trust, being comfortable socially, and tolerance towards alternative viewpoints. Post-traumatic symptoms were not significantly associated with parental perceptions as to their children's level of physical functioning problems. In other words, low levels of physical functioning were not significantly associated with an increase in post-traumatic symptoms; rather, psychological attributes played a predominant role in a child's symptomology.
A systematic review of Post-Traumatic Stress Disorder (PTSD) studies found that the trajectory of PTSD among populations varies depending on whether or not the cause of the traumatic event was unintentional or intentional [16]. Specifically, studies of unintentional traumatic events found PTSD median prevalence at 1 month was 30.1%, but that the median prevalence by 12 months reduced to 14.0%. Conversely, studies of those experiencing an intentional traumatic event had median PTSD rates of 11.8% at 1 month increasing to 23.3% at 12 months.
In a longitudinal study by Gold [17], U.S. citizen (n=270) Prisoners of War from World War II and the Korean War were interviewed in 1965 and 1990. Predictors of factors associated with PTSD and resilience were examined. Low resilience and high war trauma were predictors of current PTSD. Major factors associated with having PTSD included high levels of irritability, fearfulness/anxiety, and social withdrawal. PTSD in 1965 was only a modest predictor of PTSD in 1990. In this study social support was not a substantial protective factor for having PTSD. The study supports other findings that Prisoners of War can have PTSD many decades after captivity and a major predictor of this is the severity of trauma during captivity.
The former internees of Santo Tomas Internment Camp participating in this study were developmentally challenged in terms of reaching their full potential given that they went through a prolonged period, inevitably influences the manner in which the content is described and reflected on. Hermeneutic phenomenology places a high value on the ontological ways of being rather than epistemological ways of knowing [18]. As the son of a survivor of the internment camp, the Primary Investigator had access to other Prisoner of War survivors for recruitment to the study. However, because of this personal involvement, he was alert to potential bias while interviewing and interpreting the data.
Prior to collecting data, the PI reflected on his pre-conceived notions and potential sources of bias, and wrote memos describing this process of reflection. Collaboration then occurred with other members of the research team to ensure that interview questions were framed in a neutral manner so as to facilitate data collection with rich narratives about the lived experience of participants. Interpretation of the data, also involving the team, allowed for a deep reflection on the intended meaning and perspectives of the participants. None of the other research team members have a preexisting personal connection to the internment camp. Additionally, the 11 participants provided a more than sufficient size sample for this type of study and provided sufficiently rich narratives and a range of personal experiences, limiting the effect of potential bias.
Quantitative research often uses a positivist approach and tends to require large sample sizes. Positivism presupposes that there is one reality independent of ones perceptions. Large sample sizes are often needed for methods associated with positivism. Alternatively, interpretivism is often used in qualitative research [21]. Interpretivism views reality as being a construct of ones perception (thus there are multiple realities); the researcher and researched are in a collaborative scenario. With interpretivism, process and meaning are held most important. Interviews seek depth and the participants are selected purposefully, but not so as to generalize or to robustly represent the larger group they are associated with. For the present study, a qualitative design is appropriate since little is known about the subject matter [22].

Conclusion
We know little about the lived experience of children who were Prisoners of War. The current study seeks to gain insights based on the lived experience of civilian survivors of a World War II Internment Camp in the Philippines. This group, now in their 70s or older, were children at the time of their internment. The current literature has shown that people exposed to war and/or other trauma are at high risk for PTSD and that attributes commonly associated with resilience can play a positive role in the long term health and wellbeing of those having experienced a traumatic event. Known hardships associated with the internment suggest that Maslow's Hierarchy of Needs may form a theoretical basis that informs the lived experience of these internment camp survivors. The methodology of hermeneutic phenomenology was determined to be the best research approach for this group based on us having little research knowledge associated today's literature associated with Prisoners of War and children exposed to war. Correctly identifying themes can be a challenge, because determining how an experience informs ones perspective is complex. The term, phenomenology, is associated primarily with a philosophical perspective that everyday practice of living takes place without us immediately reflecting or making meaning of it, and that these lived experiences are based on our individual situation and context at that given moment [3]. Over time, phenomenology developed into a qualitative research approach and methodology used to understand the basic structures of lived experiences. Two major approaches to phenomenology are the descriptive approach and the interpretive approach. Descriptive (or transcendental) phenomenology was developed first and involved determining an overview of a lived experience without attempting to carefully analyze nuanced fine details of a lived experience; hermeneutic (or interpretive) phenomenology was later developed [18]. Hermeneutic phenomenology involves going over transcripts to interpret meaning as to the lived experience being indicated; early work in phenomenology represented a counterculture to historical, quantitative, research methods, and valued what is sometimes referred to as the "life world" [18]. For the current study, a hermeneutic approach was selected since the lived experience of these survivors has not been deeply examined and is likely to provide insights useful to future PTSD, resilience, and Prisoner of War research.
Reflexivity involves "a person's reflection upon or examination of a situation or experience". In hermeneutic phenomenology, reflexivity can be an asset in interpreting meaning. The researcher's reflexivity involves empathy and individual experiences that help the researcher relate to the lived experiences of the study participants. A researcher's reflexivity will inevitably influence the choice of research questions and analysis of the data. Rarely is phenomenology about opinions, rather, statements that reflect one's lived experiences tend to be much more relevant to studies using hermeneutic phenomenology.
Interviews were transcribed verbatim. Review of the transcripts involved techniques associated with Hermeneutic Phenomenology described above, but were also influenced by Grounded Theory analysis [19]. Coding occurred during transcript analysis and codes were analyzed to determine appropriate themes within the data. Because this study followed a hermeneutic approach to phenomenology, themes were sought out that best captured the essence of the lived experience. During the analytic process, opened communication channels are maintained with participants, so as to clarify potential themes as they emerged from the data in an effort to ascertain accurate results.

Addressing potential bias
In Hermeneutic phenomenology, the researcher is never perceived as being totally unbiased. Rather, the researchers should have an awareness of their own subjectivity in collecting data and interpreting results [20]. The interaction of the researcher with the subject matter