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Mental health literacy of resettled Iraqi refugees in Australia: Knowledge about posttraumatic stress disorder and beliefs about helpfulness of interventions

DOI:10.1186/s12888-014-0320-x
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Shameran Slewa-Younan at Western Sydney University
Shameran Slewa-Younan
Jonathan Mond
Jonathan Mond
Jonathan Mond
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Elise Bussion
Elise Bussion
Elise Bussion
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Yaser Mohammad
Yaser Mohammad
Yaser Mohammad
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Background Resettled refugees are a particularly vulnerable group. They have very high levels of mental health problems, in particular, trauma-related disorders, but very low uptake of mental health care. Evidence suggests that poor ¿mental health literacy¿, namely, poor knowledge and understanding of the nature and treatment of mental health problems is a major factor in low or inappropriate treatment-seeking among individuals with mental health problems. This study used a culturally adapted Mental Health Literacy Survey method to determine knowledge of, and beliefs about, helpfulness of treatment interventions and providers for posttraumatic stress disorder (PTSD) amongst resettled Iraqi refugees.Methods225 resettled Iraqi refugees in Western Sydney attending the Adult Migrant English Program (AMEP), federally funded English language tuition, were surveyed. A vignette of a fictional character meeting diagnostic criteria for PTSD was presented followed by the Mental Health Literacy Survey. PTSD symptomology was measured using the Harvard Trauma Questionnaire part IV (HTQ part IV), with Kessler Psychological Distress Scale (K10) used to measure levels of general psychological distress.ResultsOnly 14.2% of participants labelled the problem as PTSD, with ¿a problem with fear¿ being the modal response (41.8%). A total of 84.9% respondents indicated that seeing a psychiatrist would be helpful, followed by reading the Koran or Bible selected by 79.2% of those surveyed. There was some variation in problem recognition and helpfulness of treatment, most notably influenced by the length of resettlement in Australia of the respondents.Conclusions These findings have important implications for the design and implementation of mental health promotion and treatment programs for resettled refugees and those who work with them.
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... Four studies were conducted in Arab countries: two in Saudi Arabia, one in Oman, and one in Lebanon (Almanasef, 2021;Alshehri et al., 2021;Elsheshtawy et al., 2020;Naal et al., 2020). Five were conducted in non-Arab countries: four in Australia and one in Israel (Khatib & Abo-Rass, 2022;Krstanoska-Blazeska et al., 2021;May et al., 2014;Slewa-Younan et al., 2014, 2020. All were published during the last decade: two in 2014, three in 2020, and four in 2021. ...
... Five studies were conducted among university students (Almanasef, 2021;Alshehri et al., 2021;Elsheshtawy et al., 2020; Khatib & Abo-Rass, 2022; Naal et al., 2020); two among religious and community leaders (with a majority in the two samples having higher education; Krstanoska-Blazeska et al., 2021;Slewa-Younan et al., 2020); and two among refugees in Australia (May et al., 2014;Slewa-Younan et al., 2014; with a mean of 10 years of education and 42% of the sample with higher education, respectively). ...
... In the studies conducted among refugees (May et al., 2014;Slewa-Younan et al., 2014), the participants indicated more supernatural and religious treatments and reported seeing a psychiatrist and reading the Koran or Bible as the most effective intervention. ...
A scoping review of studies examining mental health literacy among Arabs worldwide
Article
  • Jul 2023
  • J PSYCHIATR MENT HLT
Background: There is growing interest in Mental health literacy (MHL) worldwide, given its important role in overcoming barriers to service use and reducing mental health disparities. However, little is known about MHL among Arabs. Aim: We conducted a scoping review to examine MHL levels and correlates among Arabs in both Arab and non-Arab countries, based on Jorm's MHL framework. Methods: We conducted a scoping review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using six electronic databases: PubMed, PsycINFO, CINAHL, Soc Index, Web of Science, and Scopus. Data were summarized and synthesized. Results: Nine studies examining MHL among Arabs met our inclusion criteria. Seven of them used a quantitative cross-sectional design. Four studies were conducted in Arab, and five were in non-Arab countries. Five studies were conducted among university students. The studies included indicate moderate to high levels of MHL. Higher MHL was associated with female gender, personal experience of mental health illness, and with help-seeking behaviours. Conclusions: Our review shows a significant lack of empirical studies on Arabs' MHL. These findings should be considered as a call for action for public health researchers, mental health workers, and policymakers to prioritize research in this field.
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... African refugees might prefer cultural practices which include seeking support from community religious leaders and elders who are traditionally "regarded as people of wisdom, experience and high standing" (Drummond et al., 2011, p. 219). Iraqi refugees in Australia, although also mentioning help from psychiatrists, referred to their religion as helpful for their post-traumatic stress disorder (Slewa-Younan et al., 2014). Similarly, West Indian migrants named religious help as preferable to psychiatric medication (Whitley et al., 2006). ...
A Qualitative Study on the Conceptualisation of Mental Health Amongst South Korean Migrants to Australia
Article
  • Apr 2024
An increase in global awareness of the mental health needs of migrant communities, and recognition of the underutilisation of support services by these communities, has prompted calls for culturally appropriate and competent interventions to address their needs. Providing such culturally effective treatment and mental health services, particularly for culturally and linguistically diverse (CALD) subgroups, requires understanding their perspectives on mental health. This research was led by a migrant from South Korea, living, studying, and working in Australia, and explored how South Korean migrants to Australia talk about mental health and what they need to support their mental health. A qualitative study was conducted via telephone or online web-conferencing using semi-structured interviews. A critical realist approach facilitated consideration and understanding of themes addressing participant perspectives of what promoted South Korean migrants’ mental health in the Australian context. All interviews were thematically analysed, and three major themes centred around (shifting) cultural norms were identified. These were increasing individualism (e.g., through self-discovery); the expression of individually new-found norms; and issues around belonging in society. The purpose of this article is to translate these findings into counselling practice and community initiatives to provide practitioners with greater insights into concepts this population group has identified as impacting their mental health.
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... Limited use of vignettes with resettled refugees has been documented to date with Iraqi refugees in Australia (Slewa-Younan et al., 2014), and with Afghan refugees resettled in Australia (Yaser et al., 2016). Both studies concluded that there was a need to understand the cultural aspects of mental health and increase mental health literacy among refugees. ...
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... In fact, 92% of participants strongly agreed with one or more biopsychosocial beliefs, whereas spiritual beliefs were strongly endorsed by only 24% of participants on average. This is consistent with earlier findings indicating that while some refugees hold spiritual beliefs, the majority of these beliefs are not a predominant explanation for mental health symptoms (Grupp et al., 2018;May et al., 2014;Slewa-Younan et al., 2014). This has previously also been observed among refugees from Arab countries residing in Germany (Lechner-Meichsner and Comtesse, 2022). ...
Trauma, genes, or spirits? Development of a scale to provide a more nuanced understanding of refugees' causal attributions for mental health problems
Article
Full-text available
  • Nov 2023
Only a small proportion of refugees requiring treatment actually receive psychotherapy. Alongside structural barriers, it has been hypothesized that causal attributions for mental health problems that deviate from Western explanatory models may reduce refugees' help-seeking behavior. Prevailing assumptions suggest that refugees predominantly hold causal beliefs that are incompatible with the rationales of psychotherapy. Testing these assumptions requires a reliable assessment tool to evaluate refugees' causal beliefs. Therefore, we developed the Causal Attributions for Mental Health Problems Scale (MH-CAUSE) and validated it in a sample of Middle Eastern refugees living in Germany (N = 429). The outcomes of the psychometric analysis, which included exploratory and confirmatory factor analysis, internal consistency, and convergent validity, indicate that the MH-CAUSE is a suitable instrument for assessing refugees' causal beliefs about mental health problems. Our findings suggest that refugees' causal attributions are in line with a biopsychosocial-spiritual model of mental illness. Contrary to common assumptions, the majority of participants predominantly explained mental illness via psychosocial and biomedical causes, whereas spiritual beliefs were relevant only for a minority of participants. We observed significant associations between causal beliefs and help-seeking attitudes and behavior. However, effect sizes were only small to moderate. While mental health beliefs might contribute to mental health inequities, alleged cultural differences of refugees should not be overemphasized.
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... [41][42][43][44],) and Arab immigrant minorities living in Western countries (e.g. [45][46][47],) have been found to highly endorse supernatural/religious causal attributions, and thereby tend to prefer seeking help from traditional healers and religious authorities when experiencing mental health problems. In Arab Muslim societies, mental illness is framed and explained through religious beliefs [10]. ...
Mental illness stigma as a moderator in the relationship between religiosity and help-seeking attitudes among Muslims from 16 Arab countries
Article
Full-text available
Background: Determining the potential barriers responsible for delaying access to care, and elucidating pathways to early intervention should be a priority, especially in Arab countries where mental health resources are limited. To the best of our knowledge, no previous studies have examined the relationship between religiosity, stigma and help-seeking in an Arab Muslim cultural background. Hence, we propose in the present study to test the moderating role of stigma toward mental illness in the relationship between religiosity and help-seeking attitudes among Muslim community people living in different Arab countries. Method: The current survey is part of a large-scale multinational collaborative project (StIgma of Mental Problems in Arab CounTries [The IMPACT Project]). We carried-out a web-based cross-sectional, and multi-country study between June and November 2021. The final sample comprised 9782 Arab Muslim participants (mean age 29.67 ± 10.80 years, 77.1% females). Results: Bivariate analyses showed that less stigmatizing attitudes toward mental illness and higher religiosity levels were significantly associated with more favorable help-seeking attitudes. Moderation analyses revealed that the interaction religiosity by mental illness stigma was significantly associated with help-seeking attitudes (Beta= .005; p <.001); at low and moderate levels of stigma, higher religiosity was significantly associated with more favorable help-seeking attitudes. Conclusion: Our findings preliminarily suggest that mental illness stigma is a modifiable individual factor that seems to strengthen the direct positive effect of religiosity on help-seeking attitudes. This provides potential insights on possible anti-stigma interventions that might help overcome reluctance to counseling in highly religious Arab Muslim communities.
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... One study found that Asian-born patients were less likely to have contact with allied health professionals than Australian-born patients [19]. Arabic-speaking individuals, as well as those from an African background also commonly utilise religious strategies, such as prayer, to manage mental illness [20][21][22], and will often seek help from a religious leader as the first point of contact [21]. Chinese individuals residing in New South Wales also endorsed seeking help from a church/temple or religious/faith-based organisation after seeking help from friends and family [23]. ...
A Qualitative Exploration of Sources of Help for Mental Illness in Arabic-, Mandarin-, and Swahili-Speaking Communities in Sydney, Australia
Article
Full-text available
Despite being disproportionately affected by poor mental health, culturally and linguistically diverse (CaLD) individuals seek help from mental health services at lower rates than others in the Australian population. The preferred sources of help for mental illness amongst CaLD individuals remain poorly understood. The aim of this study was to explore sources of help in Arabic-, Mandarin-, and Swahili-speaking communities in Sydney, Australia. Eight focus-group discussions (n = 51) and twenty-six key informant interviews were undertaken online using Zoom. Two major themes were identified: informal sources of help and formal sources of help. Under the informal sources of help theme, three sub-themes were identified: social, religious, and self-help sources. All three communities strongly recognised the role of social sources of help, with more nuanced roles held by religion and self-help activities. Formal sources of help were described by all communities, although to a lesser extent than informal sources. Our findings suggest that interventions to support help-seeking for all three communities should involve building the capacity of informal sources of help, utilising culturally appropriate environments, and the collaboration between informal and formal sources of help. We also discuss differences between the three communities and offer service providers insights into unique issues that require attention when working with these groups.
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... It includes the ability to recognize mental illness, knowing how to collect mental health information; knowledge about risk factors and causes, and about self-treatments and professional help available (Jorm, 2012). There is also evidence that different levels of knowledge and beliefs about the nature and management of mental health problems may act as barriers to help-seeking behavior in e.g., Arabicspeaking groups (Slewa-Younan et al., 2014). Following this, some MHL researchers argue that also stigma, positive mental health, and help-seeking efficacy should be added to the MHL definition (Kutcher et al., 2019;Spiker and Hammer, 2019). ...
“I can’t describe how I could get better, but I would like to” - Conception of health and illness of refugee youth in Germany
Article
Full-text available
  • May 2023
Introduction and objective Almost half of all the people displaced worldwide are children and adolescents. Many refugee children, adolescents, and young adults suffer from psychological stress. However, their utilization of (mental) health services is low, probably due to a lack of knowledge about (mental) health and (mental) health care. The current study aimed to explore concepts of (mental) health and illness of refugee youth as well as assess their mental health literacy (MHL) to arrive at conclusions for improving mental health care access and use. Method From April 2019 to October 2020, we conducted 24 face-to-face interviews with refugee children and adolescents in an outpatient clinic (n = 8), in youth welfare facilities (n = 10), and at a middle school (n = 6). A semi-structured interview was used to assess knowledge about mental and somatic health and illness as well as corresponding health strategies and care options. The material was evaluated using qualitative content analysis. Results Participants (N = 24) were between 11 and 21 years old (M = 17.9, SD = 2.4). The coded material was assigned to four thematic main areas: (1) conception of illness, (2) conception of health, (3) knowledge about health care structures in their country of origin, and (4) perceptions of mental health care structures in Germany. Compared to somatic health, the interviewed refugee children and adolescents knew little about mental health. Furthermore, respondents were more aware of opportunities of somatic health promotion, but almost none knew how to promote their mental health. In our group-comparative analysis we observed that younger children possess little knowledge about mental health-related topics. Conclusion Our results show that refugee youth have more knowledge about somatic health and somatic health care than about mental health (care). Accordingly, interventions to promote the MHL of refugee youth are necessary to improve their utilization of mental health services and to provide adequate mental health care.
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The Development and Validation of a Measure of Mental Health, Help-Seeking Beliefs in Arabic-Speaking Refugees
Article
  • Dec 2023
  • ASSESSMENT
Despite reporting elevated rates of posttraumatic stress disorder (PTSD), refugees are less likely than other groups to seek psychological treatment. Relatively little attention has been paid to the role of negative help-seeking beliefs in influencing treatment uptake. The current study sought to develop and psychometrically validate a novel measure indexing negative help-seeking beliefs for refugees (Help-Seeking Beliefs Scale [HSBS]). In this study, 262 Arabic-speaking refugee participants completed an online survey consisting of the HSBS along with measures indexing similar constructs (self-stigma of PTSD and help-seeking, perceived stigma, negative help-seeking attitudes, and help-seeking intentions). Factor analysis revealed a three-factor structure aligning with key themes identified in the literature: (a) Fear of Negative Consequences, (b) Inappropriateness, and (c) Perceived Necessity. The scale demonstrated excellent internal consistency, convergent validity, and predicted reduced help-seeking intentions. Results support the utility of a novel measure capturing a prominent help-seeking barrier in a population with high psychopathology and low treatment uptake.
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A mixed methods systematic review of mental health self-care strategies for Arabic-speaking refugees and migrants
Article
Full-text available
Background Self-care strategies can improve mental health and wellbeing, however, the evidence on preferred strategies among Arabic-speaking refugees and migrants is unclear. This mixed methods systematic review aimed to identify and synthesise the global research on mental health self-care strategies used by these populations. Methods English and Arabic language studies reporting on positive mental health self-care strategies to address symptoms of posttraumatic stress disorder, generalised anxiety and depression in the target populations were identified by systematically searching eight electronic databases and grey literature. Studies were deemed eligible if they were published from 2000 onwards and included Arabic-speaking migrants, refugees or asylum seekers aged 12 years and above. A narrative synthesis of study characteristics and relevant key findings was undertaken. The review protocol was registered on PROSPERO (registration number CRD42021265456). Results Fifty-nine records reporting 57 studies were identified, the majority appearing after 2019. There were 37 intervention studies that incorporated a self-care component and 20 observational studies that reported on self-generated self-care practices. Across both study types, four broad groups of mental health self-care were identified—social, psychological, religious/spiritual, and other (e.g., expressive arts and exercise). Psychological strategies were the most reported self-care practice overall and featured in all intervention studies. Religious/spiritual and social strategies were more common in the observational studies. Intervention studies in diverse settings reported statistical improvements on a range of outcome measures. Observational studies reported a range of individual and community benefits. Linguistic, cultural and religious considerations, inherent in the observational studies, were variably addressed in the individual and group interventions. Conclusion Overall, study participants experienced self-care as helpful although some encountered challenges in practicing their preferred strategies. Further research on mental health self-care strategies among Arabic-speaking refugees and migrants is needed in Western resettlement countries to guide mental health service delivery and primary healthcare initiatives for new arrivals and in transit countries.
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The Harvard Trauma Questionnaire: validating a cross-cultural instrument for measuring torture, trauma, and post traumatic stress disorder in refugees
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Full-text available
  • Feb 1992
There are no valid and reliable cross-cultural instruments capable of measuring torture, trauma, and trauma-related symptoms associated with the DSM-III-R diagnosis of posttraumatic stress disorder (PTSD). Generating such standardized instruments for patients from non-Western cultures involves particular methodological challenges. This study describes the development and validation of three Indochinese versions of the Harvard Trauma Questionnaire (HTQ), a simple and reliable screening instrument that is well received by refugee patients and bicultural staff. It identifies for the first time trauma symptoms related to the Indochinese refugee experience that are associated with PTSD criteria. The HTQ's cultural sensitivity may make it useful for assessing other highly traumatized non-Western populations.
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Physical and Mental Health Status of Iraqi Refugees Resettled in the United States
Article
Full-text available
  • Aug 2013
We conducted a survey among Iraqi refugees resettled in the United States to assess their physical and mental health status and healthcare access and utilization following the initial 8-month, post-arrival period. We randomly selected Iraqi refugees: ≥18 years of age; living in the United States for 8-36 months; and residents of Michigan, California, Texas and Idaho. Participants completed a household questionnaire and mental health assessment. We distributed 366 surveys. Seventy-five percent of participants had health insurance at the time of the survey; 43 % reported delaying or not seeking care for a medical problem in the past year. Sixty percent of participants reported one chronic condition; 37 % reported ≥2 conditions. The prevalence of emotional distress, anxiety, and depression was approximately 50 % of participants; 31 % were at risk for post-traumatic stress disorder. Iraqi refugees in this evaluation reported a high prevalence of chronic conditions and mental health symptoms despite relatively high access to healthcare. It is important for resettlement partners to be aware of the distinctive health concerns of this population to best address needs within this community.
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Security and Displacement in Iraq: Responding to the Forced Migration Crisis
Article
Full-text available
  • Oct 2008
  • INT SECURITY
Since the 2006 bombing of the al-Askari Mosque, 4.5 million Iraqis have fled their homes, and displacement has become a central strategy in the civil war. Militant groups have engineered these colossal population movements to consolidate their power and expand their territorial claims. As this crisis demonstrates, displacement can expand and intensify violence during a civil war. In addition, refugee flows increase the risk that conflict will spread across international borders. In some cases, refugee militarization can lead to international war and regional destabilization. Even if the displaced Iraqis do not join militant groups, their mere presence will exacerbate political tensions. To prevent the wide-scale militarization of the displaced Iraqis, donors and host states should heed the following policy recommendations. First, provide a massive infusion of humanitarian aid. Second, resist the temptation to build camps to house the displaced. Third, do not return the displaced people home against their will. Fourth, expand and expedite the resettlement process, especially for vulnerable Iraqis such as those who were once coalition employees.
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State of the Art Procedures for Translating, Validating and Using Psychoeducational Tests in Cross-Cultural Assessment
Article
Full-text available
  • Apr 1991
The purpose of this paper is to outline state of the art procedures for test translation, validation and use in multicultural, multilingual assessment. Guidelines are based on psychometric, linguistic, cultural and practical considerations. The authors encourage sound practice within the international psychological community in its assessment of children outside the intended source language and/or culture of available tests.
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Depressivität, Angst und posttraumatische Belastungsstörung bei Arbeitsmigranten, Asylbewerbern und Flüchtlingen Systematische Übersichtsarbeit zu Originalstudien Depression, Anxiety and Posttraumatic Stress Disorders in Labor Migrants, Asylum Seekers and Refugees A Systematic Overview Einleitung
Article
  • Jan 2008
  • PSYCHOTHER PSYCH MED
In 2006 there were about 200 millions of transnational "voluntary" migrants like labor migrants and "involuntary migrants" like refugees and asylum seekers worldwide. Depression, anxiety and posttraumatic stress disorder (PTSD) is the most prevalent psychiatric disorders in general populations and is reported to be highly prevalent among migrants. We aimed to assess and compare syndromes and symptoms of depression and anxiety in labor migrants and refugees; and to examine whether the prevalence rates are associated with study methods' and study quality. We systematically searched in the databases MEDLINE and EMBASE for studies published from 1994 - 2007. Studies fulfilling the inclusion criteria are 1) systematically described: 2) and evaluated with 15 quality criteria. The literature search generated 348 results; and 37 fulfilled our inclusion criteria (35 populations) with n = 24 681 migrants (labor migrants: n = 16 971; refugees: n = 7710). Size of studies varies from a minimum of n = 55 participants to a maximum of n = 4558 participants (Median: n = 338). Prevalence rates for depression vary between 3 % and 47 % (labor migrants) and between 3 % and 81 % (refugees); for anxiety between 6 % and 44 % (labor migrants) and between 5 % and 90 % (refugees) and for PTSD between 4 % and 86 %. No study fulfilled all 15 quality criteria. CONCLUSION AND OUTLOOK: Migrants are a heterogeneous group and prevalence rates vary widely between studies. There is a need of high-quality representative studies on migrants' mental health to adequately plan health and social care.
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Mental health literacy among refugee communities: Differences between the Australian lay public and the Iraqi and Sudanese refugee communities
Article
  • Nov 2013
  • SOC PSYCH PSYCH EPID
This study investigated differences in mental health knowledge and beliefs between participants from the Iraqi and Sudanese refugee communities, and Australian-born individuals, in Sydney, Australia. Ninety-seven participants were given vignettes of characters describing symptoms of major depressive disorder and posttraumatic stress. They were required to identify psychological symptoms as disorders, rate beliefs about the causes of and helpful treatments for these disorders, and rate attitude statements regarding the two characters. Australian participants recognized the presented symptoms as specific mental disorders significantly more than Iraqi and Sudanese participants did, and reported causal and treatment beliefs which were more congruent with expert beliefs as per the western medical model of mental disorder. The Sudanese group endorsed supernatural and religious causal beliefs regarding depression and posttraumatic stress symptoms most often; but both Sudanese and Iraqi participants strongly supported options from the supernatural and religious treatment items. However, evidence for pluralistic belief systems was also found. Although sampling was non-random, suggesting caution in the interpretation of results, it appears that the mental health literacy of lay Australians may be more aligned with the western medical model of mental disorder than that of Iraqi and Sudanese refugee communities. Mental health literacy support needs of Iraqi and Sudanese refugee communities resettled in western countries such as Australia might include education about specific symptoms and causes of mental disorder and the effectiveness of psychiatric treatments. These findings provide useful directions for the promotion of optimal service utilization among such communities.
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Depressivität, Angst und posttraumatische Belastungsstörung bei Arbeitsmigranten, Asylbewerbern und Flüchtlingen
Article
  • Mar 2008
Background: In 2006 there were about 200 millions of transnational "voluntary" migrants like labor migrants and "involuntary migrants" like refugees and asylum seekers worldwide. Depression, anxiety and posttraumatic stress disorder (PTSD) is the most prevalent psychiatric disorders in general populations and is reported to be highly prevalent among migrants. Aims: We aimed to assess and compare syndromes and symptoms of depression and anxiety in labor migrants and refugees; and to examine whether the prevalence rates are associated with study methods' and study quality. Methods: We systematically searched in the databases MEDLINE and EMBASE for studies published from 1994 - 2007. Studies fulfilling the inclusion criteria are 1) systematically described: 2) and evaluated with 15 quality criteria. Results: The literature search generated 348 results; and 37 fulfilled our inclusion criteria (35 populations) with n = 24 681 migrants (labor migrants: n = 16 971; refugees: n = 7710). Size of studies varies from a minimum of n = 55 participants to a maximum of n = 4558 participants (Median: n = 338). Prevalence rates for depression vary between 3 % and 47 % (labor migrants) and between 3 % and 81 % (refugees); for anxiety between 6 % and 44 % (labor migrants) and between 5 % and 90 % (refugees) and for PTSD between 4 % and 86 %. No study fulfilled all 15 quality criteria. Conclusion and outlook: Migrants are a heterogeneous group and prevalence rates vary widely between studies. There is a need of high-quality representative studies on migrants' mental health to adequately plan health and social care.
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Multiple comparison using RANK sums
Article
  • Aug 1964
  • TECHNOMETRICS
This paper considers the use of rank sums from a combined ranking of k independent samples in order to decide which populations differ. Such a procedure is suggested as a convenient alternative to making separate rankings for each pair of samples, and the two methods are compared. Asymptotic use of the normal tables is given and the treatment of ties is discussed. A numerical example is given.
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