ualitative research methods to reflect the perspectives of all participants. The research design drew on "grounded theory", which describes the inductive process of identifying analytical categories to describe and explain key issues as they emerge from the data.13 Hypotheses were developed from the ground up, rather than being defined a priori, as is usually done in quantitative research.
Recognising that the effectiveness of communication is inextricably connected with structural issues of poverty, dispossession, marginalisation, low educational achievement and racial discrimination,7 we chose a "participatory action" approach. This is a style of research in which the demarcation between "researcher" and "subject" is blurred, research design is negotiated, and the participants perceive the need to change and are willing to participate actively in the change process.14 The research process is illustrated in Box 1.
Five clinical interactions, identified beforehand in consultation with both patients and staff, were selected. These concerned diagnosis, treatment and chronic disease management. Staff were asked to follow their usual practice regarding the use of interpreters. The interactions included two medical reviews (one with a patient on regular haemodialysis and one with a patient with chronic renal disease close to needing maintenance dialysis), two education sessions (a nurse providing feedback on blood-test results and a consultation between an allied health professional and a new patient), and an interaction between a nurse and a patient during dialysis.
We selected participants using a "maximum variation sampling approach", wherein a small sample is selected to reflect maximum diversity across specified attributes.16 The participants covered as wide a range as possible in terms of age, sex, duration of renal experience (receiving or providing treatment), degree of familiarity with the culture and language of the other group, and experience in cross-cultural communication.
The five interactions were videotaped and analysed by all participants, the research team and professional interpreters. Multilayered descriptions of the interactions were constructed from these varied perspectives.
After each interaction, the participants were interviewed separately, in their first language, to explore their perceptions of the effectiveness of the communication. The post-interaction ("exit") interviews were conducted by A L (for English speakers) and B M (for Yolngu speakers). Semi-structured, in-depth interviews were also conducted with most staff and patients to develop a greater understanding of their backgrounds and wider experience.
Informed consent was obtained from all participants before videotaping. B M obtained verbal and written consent in the patients' own language.
The data from all sources were integrated to explore the extent of miscommunication; the cultural, linguistic and systemic factors influencing communication; the effectiveness of communication strategies being used; and possible strategies for improving communication.
The video descriptions and interview transcripts were entered into QSR NVivo,15 a computer software package that assists in managing qualitative data. Categories used in analysis were derived primarily from the data and through sequential analysis. To strengthen the validity of our analysis, we used "triangulation" (the comparison of results from two or more different methods of data collection) and "respondent validation" (cross-checking interim findings with the participants).17,18
A picture emerged of serious miscommunication, often unrecognised by participants, regarding fundamental issues in diagnosis, treatment and prevention. Although there were many differences of goals and structure observed in the interactions, common themes relating to miscommunication emerged. Factors impeding communication included lack of control by the patient, differing modes of discourse, dominance of the biomedical model, lack of shared knowledge and understanding, cultural and linguistic distance, lack o