taped 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 of staff training in inter-cultural communication, and failure to call on trained interpreters (see Box 2 and Box 3).
In each interaction, it was the staff who controlled the time, place, participants, purpose, structure, topics and language, as well as the form and style of discourse. There were few opportunities for the patients to initiate or influence the agenda. The staff decided whether or not interpreters would be required, even when unaware of the patient's fluency in English.
Western modes of discourse dominated, with Yolngu modes being marginalised or excluded. Question-and-answer routines, central to Western discourse, do not feature commonly in Yolngu discourse, particularly in relation to personal topics. In Yolngu discourse, the question-and-answer approach is complicated by factors such as cultural restrictions on who may ask for, or give, specific information. It is generally considered impolite to directly contradict or to respond negatively, particularly in encounters of unequal power or when the participants lack a close relationship. The patients in our study repeatedly gave responses that they believed the staff wanted to hear, a practice known in linguistics as "gratuitous concurrence".19 Triangulation showed that these responses did not represent the patient's true feelings or experience, but were attempts to give "required" or "correct" responses, as in the following example:
Physician: How much are you drinking? How much water?
Patient: Little bit water tea, little bit ga bilin ["that's it"].
Physician: How much each day? Water, tea?
Patient: Three cup, two cup, little bit [said very confidently].
The physician believed that the patient had a clear understanding of the question and was describing the amount of fluid drunk daily. However, it later became clear that the patient responded this way because she knew what was expected. Her understanding of fluid restriction was that she should drink only two cups of "fizzy drink" per day, but that drinking tea or water whenever she felt like it 