lation, respondent validation and maximum variation sampling strengthen the validity of our findings.
Videotaping the interactions did not appear to fundamentally alter the communication strategies used by staff. In any case, we would expect any bias, arising through participants' knowledge of being observed, to be towards more effective rather than less effective communication. Our results support similar findings of miscommunication in other Aboriginal health research8,11,21 and in international cross-cultural research.1,3 We believe that our research findings are both credible and relevant to the delivery of healthcare to Aboriginal people, and that similar miscommunication problems are likely to exist in other healthcare settings in which there are people whose first language is not English.
Fundamental change is required to achieve effective communication with Aboriginal patients who have renal disease. We will not be able to deliver optimal care without striking a balance between the staff's medical priorities and the patients' social needs. Some strategies for improving communication are set out in Box 4. Planning and implementing such strategies for the Yolngu will require collaboration between staff, patients and patients' families. We are currently developing such a project. Short of such radical change, attempts to improve communication can meet with only limited success.
1: The research process
* Obtaining consent, exit interviews, feedback and in-depth interviews were undertaken with participants in their first language
2: Sample interaction (A)
Setting: The doctor's office in a remote community 500 kilometres from Darwin.
Participants: Mr "A", a 24-year-old man with chronic renal disease who recently had a prolonged admission to Royal Darwin Hospital, during which he required temporary dialysis. He lives with his mother and grandmother, and is fluent in Yolngu languages but not in English. He will need relocation to Darwin within two years for maintenance dialysis.
Dr "B", a 38-year-old male physician with many years' experience working with multicultural and Aboriginal patients.
The interaction: The 20-minute interaction, in English, was initiated by Dr B, who did most of the talking. The patient's mother and grandmother assisted with communication. Mr A and his family asked no questions and gave limited, non-verbal responses to the doctor's questions.
Communication goals: Dr B had clear goals:
I wanted to reinforce that [the patient] was at risk of progression to end-stage renal disease and that he would benefit from treatment, of blood pressure in particular . . . and treatment of other things like anaemia. . . . The main thing was that he doesn't need dialysis at the moment, but that he needed to be monitored and to take his tablets.
The expectations of Mr A and his family were unclear. It later became apparent that they believed that his disease had been cured during his admission. They had no appreciation of its chronicity and of his need for regular tests and medications.
The participants' assessment: Dr B was uncertain of the outcome of the interaction:
Perhaps his mother got some idea . . . I hope they at least understand he is at risk of needing more dialysis. I think they now understand he has kidneys that aren't working so well . . .
After the consultation, the Yolngu researcher discovered that the family's understanding of the doctor's advice was that Mr A should be taking medication. Despite Dr B's extended explanation of chronicity and prognosis, the interaction did not achieve a shared understanding of the state of the patient's kidneys, the significance of test results or the importance of blood pressure control. The family had understood little. This prompted the Yolngu researcher to recall Dr B to explain further, while she provided interpreting assistance.
Consequences for clinical management: Miscommunication reduced the ability to actively engage Mr A and his family in controlling his blood pressure, in retarding progression of his renal disease and in planning for future dialysis. Lac