Devitt and McMasters (1998) suggest that the less patients understand what it is they must do and why,'the more compliance itself becomes simply an issue of "obedience"' (p.165).
This was clearly illustrated in the Sharing the True Stories study, where the rejection of treatment was a common strategy described by patients which seemed to be directly related to control, often in the context of being told what they should or should not do about their health.
Because of the politeness conventions, power dynamics, limited English proficiency and limited understanding of Western biomedical culture that influence Yolngu discourse in clinical encounters, it is unlikely that patients will directly challenge or reject information or advice they are given. Their response might be not be verbalised but, instead, might be realised through their actions.
The following examples from the Sharing the True Stories research illustrate how power relationships can influence communication.
Dietary advice, particularly related to diabetes, is one area in which
Yolŋu resist what some see as attempts by Balanda to control their actions:
I was thinking that they were lying to me (about
sugar and diabetes); I won't worry about it - it doesn't matter if I eat
sugar, I won't believe them: see where I am now (interview with a Yolŋu patient)
Another Yolŋu participant also described how she and her sister (both diabetics) rejected the advice they were given about 'healthy food' by the nutritionists:
You know that Yolŋu don't eat good food all the time, we eat junk food at the same time, like that...we like to eat any kind of food .. it's what we want to eat
In the context of haemodialysis, control issues were also evident in the patients' view of staff decision-making as based on reward and punishment and, as in this example, are discussed in terms of winning and losing:
if they're (other patients) early and I'm late and I can see these people sitting on their chairs already dialysed and I say to (the staff) 'I'm going to get 4 hours - leave one out' they can - if it's a bad tempered women they don't listen but I always win (interview with dialysis patient)
It was recognised by staff that some Yolŋu withhold information that is relevant to their renal care, either intentionally when they are concerned about how staff will respond or unintentionally because they are unaware of the significance the issue might have for their health.
One staff member explained that, although staff might recognise the importance of understanding the patients' perspectives, they are unsure about how to engage patients in such discussions:
The other communication problems are when patients are not turning up to dialysis you want to know why not, but how do you make that non-judgmental and non-threatening...but I think the non-judgment needs a lot of work as a lot of patients feel judged if they don't come; judged on their medication if the dosette box has tablets left in it so there are those issues of communication: how do you ask someone is there a problem without being judgmental and especially with fluid and alcohol and those issues as well; (how do you do it?) be truthful to them ' I'm just trying to find out the medications that you do take, if you don't take them that's OK because we are looking at your bloods and we want to see if the medication is strong enough...telling them the truth, why you're trying to find out, but it's very hard especially about the fluid, where the fluid comes from, that's very hard - because the word 'drink' has been associated with alcohol; certain types of English words are quite demeaning to aboriginal people so don't say drink when your trying to ask them for tea, coffee, coke - a lot of people get upset and say 'I don't drink alcohol'...when you say 'what do you drink?' there is an immediate association.
Asking about food is a problem as well because you don't get the whole story because either they feel embarrassed or the way they've told it 'yes, I get enough food' or if they're eating the wrong food they think they'll get told off again... (interview with educator)