Research on Translation of Chinese Medicine Constitution (Tizhi) Academic Terms: Based on Memetics and Delphi Method

Background With the continuous in-depth research of Chinese medicine constitution (tizhi) and the continuous expansion of cross research with new disciplines, internationalization will become the future trend of Chinese medicine constitution (tizhi). Translating the terms of Chinese medicine constitution (tizhi) into English is the first step for Chinese medicine constitution (tizhi) to go international. Language memes play an important role in information transmission in social interpersonal communication activities. The continuous replication and dissemination of translation memes make language spread and popularized. Because there is no fixed translation method at present, based on the particularity of Chinese medicine constitution (tizhi), we decided to use the Delphi method to complete the term translation research. Objective The purpose of this study is to provide a standard and unified translation method for terms of traditional Chinese medicine (TCM) constitution with Chinese characteristics through the Delphi expert consultation strategy. Methods Forward translation and expert consensus were conducted to complete this study. We sorted out the related terms of Chinese medicine constitution (tizhi) theory and invited an expert from the World Federation of Chinese Medicine Societies (WFCMS) to complete the initial forward translation. An expert of Chinese medicine constitution (tizhi) theory joined this process. Then, we invite relevant professionals to evaluate this translation version using the Delphi method. Results Following a 3-round Delphi survey, the translation criteria of 61 (92.42%) terms were unified, and 5 terms resulted in no consensus and reached consensus on the translation method of Chinese medicine constitution (tizhi) theory. A major problem about how to translate “中医体质学” is identified. 25 experts participated in this study, and the drop-out rate is 0% in the 3-round Delphi survey. Translation challenges include the following: (1) translation methods of “Chinese medicine constitution (tizhi) theory”; (2) experts' understanding deviation on the definitions of some terms. Conclusions The average mode, full score ratio, standard deviation, coefficient of variation, and variation ratio of expert scores are analyzed. The diversity of regions and professional titles of experts shows that they have a high degree of authority. The scores of terms indicate the consistent of study results, so they can be used as a reference for the translation of Chinese medicine constitution (tizhi) theory.


Introduction
In 1978, the research on Chinese medicine constitution (tizhi) (CMTZ) theory led by Wang Qi was put forward. is theory was based on the Yellow Emperor's Internal Classic and took Treatise on Cold Pathogenic and Miscellaneous Diseases (Shanghan Zabing Lun), classic bibliography of TCM as the main theoretical and clinical guidance [1,2], combined with many explorations and proofs in clinical and experimental studies. It is a theory that is mainly about human constitution characteristics, physiological and pathological characteristics of varying constitutions, analysis of reaction to disease, pathological nature and development trend, and guidance of disease prevention and treatment [3]. For the first time, it was confirmed that human's constitution is divided into nine types, from 2005 to 2007, and an epidemiological survey of 21948 people in nine provinces and cities of China was carried out, which confirmed the proportion of Chinese human's constitution [4]. Since 2009, the state administration of traditional Chinese medicine has added constitution (tizhi) identification to the standard of disease prevention and continuously expanded the scope of services in the next ten years [5]. CMTZ theory has been continuously developed and improved, forming a relatively complete theoretical system and becoming a characteristic project guiding the national health project of "preventive treatment of disease." Overseas, the influence of CMTZ theory is also expanding. e book Systematic introduction to CMTZ compiled by Wang Qi has been translated and published in the United States [6]. In addition, the Constitution of Chinese Medicine Questionnaire written by Wang Qi has also been translated into varying languages and applied in different countries [7]. With the continuous in-depth development of the research on CMTZ theory, some characteristic terms have been put forward, such as "threedifferentiation clinical mode" and "treatment based on tizhi differentiation [8]." ese terms are all newly created with unique expressions and definitions, which are different from any terms in TCM. As the carrier of TCM language, TCM terminology is an important part of linguistic research. Translating standardized terminology into local terms is an important step in the process of cross-cultural adaptation. At present, there is still no unified standard for the translation of TCM-related terms, but in the process of practice, we know that successful memes are easier to spread and replicate on the Internet [9].
Meme is "the information unit in the brain." Professor He ZIran, who studies language application, believes that language meme plays an important role in information transmission in social interpersonal communication activities and is "the external and visual (auditory) expression of meme in the brain." Memes in natural language are embodied in three aspects: education and knowledge transfer, the use of language itself, and communication and exchange through information [10]. Andrew Chesterman proposed that "the evolution of translation theory is caused by the continuous replication and dissemination of translation memes" [11]. At present, the research of memetics in China mainly involves the interdisciplinary research of memetics and translation, teaching, social language, and communication. A success meme should have three elements: "fecundity," "longevity," and "copying fidelity [9]." e translation methods of memetics are shown in Table 1.
Delphi method is often used in nursing practice [12], medical quality assessment [13], and translation [14]. Because we get feedback about translation through repeated surveys to obtain expert opinions, the opinions are usually unified after three rounds. As a team led by Academician Wang Qi, Research Center of CMTZ and Reproductive Medicine of Beijing University of Chinese Medicine, intends to sort out the Chinese version of CMTZ theory terms and translate them using memetics and Delphi method, it provides reference for domestic and foreign Tizhi theory researchers and promotes the popularization of CMTZ theory.

Methods
We first set up a steering group, which was responsible for drafting a detailed timetable, providing operational guidance, and facilitating the whole process. e steering group consists of a senior CMTZ theory expert, a methodological researcher, and two research secretaries. e flow chart of the whole study is shown in Figure 1.

Terminology Collection and Translation.
All specialized vocabularies of CMTZ theory are sorted out, and the related concepts are listed in table. A total of 66 terms and their concepts were sorted out. e terminology comes mainly from the Chinese Medicine Constitution (tizhi) theory [15], which covers almost all terminologies and concepts of this area. In addition, there are also a few terms picked from recent papers, such as "Constitution (tizhi)-soil theory." ose who involved in the translation work should meet a core set of qualification criteria, such as domain expertise and proficiency in the target language [16]. To make the translation more standardized and conform to the translation habits of TCM terms, we invited an expert from the Standards Department of the World Federation of Chinese Medicine Societies to cooperate with the experts in the steering group. Both experts have sufficient knowledge of TCM and English, and they will work together for preliminary translation. e main principles of translation refer to that of memetics preliminary forward translations of 66 terms which are shown in Table 2.

Identification of Core
Issues. When preparing this questionnaire, the steering group invited some experts on CMTZ theory to discuss the key issue of this questionnaire, that is, how to translate "体质," by brainstorming and referring to published documents or textbooks. We use PubMed to systematically search the literature about the tizhi theory from the establishment of the database to December 31 st 2020. As a result, by December 31 st 2020, among the 84 English literature related to the tizhi theory, there were 78 that used the term "中医体质学," among which 52 (66.67%) used "(traditional) Chinese medicine constitution (constitution of/in (traditional) Chinese medicine)," 10 (12.82%) used "(traditional) Chinese medicine body constitution (body constitution of/in (traditional) Chinese medicine," 6 (7.69%) used "body constitution," and 5 (6.41%) used "constitution." Other translations include " e constitutionology of Chinese medicine," " e Chinese constitutional theory," "TCM Physique," "constitutional theory in Chinese medicine," and "constitutional theory in Chinese medicine." Specific search steps are shown in Table 3.
Based on the above results, we did a survey on whether to accept the word "tizhi" instead of "constitution." A multiplechoice question was set at the beginning of the questionnaire. e question is set as "in order to meet the new situation of internationalization of TCM terms, after consulting experts on a small scale, it is considered that the translation of the word "体质" as "constitution," which was used more in the past, is easy to cause ambiguity and cannot reflect the characteristics of TCM." erefore, we plan to change the English expression of the word into "Chinese medicine tizhi" in this standardized translation work. It is expected to provide a transition for popularizing the expression of Chinese traditional medicine characteristics. ere are three options: agree, disagree, and others. After each option,   Essential factor Explanation Copying fidelity e more faithful the copy is to the original, the higher the fidelity Prolificacy e faster and more memes are copied, the more they can spread. Industrial printing presses print more copies in a shorter time than manual printing presses. Longevity e longer the replication exists, the more stable the propagation is Uniformity e internal value of memes is consistent, which is not contradictory to the existing beliefs of individuals Novelty Memes can add new, unusual elements that can attract the attention of receptors Simplicity Memes should be easy to master and remember Individual practicability Memes should be able to help individuals achieve their personal goals Significance It should be easy to attract the attention of the receptor, for example, words loudly shouted or printed in the font of large posters Expressive Memes should be easily expressed in language or other forms of communication Formality e expression of memes is not easily changed by individuals or contexts Infectivity Individuals carrying memes should be willing to express, teach memes to others, or convert them into a belief Conventionality Memes can be supported by most individual ideas Collective utility Memes apply to groups rather than individuals Evidence-Based Complementary and Alternative Medicine

Establishing Expert Database.
As the CMTZ theory is a branch of TCM, and the research involves the application of CMTZ theory terms in English background, therefore, we mainly invited experts who knew the relevant background in the early stage of establishing the expert database. We mainly considered their literature contributions in this field and our personal contacts. We additionally invited 5 experts from the Englishlanguage specialtyof TCM.A total of 30expertsreceived the invitation letter. e letter briefly outlines the background, objectives, and expected number of rounds of the project, and the first-round questionnaire was attached. If experts agree to participate, the results would be returned directly by mail.

Delphi Expert Consultation.
Experts reply by e-mail or fill them on an online questionnaire website (https://ww.wjx. cn/). We first collect personal information of participating experts, including gender, technical title, employer, occupation, major and years of professional experience, etc., which are used to analyze the authority of experts in statistics. Before each round of the survey, we will introduce our research purpose and details, as well as the inconsistent results of the previous rounds and answer part questions raised by experts. For experts' better understanding of the meaning of the terms and make accurate and objective judgments, each term in the questionnaire will be accompanied by its concepts, as long as these concepts can be found during collection. When the term is difficult to understand and the concept cannot be found, we will consult the opinions of CMTZ experts, and an explanation that is easy to understand will be attached to the term.
In the first round, one translation version will be given to each term, and experts will give their scores; questionnaires used by the traditional Delphi method typically consist of 4-9 points [17]. In this research, a 4-option question was used to measure the experts' attitude toward each item. Experts should look at each translation version and use a scale ranging from score 1 (very dissatisfied) to 4 (very satisfied) to classify their degree of agreement [18]. After each term, there is a comment box used to collect the reasons of their choice and provide an opportunity for experts to share their suggestions, which will be presented and resolved in the second and third rounds. When experts choose "2" or "1," they can also put forward their own translation strategies. e consistency among respondents should be ≥75% [19,20], or another round of voting should be implemented to reach a higher degree of agreement or confirm that no consensus has been reached. Experts' suggestions collected in nonagreed terms will be displayed on the new round list as new options or explanations for another vote. In an iterative manner, the same process will be repeated in certain expert groups. To ensure an adequate response rate in each round, experts are required to leave their real names to make sure they finished the questionnaire. To minimize the workload of experts, terms with an agreement level less than 50% in the previous round will not be discussed in the next, and the votes should be no more than 3 rounds.  We unified the translation version of 32 terms. For the first multiple-choice question, 17 (68%) of the experts agreed to translate "中医体质学" into "Chinese medicine constitution (tizhi)," while 7 (28%) disagreed and 1 (4%) chose others, figuring out the term can be translated into "traditional Chinese medicine constitution" as transition. We adopted their opinion and added this question to the next round, adding opinions about translation to the questionnaire in the second round.

Results of the Second Round.
e second-round questionnaire contains 34 terms and 85 translations, and 20 items achieved consensus. For the first multiple-choice question, 20 (80%) of the experts chose "Chinese medicine constitution (tizhi)," 4 (16%) thought it could be transitioned as "traditional Chinese medicine constitution"; 1 (4%) chose others and recommended to meet reader needs. We added this option to the third round.
is important issue was agreed on in this round since more than 75% of experts agreed to translate into "Chinese medicine constitution (tizhi)."

Results of the ird Round.
In this round, the questionnaire contains of 14 terms and 49 translations. e average number of translations with the highest agreement among the remaining 5 entries ranged from 2.56 to 2.8, and failure to agree or agree with each other requires further exploration in future applications. e score results of the five items of each translation are shown in Figure 2. e translation results, scores, and statistics for each entry are shown in Table 4.

Experts in the Expert Panel
We sent emails to a total of 30 experts in China, and 25 experts responded to our questionnaire; the questionnaire response rate reached 83.33%. e experts who fulfilled the 3-round Delphi survey were 25, and response rates are 100%. e background of the experts is shown in Table 5. ese experts come from 14 different units in 9 regions of China, male experts account for 40%, and female experts account for 60%. ere are 80% of experts with doctor's degrees and postdoctoral degrees and 80% of experts with senior professional titles. Most experts account for two or more in scientific research and teaching and clinical activities, and the proportion of experts engaged in scientific research reached 96%. More than 50% of the experts are postgraduate supervisors. Experts comes from 10 major categories, including CMTZ, integrated traditional Chinese and Western medicine, traditional Chinese medicine, traditional Chinese medicine English, nutrition, and acupuncture, which shows professional diversity. ree of them are the academic heirs of traditional Chinese medicine, and they also provide opinions on translation methods with traditional Chinese medicine characteristics. We searched the literature before issuing the questionnaire. All experts knew something about CMTZ or published at least one relevant paper.

Limitations
First of all, with the continuous development of CMTZ theory, the number of terms will continue to expand. If the old translation results are not updated in time, there will be no unified translation method for some terms with the increase of terms. Secondly, due to the disciplinary limitations of this study, most of the experts we selected come from Beijing University of Chinese Medicine and major in CMTZ or those who have studied in this major. When answering questionnaires, compared with experts and staff of English translation, there may be certain professional limitations. For example, most experts have published professional related papers, so there may be some fixed pattern of thinking in word expression. irdly, most of the experts major in Chinese medicine disciplines, so the words used in translation from Chinese into English are not rigorous enough. We invited some experts majoring in Chinese medicine English to fix this problem. Finally, as some experts of TCM English major have some misunderstandings about the concept of CMTZ; in the latter round, we used simpler and understandable words to explain the terms with the premise of consulting the group experts. In the future, with the development of CMTZ, the terminology can be improved by more experts, and the results we deliver now do not necessarily represent the final version.

Discussion
Likert 5 and 7 scales are most used when using Delphi methods while few use Likert 4 scales [21]. When the consensus of the three scales is defined at 75%, it indicates that Likert scores should be ≥4/5 in Likert 5 scale and ≥6/7 in Likert 7 scale, while in Likert 4 scale, Likert scores should be ≥3. Unlike Likert 5, 7, and 9, Likert 4 has no median, so experts can only choose "agree" or "disagree" when scoring. However, as our questions are all semiopen, experts can raise their own opinions in fill-in questions whether they are satisfied with the translation results. If their opinions are neutral, they can state their position in the following table.
e results show that most experts will choose a low score (most will choose (2) to promote the next round of discussion when they think the translation results are open to discussion).
In recent years, the CMTZ theory has been widely welcomed by scholars at home and abroad, and the number of related papers published has increased yearly. Translating its terms into English is conducive to global promotion. In this study, we invited experts from various regions, employers, genders, levels, and occupations in China and took three rounds of investigation based on the Delphi method. Experts are authoritative and the result was good and representative. It can be used as a preliminary reference for the translation of CMTZ terms, which will be convenient for later experts to unify the vocabulary when writing or to unify search terms when searching papers.
is translation is based on the memetics and Delphi method, which is short in words and easy to understand, and provides a standardized method for other English-speaking countries. is is the first Evidence-Based Complementary and Alternative Medicine       Evidence-Based Complementary and Alternative Medicine experiment to combine the translation of CMTZ terms with the Delphi method. Translating "中医体质学" into "Chinese medicine constitution (tizhi)" can better reflect the characteristics of TCMZ theory and provide a transition for the application of "tizhi." Abbreviations CMTZ: Traditional Chinese medicine constitution (tizhi) TCM: Traditional Chinese medicine.
Data Availability e data used and/or analyzed during the study are available from the corresponding author on reasonable request. Consent e authors obtained the informed consent of all experts before participation.