A Delphi-Based Consensus Study for the Standardization of Diagnostic Terminology in Traditional Chinese Medicine

A Delphi-Based Consensus Study for the Standardization of Diagnostic Terminology in Traditional Chinese Medicine

Hongli Feng, *Jingwen Yang

School of Foreign Languages, Ningxia Medical University, Ningxia 750004, China

*Corresponding Author

DOI: https://dx.doi.org/10.47772/IJRISS.2025.90900069

Received: 09 September 2025; Accepted: 17 September 2025; Published: 29 September 2025

ABSTRACT

Traditional Chinese Medicine (TCM) has long occupied a central position in healthcare, both within China and beyond, particularly in the prevention, diagnosis, and treatment of complex conditions. Nevertheless, its global dissemination has been hindered by persistent inconsistencies in the English translation of diagnostic terminology, which undermine cross-cultural communication and restrict TCM’s integration into the international medical discourse. To address this challenge, the present study applied the Delphi method to establish a consensus-based framework for the standardization of English translations of TCM diagnostic terms. A purposively selected panel comprising 15 experts in TCM globally, linguistics, and translation studies engaged in three iterative Delphi rounds, systematically evaluating the accuracy, appropriateness, and communicative effectiveness of candidate terms through structured questionnaires. Consensus levels were measured using the Content Validity Index (CVI) and Kendall’s coefficient of concordance (W). The iterative process yielded progressively stronger agreement across rounds, ultimately producing a standardized set of 120 diagnostic terms characterized by high expert consensus. These results underscore the utility of the Delphi method as a rigorous and systematic approach to terminology standardization in TCM, offering a practical model for bridging linguistic and cultural divides and providing a transferable framework applicable to other specialized medical fields.

Keywords: Delphi Method; Consensus Study; Standardization; Diagnostic Terminology; Traditional Chinese Medicine

INTRODUCTION

Research Background

Traditional Chinese Medicine (TCM), with a history extending over two millennia, represents a distinctive medical system grounded in holistic diagnostic principles and individualized therapeutic strategies (Unschuld, 2009). In recent decades, TCM has garnered increasing international attention, particularly for its contributions to integrative medicine, chronic disease management, and preventive healthcare (Zhang, Sun, & Wang, 2020). Notably, landmark achievements such as Tu Youyou’s discovery of artemisinin, an antimalarial compound extracted from Artemisia annua, which was awarded the 2015 Nobel Prize in Physiology or Medicine, have further reinforced the global relevance of TCM (NobelPrize.org, 2015).

Despite its growing prominence, the international dissemination of TCM continues to encounter significant challenges. One of the most critical barriers lies in the inconsistency of English translations of core diagnostic terminology. For example, the fundamental concept of “Zheng” (证) has been variously translated as “syndrome,” “pattern,” or “manifestation” across textbooks, scholarly journals, and clinical practice guidelines (Li, Wang, & Chen, 2019). Such terminological variability undermines the establishment of a standardized professional lexicon, constrains the comparability of clinical research outcomes, and hinders the integration of TCM into international healthcare frameworks, including those promoted by the World Health Organization (WHO, 2019).

Problem Statement

Translation is not solely a linguistic activity but rather a complex cultural and communicative endeavor (Venuti, 2012). Within the domain of Traditional Chinese Medicine (TCM), diagnostic terminology encapsulates culturally embedded epistemologies that are challenging to convey in English without compromising their conceptual integrity (Unschuld, 2009; Li et al., 2019). Existing translations frequently oscillate between two extremes: prioritizing readability and accessibility for international audiences at the expense of terminological precision, or preserving cultural specificity in ways that hinder comprehensibility. This unresolved tension has led to fragmented and inconsistent usage of diagnostic terms across both academic and clinical contexts, thereby undermining the credibility of TCM scholarship and constraining its global acceptance (Wang & Chen, 2018). Consequently, the absence of a standardized translation framework constitutes a major impediment to effective cross-cultural communication, the comparability of research findings, and the broader international dissemination of TCM knowledge.

Rationale for Using the Delphi Method

The Delphi method, first developed by the RAND Corporation in the 1950s, represents a structured and iterative process designed to achieve expert consensus through successive rounds of anonymous questionnaires accompanied by controlled feedback (Linstone & Turoff, 2002). Owing to its methodological rigor and flexibility, the technique has been widely employed in healthcare research for the development of clinical guidelines, the standardization of specialized terminology, and the establishment of expert consensus in fields where empirical evidence is limited, inconsistent, or absent (Hasson, Keeney, & McKenna, 2000; Powell, 2003).

In the context of TCM diagnostic terminology, the Delphi method offers several distinct advantages. It enables the systematic integration of expert knowledge across multiple disciplines, reduces the potential bias introduced by dominant individuals, and allows for the incremental refinement of consensus using statistical measures such as the Content Validity Index (CVI) and Kendall’s coefficient of concordance (W) (Rowe & Wright, 1999). By applying this approach, the present study seeks to construct a standardized framework for the English translation of TCM diagnostic terms-one that reconciles linguistic accuracy, cultural fidelity, and communicative effectiveness. This orientation is consistent with Hu Gengshen’s theory of Translation as Adaptation and Selection, which highlights the necessity of adaptive choices across linguistic, cultural, and communicative dimensions to optimize the quality and functionality of the target text (Hu, 2005).

Due to its authority, representativeness, and globalization context, in this research, the terms we studied fro three publications: the WHO International Standard Terminologies on Traditional Medicine in the Western Pacific Region (abbreviated as IST),The International Standard Chinese-English Basic Nomenclature of Chinese Medicine (abbreviated ISN), The Study of International Standard Chinese-English Basic Nomenclature of Chinese Medicine(abbreviated ISBT).

Study Objectives and Significance

This study is guided by four primary objectives:

1. To systematically examine inconsistencies in the English translation of core TCM diagnostic terminology across ISN, IST, and ISBT.
2. To establish expert consensus on translations that ensure linguistic precision, cultural fidelity, and communicative effectiveness for selected TCM diagnostic terms through the Delphi method.
3. To compile a standardized reference list of TCM diagnostic terms that can inform clinical practice, enhance academic research, and promote the international dissemination of TCM knowledge.
4. To assess the broader applicability of the Delphi method as a replicable framework for terminology standardization in other specialized domains of medicine.

The significance of this study is threefold. First, it contributes to the linguistic and cultural standardization of TCM, thereby enhancing its credibility, consistency, and accessibility within the global healthcare discourse (Li et al., 2019; WHO, 2019). Second, it provides a rigorous methodological model for addressing terminology inconsistencies in other specialized medical domains where accurate translation is critical (Powell, 2003; Hasson et al., 2000). Third, it advances theoretical discussions in translation studies by operationalizing the principle of adaptive selection within a structured, consensus-driven framework (Hu, 2005; Venuti, 2012). By integrating perspectives from translation theory, TCM practice, and expert consensus methodologies, this research bridges the gap between locally embedded knowledge and international applicability, enabling the accurate and culturally sensitive representation of TCM in global contexts and fostering intercultural dialogue in healthcare (Zhang et al., 2020; Unschuld, 2009).

LITERATURE REVIEW

Current State of TCM Diagnostic Terminology Translation

The translation of Traditional Chinese Medicine (TCM) diagnostic terminology into English has long been a focal point of scholarly discussion, reflecting the epistemological and cultural complexities intrinsic to the discipline (Unschuld, 2009; Li, Wang, & Chen, 2019). Unlike biomedical terminology, TCM diagnostic terms are embedded within a conceptual framework that emphasizes the holistic interplay among the human body, nature, and the environment. For instance, the term Zheng (证) is frequently translated as “syndrome” to enhance accessibility; however, Zheng encompasses more than the biomedical concept of a “syndrome,” representing a dynamic functional state that integrates symptom constellations, pathophysiological changes, and contextualized interpretations within the TCM paradigm (Wiseman & Feng, 1998). Similarly, Qi Xu (气虚) is often rendered as “Qi deficiency,” and Shi Re (湿热) as “damp-heat.” While such translations facilitate initial understanding, they often fail to capture the full philosophical and diagnostic implications of these concepts.

Inconsistencies in translation have been widely documented across medical textbooks, clinical case reports, and international guidelines (Wang & Chen, 2018; Zhao, 2015). For example, Zheng is variably translated as “pattern,” “syndrome,” or “manifestation,” depending on the translator’s theoretical orientation or communicative priorities. Such variability impedes effective communication among practitioners and researchers, complicates the development of standardized instructional materials, and undermines the credibility of TCM within international academic and clinical contexts (Li et al., 2019).

Institutional and international initiatives have sought to address this challenge. The World Health Organization (WHO) published the International Standard Terminologies on Traditional Medicine in the Western Pacific Region (2007), providing standardized translations for numerous diagnostic and therapeutic terms. Although this represents a significant step toward terminological unification, adoption has been uneven. Many practitioners, educators, and researchers continue to rely on localized or institution-specific translations, reflecting entrenched disciplinary traditions and preferences (WHO, 2007; Wang & Chen, 2018). This ongoing divergence underscores the urgent need for a systematic, consensus-driven approach to translation standardization-one that balances linguistic precision, cultural fidelity, and communicative clarity-thereby promoting the international recognition and integration of TCM.

Major Contributions by Western Scholars

Several Western scholars have made seminal contributions to the study of Traditional Chinese Medicine (TCM) terminology translation, each employing distinctive methodologies that reflect the enduring tensions between linguistic accuracy, cultural fidelity, and communicative accessibility.

Manfred Porkert (1974), in his influential monograph The Theoretical Foundations of Chinese Medicine, was among the first to systematically introduce TCM concepts into English. He proposed a series of neologisms derived from Greco-Latin roots-for example, rendering Qi (气) as pneuma and Xue (血) as sanguis-with the aim of situating TCM concepts within the lexicon of Western scientific discourse. While innovative, Porkert’s system was frequently critiqued for being overly esoteric and abstruse, rendering it largely inaccessible to clinicians and students without a background in classical languages (Unschuld, 2009).

In contrast, Paul U. Unschuld (1985, 2003) adopted a philological and historically grounded approach. Emphasizing textual fidelity and cultural specificity, he sought to preserve the epistemological integrity of TCM concepts, even at the cost of immediate readability for international audiences. For instance, his translation of Qi as “influences” was intended to maintain conceptual neutrality and avoid misleading biomedical analogies. Although praised for its historical rigor, Unschuld’s approach has been criticized for producing translations that are occasionally opaque and less practical in clinical or pedagogical contexts (Scheid, 2002).

Joseph Needham’s monumental series Science and Civilisation in China (1954–2004) further shaped Western understanding of TCM by situating its conceptual evolution within the broader history of Chinese science and civilization. While Needham did not focus explicitly on translation, his integrative analyses highlighted the epistemological distinctiveness of TCM and underscored the challenges inherent in rendering culturally embedded concepts intelligible to non-Chinese audiences (Elman, 2006).

Collectively, these scholarly endeavors illustrate the persistent tensions in the translation of TCM terminology: balancing historical and cultural fidelity, linguistic precision, and international communicability. The divergent strategies adopted by Porkert, Unschuld, and Needham underscore the absence of a unified translation framework, a gap that continues to influence both academic discourse and practical translation practices in contemporary TCM scholarship.

Theoretical Frameworks for Translation

Translation theories provide essential conceptual tools for addressing the challenges associated with the standardization of TCM terminology. Eugene Nida’s Dynamic Equivalence Theory (1964, 2001) emphasizes communicative effectiveness, advocating for translations that prioritize the comprehension and natural reception of the target audience. This approach has been highly influential in cross-cultural and medical translation contexts, as it privileges functional clarity over strict literal fidelity. However, when applied to TCM, the tendency to simplify or domesticate complex conceptual systems may compromise the epistemological richness inherent in key diagnostic terms (Wang & Zhang, 2017).

Lawrence Venuti’s (1995, 1998) framework of domestication versus foreignization offers an additional lens through which TCM translation practices can be examined. Domestication aligns source texts with target-language conventions, thereby enhancing readability and facilitating integration into biomedical discourse; for example, translating Zheng (证) as “syndrome” exemplifies domestication by leveraging biomedical familiarity. Conversely, foreignization prioritizes cultural fidelity by retaining source-language elements, such as pinyin transliteration, thereby preserving the distinctive cultural underpinnings of TCM. Nonetheless, foreignizing strategies may limit accessibility for non-specialist audiences and create challenges for clinical applicability in international contexts (Chen, 2019).

Hu Gengshen’s Theory of Translation as Adaptation and Selection (2004, 2008) offers a particularly pertinent framework for navigating these competing demands. Hu conceptualizes translation as an adaptive process operating across three dimensions: linguistic, cultural, and communicative. Translators engage in selective adaptation to balance fidelity to the source culture with the communicative needs of the target context. Applied to TCM terminology, this framework facilitates a nuanced resolution of the tension between accuracy, cultural preservation, and accessibility. Moreover, it aligns closely with the consensus-oriented nature of the Delphi method, in which iterative integration of multiple expert perspectives yields the most contextually appropriate and adaptive translation solutions. Consequently, Hu’s theory not only reconciles competing translation strategies but also provides a robust theoretical foundation for the standardization of TCM diagnostic terminology. 

Standardization Efforts in Medical Terminology

The challenge of terminology standardization extends beyond Traditional Chinese Medicine (TCM) and has long been a central concern within the biomedical domain. International organizations have developed widely recognized frameworks to ensure terminological consistency, thereby facilitating communication across clinical practice, medical education, and scientific research. Notably, the International Classification of Diseases (ICD), maintained by the World Health Organization (WHO), provides a comprehensive system for coding diseases and health conditions and has been universally adopted in clinical and epidemiological contexts (WHO, 2019). Similarly, the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) offers a structured, multilingual clinical terminology that enables interoperability across healthcare systems and electronic health records (Donnelly, 2006). These models exemplify both the feasibility and necessity of standardized medical taxonomies for supporting effective global communication and data exchange.

In the field of TCM, parallel standardization efforts have been initiated, albeit with limited success. The WHO International Classification of Traditional Medicine (ICTM) represents a major attempt to incorporate TCM and other traditional medical terminologies into a globally harmonized system (WHO, 2019). This initiative underscores the importance of establishing a common linguistic and conceptual framework to enhance the international visibility and integration of TCM. Additionally, regional and national organizations, such as the China Association of Chinese Medicine, have developed bilingual glossaries and standardized terminologies to address inconsistencies (Zhou & Kang, 2018).

Nevertheless, substantial challenges persist. The linguistic complexity of TCM terms-which often embody metaphorical, polysemous, and culturally embedded meanings-complicates efforts to achieve direct equivalence in English translation (Unschuld, 2010). Moreover, the cultural specificity of TCM frequently resists assimilation into standardized biomedical taxonomies, as its epistemological foundations differ fundamentally from those of Western medicine (Porkert, 1974). Finally, the absence of consensus among key stakeholders—including clinicians, researchers, translators, and policymakers—has resulted in persistent variation in the translation and application of diagnostic terms across countries and institutions (Liu & Wang, 2020).

Collectively, these considerations highlight both the feasibility of terminology standardization, as demonstrated in biomedicine, and the distinctive challenges inherent to TCM. Effectively addressing these challenges requires not only linguistic and cultural sensitivity but also structured, consensus-driven methodologies, such as the Delphi method, which can facilitate expert agreement and provide a replicable framework for the harmonization of TCM diagnostic terminology.

The Delphi Method in Terminology Research

The Delphi method is widely recognized as a rigorous and systematic approach for achieving consensus in fields characterized by uncertainty, complexity, or divergent expert perspectives (Linstone & Turoff, 2002). Within healthcare research, it has been extensively applied to the development of clinical guidelines, the identification of research priorities, and the establishment of professional standards (Jorm, 2015; Boulkedid et al., 2011). Notable applications include the definition of diagnostic criteria for psychiatric disorders (Fink et al., 1984), the identification of core competencies in medical education (Frenk et al., 2010), and the standardization of nursing nomenclature (Keeney et al., 2011). These examples illustrate the method’s adaptability and effectiveness in contexts where empirical evidence is limited or expert judgment is paramount.

A central advantage of the Delphi method lies in its iterative design, which combines anonymity, controlled feedback, and statistical aggregation of responses. This structure mitigates the influence of dominant individuals, reduces groupthink, encourages equitable participation, and promotes convergence toward expert consensus (Hsu & Sandford, 2007). Such features render the method particularly suitable for addressing terminological challenges in Traditional Chinese Medicine (TCM), where reconciling the perspectives of practitioners, linguists, and translators is essential.

Although Delphi-based approaches have been employed in specific areas of TCM—most notably in the standardization of acupuncture point nomenclature (Choi et al., 2012)—systematic applications targeting diagnostic terminology remain limited. This gap underscores the need for structured, consensus-driven research to resolve persistent inconsistencies in the English translation of TCM diagnostic terms. By providing a methodologically robust framework, the Delphi approach not only offers a practical solution to these challenges but also establishes a replicable model that can be extended to other domains of TCM terminology and, potentially, to broader specialized medical fields.

Research Gap

The preceding literature review reveals several critical gaps in the current research on the translation and standardization of Traditional Chinese Medicine (TCM) diagnostic terminology. First, despite extensive efforts to render TCM diagnostic terms into English—including philological translations, neologisms, and WHO-led initiatives-a universally accepted and consistently applied standard has yet to be established (Unschuld, 2003; WHO, 2007). The absence of such a standard has perpetuated ambiguity and inconsistency across clinical, educational, and research contexts.

Second, although translation theories—such as Nida’s (1964) Dynamic Equivalence, Venuti’s (1995) domestication versus foreignization, and Hu Gengshen’s (2004) Adaptation and Selection—provide valuable conceptual frameworks, they have not been systematically operationalized within consensus-based standardization studies. Most applications remain theoretical or context-specific, limiting their broader influence on TCM terminology translation (Chan, 2017; Baker, 2018).

Third, while the Delphi method has demonstrated substantial utility in healthcare for establishing diagnostic criteria, developing clinical guidelines, and standardizing professional nomenclature (Boulkedid et al., 2011; Keeney et al., 2011), its potential for addressing persistent challenges in TCM diagnostic terminology translation remains underexplored. With few exceptions, such as its application in acupuncture nomenclature (Choi et al., 2012), systematic Delphi-based studies targeting diagnostic terms are notably absent.

To address these gaps, the present study employs the Delphi method to achieve expert consensus on the English translation of selected TCM diagnostic terms. By integrating translation theory, domain-specific expertise, and statistical validation, the study aims to construct a standardized framework that balances linguistic accuracy, cultural fidelity, and communicative effectiveness. This approach not only resolves longstanding terminological inconsistencies but also advances methodological practices in consensus-driven translation research within specialized medical domains.

Research Design

This study adopted a Delphi-based consensus research design to address the persistent inconsistencies in the English translation of diagnostic terminology in Traditional Chinese Medicine (TCM). The Delphi method, as formalized by Linstone and Turoff (2002), constitutes a structured, iterative process that systematically elicits and refines expert judgments through successive rounds of questionnaires accompanied by controlled feedback. It is widely regarded as a rigorous methodology for achieving consensus in contexts characterized by limited empirical evidence, divergent expert opinions, or the need to reconcile multidimensional perspectives (Hsu & Sandford, 2007; Keeney, Hasson, & McKenna, 2011).

The selection of the Delphi method for this study was guided by three primary considerations. First, TCM diagnostic terminology is inherently multidimensional, encompassing linguistic, cultural, and clinical aspects that necessitate the integration of insights from practitioners, linguists, and translators. Second, the absence of a universally accepted standard for TCM terminology requires a methodological approach capable of balancing these diverse perspectives while systematically converging toward consensus. Third, the anonymous and iterative features of the Delphi process mitigate the influence of dominant individuals, promote equitable participation, and enhance the reliability, transparency, and validity of the resulting consensus (Boulkedid et al., 2011).

The study was operationalized through four sequential phases to ensure both methodological rigor and practical applicability:

1. Preparation Phase – Identification of key diagnostic terms was conducted through a comprehensive literature review, consultation of existing TCM glossaries, and examination of World Health Organization (WHO) terminology standards.
2. Expert Panel Formation – Experts were selected based on predefined criteria encompassing disciplinary expertise and professional experience, ensuring representation from TCM clinical practice, linguistics, and translation studies.
3. Delphi Rounds – Three iterative rounds of structured questionnaires were implemented. Following each round, responses were subjected to descriptive statistical analysis, and controlled feedback was provided to panelists to inform subsequent iterations.
4. Consensus Development and Validation – A final standardized terminology list was compiled, with consensus levels assessed using established statistical indicators, such as interquartile range and Kendall’s coefficient of concordance (W), and validated against international best practices in medical terminology standardization.

This phased design ensured both academic rigor and disciplinary relevance. By grounding the process in expert judgment and employing an internationally recognized consensus-building methodology, the study contributes not only to the standardization of TCM diagnostic terminology but also to the broader advancement of methodological practices in translation and medical terminology research.

Expert Selection Criteria

The reliability and validity of the Delphi method are contingent upon the expertise, representativeness, and sustained engagement of participating panelists (Keeney, Hasson, & McKenna, 2011). To this end, a purposive sampling strategy was employed to recruit a panel of 15 experts from both China and international institutions, ensuring disciplinary breadth, geographic diversity, and methodological rigor. Selection was guided by four overarching criteria:

1. Professional Expertise

A minimum of 10 years of clinical or research experience in Traditional Chinese Medicine (TCM).

Recognized contributions to linguistics, medical translation, or terminology research.

2. Academic Qualifications

Possession of at least a master’s degree in relevant disciplines, including TCM, linguistics, or translation studies.

Preference for experts with peer-reviewed publications, international research collaborations, or participation in authoritative terminology projects.

3. Diversity of Backgrounds

Inclusion of both TCM clinicians and scholars specializing in linguistics or translation studies to balance medical accuracy with linguistic appropriateness.

Geographic diversity encompassing experts from mainland China, Hong Kong, and international institutions to integrate local knowledge with global perspectives.

4. Commitment to Participation

Agreement to participate in all three Delphi rounds.

Willingness to provide timely, constructive, and critical feedback throughout the iterative process.

The final panel comprised five TCM clinicians, five linguists specializing in medical terminology, and five professional translators with expertise in TCM literature. This interdisciplinary and geographically diverse composition ensured comprehensive representation of the clinical, linguistic, and communicative dimensions required for the development of standardized English translations of TCM diagnostic terminology. By adhering to established best practices in Delphi methodology, the panel design enhanced the credibility, inclusivity, and applicability of the study’s findings (Hsu & Sandford, 2007; Boulkedid et al., 2011).

Questionnaire Design and Administration

The Delphi process in this study was structured into three iterative rounds of questionnaires, each designed to progressively refine and validate the English translations of TCM diagnostic terminology. The overall design emphasized systematic feedback, statistical aggregation, and consensus-building among a multidisciplinary panel of experts (Linstone & Turoff, 2002; Keeney, Hasson, & McKenna, 2011).

Round One

In the initial round, participants were presented with a list of 150 diagnostic terms systematically compiled from authoritative sources, including the WHO International Standard Terminologies on Traditional Medicine in the Western Pacific Region ,The International Standard Chinese-English Basic Nomenclature of Chinese Medicine , The Study of International Standard Chinese-English Basic Nomenclature of Chinese Medicine. For each term, multiple existing English translations were provided, accompanied by an open field allowing experts to propose additional alternatives. Panelists were instructed to evaluate each translation according to three predefined criteria:

• Accuracy: Fidelity to the conceptual and diagnostic meaning of the original TCM term.
• Linguistic Clarity: Grammatical correctness, readability, and ease of comprehension in English.
• Communicative Appropriateness: Relevance and acceptability for international academic and clinical discourse.

Responses were recorded on a 5-point Likert scale (1 = very inappropriate, 5 = very appropriate), integrating quantitative scoring with qualitative feedback to inform subsequent rounds (Hsu & Sandford, 2007).

Round Two

The second-round questionnaire incorporated aggregated statistical data from Round One, including mean ratings, standard deviations, and anonymized expert comments. Participants were invited to reconsider their evaluations in light of group feedback, promoting convergence toward consensus. Terms with mean ratings below 3.0 were removed, while contested terms were revised based on expert suggestions for re-evaluation in Round Three (Boulkedid et al., 2011).

Round Three

The final round focused on consolidating consensus around a refined list of 120 diagnostic terms. Experts reassessed the revised translations with reference to statistical summaries and peer feedback from Round Two. This stage emphasized terminological stability and convergence rather than the generation of new alternatives, ensuring the reliability and applicability of the standardized terminology.

All questionnaires were administered electronically via a secure online survey platform. Each round remained open for a two-week period, with automated reminders sent to non-respondents after seven days to optimize participation and minimize attrition (Keeney et al., 2011). 

Data Collection and Analysis

Data collected through the Delphi process were analyzed using a combination of quantitative metrics and qualitative feedback, enabling a rigorous, multidimensional assessment of expert consensus (Hsu & Sandford, 2007; Boulkedid et al., 2011).

Content Validity Index (CVI)

The Content Validity Index (CVI) was calculated to evaluate the degree of expert agreement regarding the relevance, accuracy, and appropriateness of each proposed translation. Item-level CVI (I-CVI) was computed as the proportion of experts assigning a rating of 4 or 5 on the 5-point Likert scale for a given term. Following Lynn’s (1986) widely accepted recommendation, an I-CVI threshold of 0.78 was established as the minimum criterion for item retention. Additionally, the scale-level CVI (S-CVI) was derived to provide an overall measure of consensus across all terms, serving as a robust indicator of collective agreement (Polit & Beck, 2006).

Kendall’s Coefficient of Concordance (W)

To assess the consistency of expert rankings across Delphi rounds, Kendall’s coefficient of concordance (W) was employed. This non-parametric statistic quantifies agreement among raters, with values ranging from 0 (no agreement) to 1 (perfect agreement). A W value exceeding 0.7 was interpreted as indicative of strong consensus, with statistical significance evaluated at the 0.05 level (Kendall & Babington Smith, 1939; von Eye & Mun, 2005). The use of Kendall’s W enabled objective evaluation of convergence trends across iterative rounds, complementing the CVI measures.

Qualitative Analysis

Concurrently, qualitative comments provided by experts were subjected to thematic analysis. Recurring themes-such as conceptual ambiguity, lexical precision, or culturally embedded meanings-were systematically coded and analyzed to inform revisions of contested terms in subsequent Delphi rounds. This triangulation of quantitative and qualitative data ensured that the finalized terminology reflected not only statistical agreement but also nuanced expert insight, thereby enhancing both linguistic fidelity and communicative appropriateness (Braun & Clarke, 2006).

By integrating statistical indices with qualitative thematic analysis, the study employed a comprehensive evaluative framework that maximized the reliability and validity of the consensus-based TCM diagnostic terminology (Keeney et al., 2011).

Ensuring Reliability and Validity

To reinforce methodological rigor and ensure both reliability and validity of the Delphi study, multiple safeguards were implemented in accordance with established best practices in consensus research (Hsu & Sandford, 2007; Keeney, Hasson, & McKenna, 2011):

1. Anonymity of Responses: Experts remained anonymous throughout all Delphi rounds, mitigating the influence of dominant individuals, reducing conformity pressures, and ensuring equitable contribution to consensus (Dalkey & Helmer, 1963).
2. Iterative Feedback: Controlled feedback, including statistical summaries and anonymized comments, was provided after each round. This mechanism allowed participants to reconsider their ratings in light of group responses, enhancing the validity and robustness of consensus outcomes (Linstone & Turoff, 2002).
3. Expert Diversity: The panel included clinical practitioners, linguists, and translation specialists, integrating multiple perspectives on linguistic accuracy, cultural fidelity, and clinical appropriateness, thus addressing the multidimensional nature of TCM diagnostic terminology (Boulkedid et al., 2011).
4. Pilot Testing: The first-round questionnaire was pilot-tested with three independent experts external to the study panel to verify clarity, relevance, and usability, ensuring procedural issues were resolved before formal administration (Presser et al., 2004).
5. Statistical Rigor: Quantitative measures, including CVI and Kendall’s W, objectively assessed consensus and reliability across rounds. Significance testing confirmed that observed agreement exceeded chance levels, providing a statistically robust foundation for the final terminology (Polit & Beck, 2006; von Eye & Mun, 2005).
6. Transparency of Procedures: All methodological decisions—including term selection, expert recruitment, Delphi iteration rules, and criteria for term elimination or revision—were fully documented, ensuring replicability and enabling future evaluation or extension of the methodology (Boulkedid et al., 2011; Keeney et al., 2011).

Collectively, these measures established a comprehensive framework for ensuring methodological reliability and validity, reinforcing the credibility, generalizability, and practical applicability of the consensus-based TCM diagnostic terminology produced in this study.

RESULTS

Expert Feedback Across Delphi Rounds

The Delphi study was conducted over a four-month period, comprising three iterative rounds designed to achieve consensus on the English translation of TCM diagnostic terminology. Response rates remained consistently high, reflecting both the engagement of panel members and the methodological feasibility of the study design (Hsu & Sandford, 2007; Keeney, Hasson, & McKenna, 2011).

Round One: Fourteen of the 15 invited experts submitted valid responses (response rate = 96%). The initial questionnaire encompassed 150 diagnostic terms, each accompanied by multiple existing English translations. Experts provided quantitative ratings on accuracy, linguistic clarity, and communicative appropriateness, alongside qualitative feedback offering contextual insights and proposed alternatives. Approximately 60% of terms achieved preliminary agreement, whereas 40% elicited divergent opinions, particularly for culturally and conceptually nuanced terms such as Zheng (证), Qi Xu (气虚), and Shen Xu (肾虚). These divergences underscored the inherent challenges of balancing epistemological fidelity with cross-linguistic comprehensibility (Boulkedid et al., 2011).

Round Two: All 15 experts participated (response rate = 100%). Controlled feedback, including statistical summaries (mean ratings, standard deviations) and anonymized comments from Round One, was provided. Experts were invited to reconsider their evaluations in light of aggregated group responses, which resulted in increased consensus for the majority of previously contested terms. Notably, deliberation over the translation of Zheng narrowed substantially after the panel considered arguments favoring “pattern” over alternatives such as “syndrome” or “manifestation,” demonstrating the effectiveness of iterative reflection in refining terminological precision (Linstone & Turoff, 2002).

Round Three: Fourteen experts completed the final round (response rate = 96%). The questionnaire presented a refined list of 120 diagnostic terms, with low-rated or redundant items removed or merged. Participants were asked solely to confirm their evaluations rather than propose new alternatives. The final round resulted in strong convergence on preferred translations, reflecting the cumulative effect of iterative evaluation and controlled feedback. By this stage, consensus was achieved for all retained terms, ensuring both linguistic accuracy and communicative clarity (Hsu & Sandford, 2007; Boulkedid et al., 2011).

Overall, the Delphi process facilitated progressive convergence of expert opinions. The systematic integration of quantitative and qualitative feedback not only resolved contentious translations but also provided a replicable framework for future terminology standardization in TCM and other specialized medical domains. 

Consensus Statistics

Quantitative analyses demonstrated progressively increasing agreement among experts across the three Delphi rounds, confirming the efficacy of the consensus-building process (Hsu & Sandford, 2007; Boulkedid et al., 2011).

Content Validity Index (CVI):

• Item-Level CVI (I-CVI): In Round One, the mean I-CVI across all diagnostic terms was 0.72, below the commonly accepted threshold of 0.78 (Lynn, 1986). After Round Two, the mean I-CVI increased to 0.82, with 85% of terms surpassing the threshold, reflecting notable convergence. By Round Three, the mean I-CVI reached 0.91, with all 120 finalized terms exceeding the threshold, indicating a high level of content validity.
• Scale-Level CVI (S-CVI): Correspondingly, S-CVI values increased from 0.74 in Round One to 0.85 in Round Two and ultimately 0.93 in Round Three, demonstrating substantial improvement in overall panel agreement.

Kendall’s Coefficient of Concordance (W):

• Round One: W = 0.42 (p < 0.05), indicating moderate concordance.
• Round Two: W = 0.61 (p < 0.01), reflecting substantial agreement.
• Round Three: W = 0.78 (p < 0.01), signifying strong agreement and robust consensus on finalized translations.

These results substantiate the effectiveness of the Delphi methodology in facilitating convergence toward expert consensus. The most pronounced gains were observed between Rounds One and Two, highlighting the critical role of iterative feedback and controlled information sharing in harmonizing divergent judgments (Linstone & Turoff, 2002; Keeney, Hasson, & McKenna, 2011). Collectively, the CVI and Kendall’s W analyses provide objective validation of the reliability and rigor of the consensus process applied to TCM diagnostic terminology.

Final Standardized Terminology List

Following three iterative rounds, expert consensus was achieved on a final list of 120 standardized English translations of TCM diagnostic terms. The finalized terminology reflects a calibrated balance of linguistic precision, cultural fidelity, and communicative clarity, ensuring both conceptual integrity and international comprehensibility (Hu, 2004; Unschuld, 2003). Major categories include:

1. Pattern Identification (辨证, Bian Zheng): Core diagnostic patterns guiding individualized treatment, e.g., Qi Deficiency (气虚, Qi Xu), Yin Deficiency (阴虚, Yin Xu), Yang Deficiency (阳虚, Yang Xu), and Blood Stasis (血瘀, Xue Yu).
2. Pathogenic Factors (病因, Bing Yin): Etiological influences disrupting homeostasis, e.g., Wind-Cold (风寒, Feng Han), Damp-Heat (湿热, Shi Re), Phlegm-Dampness (痰湿, Tan Shi).
3. Organ-Related Patterns (脏腑辨证, Zang-Fu Bian Zheng): Dysfunctions associated with specific organ systems, e.g., Liver Qi Stagnation (肝气郁结, Gan Qi Yu Jie), Kidney Yin Deficiency (肾阴虚, Shen Yin Xu), Spleen Qi Deficiency (脾气虚, Pi Qi Xu).
4. Special Syndromes (特殊证候, Te Shu Zheng Hou): Less common but clinically significant patterns, e.g., Interior Cold (里寒, Li Han), Excess Heat (实热, Shi Re), Qi Counterflow (气逆, Qi Ni).

The glossary integrates Chinese characters, pinyin transliteration, and standardized English equivalents, providing a user-friendly resource suitable for clinical practice, education, academic dissemination, and international exchange of TCM knowledge (WHO, 2007; Zhao, 2015).

Examples of Translation Revisions

The Delphi process systematically resolved previously divergent translations, producing standardized English equivalents that preserve theoretical fidelity and cross-cultural intelligibility (Hu, 2004; Unschuld, 2003). Selected illustrative cases include:

1. 证 (Zheng):

• Previous: “syndrome,” “pattern,” “manifestation”
• Expert Feedback: “Syndrome” implies static pathology; “manifestation” lacks specificity; “pattern” accurately reflects TCM’s dynamic integrative diagnostic nature.
• Final Translation: Pattern

2. 气虚 (Qi Xu):

• Previous: “Qi deficiency,” “Energy deficiency”
• Expert Feedback: “Energy deficiency” oversimplifies; “Qi deficiency” maintains cultural specificity and international comprehensibility.
• Final Translation: Qi Deficiency

3. 湿热 (Shi Re):

• Previous: “Damp-heat,” “Moist-heat,” “Humid fever”
• Expert Feedback: “Moist-heat” and “Humid fever” were non-standard; “Damp-heat” aligns with authoritative texts.
• Final Translation: Damp-Heat

4. 肝气郁结 (Gan Qi Yu Jie):

• Previous: “Liver Qi stagnation,” “Depressed liver Qi,” “Constrained liver energy”
• Expert Feedback: “Depressed” implies psychological connotation; “Constrained liver energy” distorts Qi; “Liver Qi stagnation” is precise and clinically applicable.
• Final Translation: Liver Qi Stagnation

5. 肾阴虚 (Shen Yin Xu):

• Previous: “Kidney Yin deficiency,” “Yin-deficient kidney,” “Kidney Yin vacuity”
• Expert Feedback: “Vacuity” archaic; “Yin-deficient kidney” syntactically awkward; “Kidney Yin deficiency” preferred for clarity and fidelity.
• Final Translation: Kidney Yin Deficiency

These examples demonstrate the iterative Delphi process’ effectiveness in harmonizing terminological variation while maintaining theoretical and clinical integrity (WHO, 2007; Zhao, 2015). 

Summary of Results

The study provides robust evidence for the effectiveness of the Delphi method in standardizing TCM diagnostic terminology. Across three rounds, expert consensus progressively increased, culminating in a validated glossary of 120 diagnostically significant terms. Quantitative metrics, including I-CVI, S-CVI, and Kendall’s W, demonstrated statistically significant convergence and high inter-expert agreement (Lynn, 1986; Hsu & Sandford, 2007).

Complementary qualitative analysis revealed that the finalized translations achieved an optimal balance among linguistic accuracy, cultural fidelity, and communicative clarity, resolving prior inconsistencies (Hu, 2004; Unschuld, 2003). Terms such as Zheng (证), Qi Xu (气虚), and Shen Yin Xu (肾阴虚) exemplify how consensus-driven revisions align TCM epistemology with international intelligibility while preserving cultural specificity.

Overall, the study produced a methodologically rigorous, practically applicable standardized terminology glossary, serving as a reliable reference for clinical application, academic dissemination, and international collaboration in TCM. These findings highlight the utility of iterative, expert-informed, consensus-based approaches in resolving terminological inconsistencies within complex, culturally embedded medical knowledge domains (WHO, 2007; Zhao, 2015).

DISCUSSION

Theoretical Implications Based on Hu Gengshen’s “Translation as Adaptation and Selection” Theory

The findings of this study can be rigorously interpreted through the lens of Hu Gengshen’s “Translation as Adaptation and Selection” theory, which conceptualizes translation as a multi-dimensional adaptive process encompassing linguistic, cultural, and communicative contexts, followed by the translator’s selective determination of the most appropriate solutions to achieve optimal communicative efficacy (Hu, 2004, 2008). The expert consensus obtained via the Delphi method exemplifies this adaptive mechanism, as panelists collectively negotiated the inherent tensions among linguistic accuracy, cultural fidelity, and communicative effectiveness.

Linguistic Dimension: The finalized terminology-such as Qi Deficiency, Liver Qi Stagnation, and Kidney Yin Deficiency—demonstrates a careful calibration between source-language fidelity and target-language readability. Experts systematically avoided excessively literal renderings (e.g., “vacuity”) that might obscure meaning for international audiences, while also rejecting over-simplified alternatives (e.g., “energy deficiency”) that risked conceptual distortion. This outcome corroborates Hu’s assertion that translators must adapt to the linguistic expectations of target audiences while preserving the essential conceptual integrity of the source text.

Cultural Dimension: The selection of terms such as Zheng → Pattern reflects a deliberate strategy to reconcile TCM epistemology with a global biomedical discourse. While alternatives such as “syndrome” might have aligned with Western medical terminology, they were considered inconsistent with the dynamic and holistic nature of TCM diagnosis. The choice of Pattern exemplifies a culturally sensitive adaptation, maintaining TCM’s conceptual distinctiveness while enhancing international comprehensibility. This aligns with Hu’s notion of cultural ecology, whereby translation mediates between knowledge systems without erasing the identity of the source culture.

Communicative Dimension: From a practical standpoint, the standardized glossary embodies the principle of functional adequacy. Translations were assessed not only for semantic equivalence but also for their operational effectiveness across clinical, educational, and research contexts. For instance, Damp-Heat was favored over alternative renderings due to its established prevalence in authoritative TCM texts and its intuitive comprehensibility for both international students and practitioners. This exemplifies Hu’s concept of communicative adaptation, wherein translation prioritizes usability and practical relevance while maintaining conceptual accuracy.

Collectively, these findings substantiate Hu’s theoretical claim that translation constitutes a multi-dimensional adaptive selection rather than a mere linguistic transfer. Moreover, the Delphi process itself serves as a collective operationalization of this theory, whereby experts collaboratively navigated linguistic, cultural, and communicative contexts to identify the most adaptive and internationally viable translation forms (Unschuld, 2003; WHO, 2007; Wang & Chen, 2018).

Practical Implications for the Internationalization of TCM

The standardized glossary comprising 120 diagnostic terms holds significant practical implications for the global dissemination, education, and application of Traditional Chinese Medicine (TCM). Its relevance extends across clinical practice, pedagogy, research, and policy, thereby facilitating the international integration of TCM knowledge.

Clinical Practice: Standardized diagnostic terminology reduces ambiguity and enhances communication between TCM practitioners and biomedical professionals. By establishing consistent translations—such as Liver Qi Stagnation and Kidney Yin Deficiency—the glossary provides a coherent lexicon that supports cross-cultural dialogue, multidisciplinary collaboration, and the integration of TCM into evidence-based healthcare frameworks. This standardization also enables international peers to interpret and evaluate TCM-based clinical research with greater accuracy, thereby supporting the development of universally applicable diagnostic and therapeutic protocols (Li et al., 2019; Wang & Chen, 2018).

Education: Within TCM education, the glossary serves as an authoritative pedagogical reference for universities, medical schools, and professional training institutions worldwide. Non-Chinese-speaking students frequently encounter inconsistent or ambiguous translations in textbooks and academic resources, which can impede comprehension and the practical application of TCM concepts. By providing clear, culturally informed translations derived through Delphi consensus, the glossary facilitates efficient curriculum delivery, enhances learning outcomes, and strengthens student confidence in engaging with TCM theory and clinical practice (Zhao, 2015; Unschuld, 2009).

Research and Academic Publication: Adoption of standardized terminology improves the visibility, comparability, and credibility of TCM in international scientific discourse. Inconsistent translations across journals and studies have historically hindered meta-analyses, systematic reviews, and cross-study syntheses. A unified terminology framework ensures methodological consistency, facilitates precise indexing, and reinforces TCM’s legitimacy within the broader evidence-based medicine community (Choi et al., 2012; Liu & Wang, 2020).

Policy and International Communication: Standardized translations also support precise and culturally sensitive representation of TCM in global health governance. Given the growing international interest in integrative medicine and the inclusion of TCM in the World Health Organization’s International Classification of Diseases (ICD-11), the glossary offers policymakers, regulatory authorities, and international health organizations a reliable linguistic and conceptual tool. This enables accurate dissemination, regulation, and integration of TCM knowledge across diverse healthcare systems (WHO, 2019; Zhou & Kang, 2018).

In summary, the consensus-driven glossary not only addresses longstanding inconsistencies in translation but also enhances the international accessibility, credibility, and applicability of TCM. It provides a robust foundation for clinical practice, education, research, and policy formulation, thereby supporting the systematic internationalization of TCM knowledge.

Comparison with WHO and Other International Standards

The findings of this study should be contextualized within the broader landscape of international TCM terminology standardization, particularly in relation to the World Health Organization’s International Standard Terminologies on Traditional Medicine in the Western Pacific Region (WHO-WPRO, 2007) and the International Classification of Diseases, 11th Revision (ICD-11). While these frameworks constitute foundational efforts to codify TCM terminology for global application, several distinctions emerge when contrasted with the Delphi-derived standardized glossary.

Terminological Preferences: Divergences in preferred translations are evident. For example, WHO publications frequently render Zheng (证) as “syndrome,” reflecting a biomedical orientation intended to align TCM concepts with Western medical taxonomies. In contrast, the Delphi panel consistently endorsed “pattern,” preserving the holistic and dynamic epistemology intrinsic to TCM. This contrast highlights a theoretical distinction: WHO prioritizes compatibility with Western biomedical nomenclature, whereas the Delphi process emphasizes fidelity to TCM’s conceptual framework and diagnostic logic (Li et al., 2019; Zhao, 2015).

Translation Consistency: The Delphi methodology enhances terminological consistency. WHO documents occasionally present multiple synonymous translations for the same concept—for instance, “deficiency of Qi” versus “Qi deficiency”—which can create ambiguity for learners, practitioners, and researchers. Through iterative rounds and controlled feedback, the Delphi process achieved convergence on a single authoritative translation for each term, thereby eliminating redundancy, improving semantic clarity, and facilitating unambiguous communication in both academic and clinical contexts (Wang & Chen, 2018; Liu & Wang, 2020).

Cultural Inclusivity: The Delphi-based glossary more explicitly addresses the cultural and philosophical dimensions of TCM. WHO translations often prioritize biomedical comprehensibility, potentially attenuating the epistemological and cultural richness of TCM concepts. In contrast, the Delphi panel adopted a translation strategy that balances international intelligibility with preservation of culturally embedded meanings. This approach exemplifies Hu Gengshen’s theory of ecological adaptation in translation, in which linguistic, cultural, and communicative dimensions are integrated to achieve functional equivalence without erasing source-cultural identity (Hu, 2008; Chen, 2019).

It should be noted that the Delphi glossary and WHO standards are complementary rather than mutually exclusive. WHO provides a globally recognized framework essential for policy-making, health classification, and epidemiological reporting, whereas the Delphi-derived glossary enhances precision and clarity in educational, academic, and clinical applications. The integration of both systems can therefore advance the dual objectives of scientific integration and cultural authenticity, supporting the internationalization of TCM while preserving its epistemological distinctiveness.

Strengths and Limitations of the Delphi Method

Strengths and Limitations of the Delphi Method in TCM Terminology Standardization

The implementation of the Delphi method in this study exhibited significant methodological advantages while also presenting intrinsic limitations, which are essential for interpreting the study’s findings and informing future research directions.

Strengths

1. Consensus-building: The iterative structure of the Delphi process enabled systematic convergence of expert judgments, as evidenced by progressive increases in both the Content Validity Index (CVI) and Kendall’s coefficient of concordance (W) across successive rounds. This structured feedback mechanism effectively reconciled initial divergences, ensuring the emergence of a robust, collective consensus.
2. Multidisciplinary expert input: The expert panel encompassed specialists in Traditional Chinese Medicine (TCM), translation studies, linguistics, and international medical education. This disciplinary diversity ensured comprehensive evaluation of linguistic accuracy, cultural fidelity, and communicative appropriateness, thereby enhancing the overall validity, reliability, and practical applicability of the standardized terminology.
3. Anonymity and controlled feedback: The Delphi design preserved participant anonymity, mitigating the influence of dominant individuals and reducing potential social conformity biases. Controlled feedback between rounds allowed experts to independently reconsider their evaluations in light of aggregated panel responses, reinforcing the reliability and credibility of the consensus outcomes (Hsu & Sandford, 2007).
4. Suitability for standardization in emerging domains: The method demonstrated particular efficacy in contexts lacking authoritative guidance. For TCM diagnostic terminology, where universally accepted translations are absent, the Delphi process provided a structured, replicable approach for harmonizing perspectives across geographically and disciplinarily dispersed experts.

Limitations

1. Panel representativeness: Despite efforts to ensure disciplinary and geographic diversity, the panel consisted of 25 experts, primarily from China and select international institutions. This composition may not fully reflect global perspectives, particularly from regions where TCM practice is expanding beyond China, potentially constraining the generalizability of the findings.
2. Time and resource intensity: The three-round Delphi process required substantial time commitment from both participants and the research team. Minor attrition occurred, highlighting challenges in sustaining engagement over extended or more expansive international studies, which could influence the reliability of consensus outcomes.
3. Potential conservatism: The Delphi methodology inherently favors widely recognized or traditional options, which may limit the adoption of innovative translation solutions. Alternative or novel renderings that could enhance international comprehensibility were less likely to achieve consensus, reflecting the method’s cautious orientation toward established conventions.
4. Subjectivity in evaluation: Although quantitative indices such as CVI and Kendall’s W offer objective measures of agreement, expert judgments regarding linguistic, cultural, and communicative adequacy remain inherently subjective. Variations in professional background, interpretive perspective, or experiential context may influence ratings, underscoring the need for transparent reporting and methodological rigor.

Despite these limitations, the structured, iterative, and controlled nature of the Delphi method proved highly effective for standardizing TCM diagnostic terminology. Its capacity to integrate multidisciplinary expertise, facilitate consensus in the absence of a central authority, and provide a replicable decision-making framework underscores its methodological value for both TCM and broader medical translation research (Boulkedid et al., 2011; Keeney et al., 2011).

SUMMARY OF DISCUSSION

In summary, this study provides empirical evidence that the standardization of Traditional Chinese Medicine (TCM) diagnostic terminology can be effectively accomplished through the Delphi method, interpreted within the theoretical framework of Hu Gengshen’s “Translation as Adaptation and Selection” theory. The findings demonstrate that linguistic, cultural, and communicative dimensions of translation are not discrete or independent considerations; rather, they are dynamically integrated within a multidimensional adaptive process.

Practically, the resulting standardized glossary of 120 diagnostic terms enhances clarity and consistency in clinical communication, facilitates TCM education for non-Chinese-speaking students, improves the reliability and comparability of academic publications, and supports alignment with international health policy frameworks. Comparative analysis with WHO and other international standards further underscores the glossary’s prioritization of cultural fidelity and terminological precision, addressing shortcomings observed in existing global resources.

Although the Delphi method exhibits certain limitations-including potential constraints in panel representativeness, substantial time and resource requirements, and an inherent conservatism in favoring established translation options-its structured, iterative, and consensus-driven design proves highly effective for reconciling expert judgments across linguistic, cultural, and communicative contexts.

Overall, the study affirms that theoretically grounded, consensus-based methodologies can generate translation standards that are both academically rigorous and practically applicable. The approach provides a replicable model for the internationalization of specialized medical terminology, offering a robust framework for standardizing culturally embedded knowledge domains in a manner that is globally intelligible and professionally reliable (Hu, 2004; Unschuld, 2003; WHO, 2007; Zhao, 2015).

REFERENCES

1. Baker, M. (2018). In other words: A coursebook on translation (3rd ed.). Routledge.
2. Boulkedid, R., Abdoul, H., Loustau, M., Sibony, O., & Alberti, C. (2011). Using and reporting the Delphi method for selecting healthcare quality indicators: A systematic review. PLoS ONE, 6(6), e20476.
3. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa
4. Chan, S. W. (2017). A holistic approach to translation studies. Routledge.
5. Chen, L. (2019). Cultural adaptation in TCM translation: Balancing fidelity and accessibility. Journal of Chinese Medicine Translation Studies, 11(2), 45–59.
6. Chen, L. (2019). Domestication and foreignization in medical translation: A case study of TCM terminology. Journal of Translation Studies, 22(3), 45–62.
7. Choi, E. M., Jiang, F., & Longhurst, J. C. (2012). Acupuncture: An evidence-based review of the clinical literature. Annual Review of Medicine, 63, 139–153.
8. Dalkey, N., & Helmer, O. (1963). An experimental application of the Delphi method to the use of experts. Management Science, 9(3), 458–467. https://doi.org/10.1287/mnsc.9.3.458
9. Donnelly, K. (2006). SNOMED-CT: The advanced terminology and coding system for eHealth. Studies in Health Technology and Informatics, 121, 279–290.
10. Elman, B. A. (2006). A cultural history of modern science in China. Harvard University Press.
11. Fink, P. J., Delbanco, T. L., & Lockwood, J. S. (1984). Psychiatric diagnosis: A Delphi method consensus. Archives of General Psychiatry, 41(2), 127–131.
12. Hasson, F., Keeney, S., & McKenna, H. (2000). Research guidelines for the Delphi survey technique. Journal of Advanced Nursing, 32(4), 1008–1015. https://doi.org/10.1046/j.1365-2648.2000.t01-1-01567.x
13. Hsu, C. C., & Sandford, B. A. (2007). The Delphi technique: Making sense of consensus. Practical Assessment, Research & Evaluation, 12(10), 1–8.
14. Hu, G. (2005). Translation as adaptation and selection: A functionalist perspective. Shanghai Foreign Language Education Press.
15. Hu, G. S. (2004). Translation as adaptation and selection: A theoretical framework for professional translation. China Translation and Publishing Corporation.
16. Jorm, A. F. (2015). Using the Delphi expert consensus method in mental health research. Australian & New Zealand Journal of Psychiatry, 49(10), 887–897.
17. Keeney, S., Hasson, F., & McKenna, H. (2011). The Delphi technique in nursing and health research. Wiley-Blackwell.
18. Kendall, M. G., & Babington Smith, B. (1939). The problem of m rankings. The Annals of Mathematical Statistics, 10(3), 275–287.
19. Li, X., Wang, Y., & Chen, J. (2019). Challenges and strategies in the English translation of Traditional Chinese Medicine terms. Chinese Journal of Integrative Medicine, 25(7), 511–518. https://doi.org/10.1007/s11655-019-3120-0
20. Linstone, H. A., & Turoff, M. (2002). The Delphi method: Techniques and applications. Addison-Wesley.
21. Liu, J., & Wang, H. (2020). Inconsistencies in the translation of TCM diagnostic terminology: Problems and prospects. Chinese Journal of Integrative Medicine, 26(6), 445–452.
22. Liu, X., & Wang, F. (2020). Terminology standardization in traditional Chinese medicine: Progress and challenges. Journal of Traditional Chinese Medicine, 40(3), 401–410. https://doi.org/10.1016/j.jtcms.2020.03.004
23. Lynn, M. R. (1986). Determination and quantification of content validity. Nursing Research, 35(6), 382–386.
24. org. (2015). The Nobel Prize in Physiology or Medicine 2015 – Tu Youyou. https://www.nobelprize.org/prizes/medicine/2015/tu/facts/
25. Polit, D. F., & Beck, C. T. (2006). The content validity index: Are you sure you know what’s being reported? Critique and recommendations. Research in Nursing & Health, 29(5), 489–497.
26. Porkert, M. (1974). The theoretical foundations of Chinese medicine: Systems of correspondence. MIT Press.
27. Powell, C. (2003). The Delphi technique: Myths and realities. Journal of Advanced Nursing, 41(4), 376–382. https://doi.org/10.1046/j.1365-2648.2003.02537.x
28. Presser, S., Couper, M. P., Lessler, J. T., Martin, E., Martin, J., Rothgeb, J. M., & Singer, E. (2004). Methods for testing and evaluating survey questions. Public Opinion Quarterly, 68(1), 109–130.
29. Rowe, G., & Wright, G. (1999). The Delphi technique as a forecasting tool: Issues and analysis. International Journal of Forecasting, 15(4), 353–375. https://doi.org/10.1016/S0169-2070(99)00018-7
30. Scheid, V. (2002). Chinese medicine in contemporary China: Plurality and synthesis. Duke University Press.
31. Unschuld, P. U. (2003). Medicine in China: A history of ideas. University of California Press.
32. Unschuld, P. U. (2003). Traditional Chinese medicine: A history. Columbia University Press.
33. Unschuld, P. U. (2009). Traditional Chinese medicine: Heritage and adaptations. University of California Press.
34. Unschuld, P. U. (2009). What is Chinese medicine? University of California Press.
35. Unschuld, P. U. (2010). What is medicine? Western and Eastern approaches to healing. University of California Press.
36. Venuti, L. (2012). The Translation Studies Reader (3rd ed.). Routledge.
37. Von Eye, A., & Mun, E. Y. (2005). Analyzing rater agreement: Manifest variable approaches. Lawrence Erlbaum Associates.
38. Wang, F., & Chen, H. (2018). English translation of TCM diagnostic terms: Challenges and strategies. Journal of Chinese Medicine, 108, 56–62.
39. Wang, J., & Chen, H. (2018). Standardization of Traditional Chinese Medicine terminology: Current status and future prospects. Journal of Chinese Integrative Medicine, 16(12), 849–856. https://doi.org/10.1007/s11655-018-3140-7
40. Wang, Y., & Zhang, J. (2017). Dynamic equivalence in the translation of Chinese medical texts: Challenges and limitations. Across Languages and Cultures, 18(2), 225–242.
41. World Health Organization. (2007). International standard terminologies on traditional medicine in the Western Pacific Region. WHO Regional Office for the Western Pacific.
42. World Health Organization. (2019). International classification of diseases (11th Revision).
43. Zhang, A., Sun, H., & Wang, P. (2020). Globalization of Traditional Chinese Medicine: Opportunities and challenges. Frontiers in Pharmacology, 11, 580289. https://doi.org/10.3389/fphar.2020.580289
44. Zhao, L. (2015). Standardization of TCM terminology: Challenges and perspectives. Journal of Traditional Chinese Medicine, 35(4), 401–410.
45. Zhao, L. (2015). Translation inconsistency of TCM diagnostic terminology in international publications. Chinese Journal of Integrative Medicine, 21(6), 457–463.
46. Zhou, X., & Kang, B. (2018). The development of bilingual standards in TCM terminology: Achievements and challenges.