The programme being implemented is a partnership between the University of Toronto research team and local Tibet Centre for Disease Control (CDC) stakeholders. Thus, the research team was jointly based in China and Canada to support implementation research efforts. At the start of the project training sessions were held on site in Tibet, and in Toronto, to onboard research team members, including interviewers and translators. We also defined a process to guide our research activities to ensure coordination between activities across sites. We offer an overview of our transcription and translation process in figure 1.
Translation to English
The Chinese transcripts were then sent to the Research Coordinator in Toronto (VH) who assigned them at random to the four members of the translation team. The translation team in Canada was composed of trainees who are bilingual in English and Mandarin. Translators were selected based on an interview process to determine their skillset, their familiarity with Chinese or Tibetan and past translation experience. Translators were given documents to familiarise them with the study and were briefed by both the local Trial Coordinator (ZZ) and the Research Coordinator (VH). Briefings included information on the study, the study context, as well as expectations and approaches to translating the documents such as ensuring completeness of meaning rather than word-for-word translation. After receiving the Chinese transcript file, they then translated these texts from Chinese into English. This process involved the creation of a ‘word bank’ to ensure that the translation team had a shared understanding of uncommon or context-specific words. This word bank included words identified a priori by ZZ, the Trial Coordinator, as being likely to be misinterpreted by those not familiar with the setting, context or clinical aspects of the interviews. It then grew to include words requiring clarification by translation team members as they encountered unfamiliar or professional/clinical terms in the Chinese transcripts.
Translators described that it took some time to develop their approach to translation. In general, once settled into the work, translators described a similar process. Translation would begin with reading through the entire manuscript to get a sense of the content of the interview, both the questions posed and the answers provided. This process included understanding the target interviewee given that different interview guides were used for different categories of participant (eg, patients, family treatment supporters and village/township/county hospital doctors all had unique interview guides). The translators would then go phrase by phrase to translate the words while retaining the same meaning across the phrase. This process was at times challenging as translators described the tensions that arose between accuracy, their interpretation of the text, and ensuring that they were not introducing bias through their translation or interpretation. Translators described how after conducting a first round of translation they would reread the transcript for grammar and spelling, but also to ensure that the text was coherent and that the English translation accurately reflected the Chinese text. This included understanding the implicit meaning in the Chinese text, which would need to be made explicit in the English translation, otherwise the meaning could not be fully understood by reading a direct translation from Chinese to English. Importantly, this included a need to consider the ‘bigger picture’ of the sentence or conversation to convey the correct contextual use of the word from Chinese to English.
Key challenges: developing a voice, conveying idioms, distance
The team described several challenges during the translation process. First, there was a learning process around developing a ‘voice’ and tone as a translator. Translators described an iterative process of translating and reviewing, and how particularly with the first set of transcripts there was a clear learning curve as they engaged with the content and texts. One translator described the process,
It wasn't until I got to the first ten or fifteen, I was like okay, this is my style. And the ones I translated afterwards have a very distinct kind of more objective style, because I think with the first two, I was almost struggling with wanting to translate word-for-word but I also know that [doing so] did not click as well… Like it is a skill that you're developing, you're still finding out how to do in a very standardised same way. It’s almost like you need a little bit of trial period, almost needing to hone that skill a bit more. And then you can produce your best work from that onwards. (P02)
One translator expanded on the interpretative aspect of translating tone and the process of developing translation skills to express this well, explaining:
Even though we were told to transcribe it word-for-word it’s just your own interpretation of how the words come together. And even how you choose to write how those words come together can actually influence what that sentence ends up meaning in a way… As I translated more, it became easier for me, and I knew like which steps I should take before. I knew the whole process of how, what is the best way to approach this. I tried out several methods. And I finally, like found the best one I should go with, and I just stick to that one for most of the other transcripts. (P01)
A second challenge during the translation process was correct word choice, conveying the depth of Chinese idioms and capturing the nuance of these expressions. Translators described the challenges in word choice when translating. As one translator described:
One word in Chinese doesn’t have just one meaning, it can have multiple meanings, but the true meaning is greatly affected by the other words around it. The phrasing is at times more important that the solitary word itself. The idea of a word for word direct translation approach doesn’t really apply as well in that case because of this. Like anything else the translational process depends on the context, on the words around it to better elucidate the meaning. (P03)
Translators described how participants would use idioms to possibly signal their emotions in answering questions. Often these idioms were difficult to convey in English with the same emotional nuance and contextual understanding of the emotions and experiences they signal towards. As one translator summed up ‘sometimes in Chinese when they converse with each other they tend to use something a little bit more abstract,’ (P03). Another translator explained how this aspect of the translation process was challenging:
Even just looking at the transcriptions I feel there were undertones of maybe emotions that when I translate to English it doesn't seem to carry as much weight. And in Chinese, we have these groups of four words which they almost rhyme and then it just gives the technical [phrase] a lyrical feel to it. But when I translate it word for word, it never kind of quite comes across…and we do try to get it across, but you always carry a personal bias in how you choose to write it. (P02)
A third translator described how there were differences across transcripts in the expressions used given that our study population comprised healthcare providers, and a variety of patients and their family members. The translator highlighted that ‘Some people’s word choice is quite simple, while others are more poetic,’ (P01).
A related challenge was the difficulty in conveying the discrepancy between some commonly used phrases in Chinese and their literal translations in English, with the latter coming out as more emotionally charged. One translator offered an example, describing ‘A lot of Chinese people would say ‘I don't think so’ if they’re arguing [a point] but they're really just saying ‘maybe we should consider other ideas.’ But you know, in English ‘I don't think so’ it’s a stronger expression [in this situation],’ (P03).
When considering the Tibetan interviews, the translator reflected on how not only words, but also silences can hold meaning, describing:
I feel like the formalized format of the interviews and the data compilation and conversion process sometimes overlooked or failed to recognize the nuances in the interviewee’s response. There was hesitancy heard before answering some questions, however, these could not be completely reflected in the transcript because they were sometimes long pauses, (P05).
The research coordinator reflected how the translation process can try to manage the use of idiom and differences in phrases saying:
There’s so much layer to these four-character Chinese sayings that doesn't come across in English. There’s a whole tapestry of meaning that you feel is being lost. I think that’s a limitation maybe with translating to English because Chinese uses so much metaphor and imagery, like, what can you do? I think that the best we can do is expand as much as possible on the meaning through notes or in discussions and be transparent where we’ve had more personal interpretation in the text. This holds true where perhaps English readers may read more tone into a text than is there, we can make notes about where phrases may be more or less emotional, (P07).
In the interviews conducted in Tibetan, a related challenge was the use of different dialects. While the researchers verifying the accuracy of the translations was able to understand these dialects, this too involved a learning curve, particularly when different words were used interchangeably across the dialects. For instance, patients would interchangeably use words for ‘food’ or ‘child’ in the Tsang dialect of Shigatse with the Ü dialect’s terms for the same terms.19
Finally, the team based in Canada described challenges given their distance from the study context. This manifested as challenges with word choice, understanding how concepts related to each other, and the experience, research and learning needed to gain an understanding of the context. Regarding word choice, a specific challenge was how to romanise place names that at times used the Chinese pinyin and at other times used the Tibetan transliteration, as well as navigating the implication of these choices in the study context. One translator described how they managed word choice considerations and the work to supplement their understanding:
If I really don't have the word for those I usually go to the dictionaries. And you know, often I don't find the answer in the dictionaries. For example, when they're referring to their own group within the CDC or within the township hospital, they usually just omit the names or omit the subject. So, who are they talking about? Sometimes translating you're like, I should try to research more, (P03).
The researcher verifying the Tibetan interviews reflected on the nuance of his linguistic and cultural connection saying:
You felt like you were studying something that you were familiar with, but at the same time, you could sense that there was this unfamiliarity…you’re able to really appreciate how you can connect with the patients through these interviews, not only because of the shared language but also because of the shared cultural values that you could instinctively sense from the conversations. However, there were indeed moments where differences became evident—this was especially the case when patients included borrowed terms from Mandarin. But then, when you reflect on the conversations during the interviews, you realise that these are experiences that are not easily accessible, and it’s a privilege to be able to hear them share their experiences in Tibetan, (P05).
This complements a reflection from the Research Coordinator on interpreting and analysing the data considering the foreign gaze, explaining that:
This is the fundamental issue with being a researcher who doesn't speak the language, that we don’t have the ability to access a more nuanced side of the conversation and I don't try and go there alone with the text. I'm not going to just presume to understand or access these experiences that people trust us with when they are interviewed. I'd rather acknowledge my position, my foreign gaze, and work more closely with someone closer to the context, who can dig in a bit more, than try myself to interpret and overstep. I want to co-create an understanding of the situation so that I'm not assuming things I can't assume, (P07).
Some team members reflected on the importance of the connection with the Trial Coordinator who had extensive knowledge of the implementation site. The Trial Coordinator in turn explained the importance of his connections and relationships at the local level to elaborate on the context.
Lessons learnt: word banks, team building, introspection and reflexivity
The team also identified key lessons learnt that may benefit others undertaking similar work. First, the team emphasised the importance of creating unified word banks of jargon or technical/clinical words and phrases commonly used in the interviews. These word banks should offer standard ‘unified’ translations of common words be shared between the translation and implementation team and regularly updated through an iterative process during translation. The study team had an extensive word bank first established by the Trial Coordinator and updated by translation team members. One translator described how:
The document on unified words was very helpful, especially when I was first starting the translation…because there’s some specific nouns like the ‘e-monitor box’ that if I didn’t receive the [unified word] list I would have translated it in a different way. It’s helpful to know how other people are translating and follow it, (P01).
Another translator explained how having this document accessible to all team members was important because as questions or words were added by translators, the Trial Coordinator’s replies were visible and enabled transcripts to be updated.
Another lesson emphasised by many on the team was the importance of collaborating between translators. This was in some ways a missed opportunity in the current work. Although the team had an introduction to the work, the shared unified word bank, and transcripts were checked for accuracy after their completion, there was room for greater connection and checking between team members. This team building effort can help with increasing confidence in decision making among translators regarding word choice, as well as creates a space for shared solution-finding during difficulties in the process. Further, such a team approach would allow the group to develop a more consistent style or ‘voice’ that may help reduce bias or inconsistencies during the process. As one translator described:
I think looking back, it would have been helpful to have a meeting and gone through a transcription together…because I think I was always like ‘Am I doing this right? What are other people doing’ and it would have been nice to develop a team approach and then go off into your individual work…I think it helps to have the [Trial Coordinator], but it’s good to have [a translator] there to second check your work, (P02).
Another translator underscored this need for connection saying:
If you’re unsure about how to translate something, where you have difficulty in the process…maybe together you can find a better solution instead of just trying to find the solution on your own, (P01).
The Research Coordinator explained how:
It was challenging because there were a lot of moving parts, data coming in at different times, different availabilities and I think sometimes translation is seen as a more technical skill, when really it is a skill that needs teamwork and connection. This was a lesson learned about how conducting this type of research also needs attention to the translation team and their experience, (P07).
Another translator explained how sharing protocols, interview notes from the field, emerging findings and other materials associated with the overall project and how the data was collected could further strengthen translation by providing greater contextual understanding and help identify words for the unified word bank.
Finally, team members highlighted the importance of introspection and reflexivity towards sense-making when interpreting the texts. Translators discussed how the work allowed them to connect to aspects of their own culture, while also reflecting on the experience of others. This was important to their ongoing engagement in the work. As one translator described:
I guess being in Canada you actually don't get as many exposures to Chinese language as much, so for me personally was a good kind of learning opportunity…It kind of helps me keep engaged with my own language and culture, which is really nice, (P02).
Another described how the process involved empathy to the participants situation, explaining that:
Every time I translate, I just read through, and I sort of know what the interviewees they're going through. I think it’s very just fascinating for me to learn about their experiences and the entire system of the medical environment, how it’s working in Tibet, or can it be applied to other rural areas in China, (P04).
Another reflected on the ways in which a translator’s ‘background, upbringing, as well as their interpretation of the text, as well as the whole translation process, created a complex macrocosm of interconnected microcosms’ (P03) that shaped the act of translating.
The translator verifying the Tibetan interviews, reflected how few studies there are exploring the Tibetan experience with TB in their native language and the importance of studies that connect to these experiences. The translator noted the importance of interacting with the patients in their own language and suggested that this can help the study, to some degree, pivot away from ‘Othering’ the patients and provide a more authentic understanding of their circumstances. The translator said:
By communicating through their Indigenous language, Tibetan, the conveyance of true, and whole perspectives, is enabled, and this in turn can help in our endeavor towards establishing a database that can genuinely be representative of the patient population, (P05).
However, team members reflected on inherent challenges due to distance from the study site and for some, limited insights into the culture that may limit the completeness of any translation. These reflections also engaged with an exploration of our ‘Otherness’ when engaging with the text and the challenges in rendering unfamiliar concepts, forms, and language into a different cultural context.15