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Jogikalmat krithikadatta.
Department of Conservative Dentistry and Endodontics, Mennakshi Ammal Dental College and Hospitals, Maduravoyal, Chennai – 600095, India
The need for scientific evidence should be the basis of clinical practice. The field of restorative dentistry and endodontics is evolving at a rapid pace, with the introduction of several materials, instruments, and equipments. However, there is minimal information of their relevance in clinical practice. On the one hand, material and laboratory research is critical, however; its translation into clinical practice is not being substantiated enough with clinical research. This four part review series focuses on methods to improve evidence-based practice, by improving methods to integrate laboratory and clinical research.
The field of dental research in India has witnessed exponential growth in the last five years.[ 1 ] However, scientific publications in international peer-reviewed journals have been few.[ 2 ] The lacuna of Indian contribution to international scientific literature is probably a skewed understanding of research and its contribution in effecting improved patient care. The primary purpose of research is to produce new knowledge or find new ways of making the existing knowledge available to those who need it. Research is not a separate speciality which is practiced by a few but it is a systematic approach of reasoning, documenting, analysing and reporting unusual clinical observations that we come across in everyday clinical practice. Whether one is a “doer” or a “user” of research, a thorough understanding of the methodology is essential. In addition to individual practitioners, the “users” of research includes 1) professional organizations that set “practice guidelines”;2) policy makers (sometimes called as “decision makers”) and 3) program managers (for example, state or national government managers of dental health programs). While the academicians and research scholars (teaching institutions) have a unique position to be “Doers” of research. The value for research for its own sake is limited, and therefore understanding the essential concepts in Research Methodology is vital in producing dependable knowledge.
The purpose of this review series is to help the reader to organize the thought process when considering research needs and methods. It also aims to sensitize the mind to research avenues that would be beneficial to material and clinical research in particular and improving the quality of clinical care in general. This four-part review series encompasses topics on essentials of research, fundamentals in biostatistics, observational studies, and experimental studies in each part.
Every action is first conceived in the mind and later executed. Planning a good research project forms the primary basis of meaningful publication. Certain fundamental requisites are listed in Table 1 . Focus in a particular area of interest is essential to build up a strong forte in academic excellence. Random choice of research projects dilutes the resource contribution in random directions and results in lack of identity of the person or faculty. Generating research hypothesis must aim at answering clinically relevant questions. The rationale for the choice of a particular stream could also result in a new concept of thinking or change the methods of treatment protocols.
Requisites of good research
It is prudent to decide apriori as to whom the results of a particular research question would be useful and will the results be applicable to patients in dental practices in the real world. Conventionally, in-vitro or laboratory research studies have good internal validity but poor external validity which means that the results obtained are only applicable to similar samples of the study. In other words, the results may not transfer to the clinical behaviour of the material. On the other hand, clinical studies have good external validity because they are tested on samples/ subjects that are closely related to the clinical condition and most often representative of all individuals with the condition; however they are more complex since so many other factors may influence the outcome of interest.
To understand validity, let us consider the research question on dentin bonding agents (DBA). In-vitro assessment of dentin bonding agents is usually measured in terms of bond strength and microleakage. In this scenario, all the samples and procedures are standardized to a specific methodology, that is, dentin cylinders 5 mm in height, with 4 mm of composite material, × N force at 0.5 cross-head speed, and so on. The bond strength values obtained can be best extrapolated to a similar set of conditions in the laboratory and may not deliver the same performance clinically to patients. On the contrary, if we conduct a clinical study to evaluate the performance of dentin bonding agents, the methodology would include a randomized controlled trial involving the restoration of non-carious cervical lesions ((NCCL), considered the ideal for bonding agent testing), the clinical evaluation criteria recommended by the United States Public Health System (USPHS), and followed over a period of time. The results of the study can be extrapolated to all similar patients requiring restoration of NCCLs. Hence, the valid method of testing the ultimate performance of DBA is by a clinical trial and not just bond strength testing. However, in-vitro studies provide an insight into which DBA is the best among the available, to be tested clinically. In-vitro studies provide internal validity , that is, they tell us if a particular drug or procedure works, but external validity questions if it is of use to the patient population at large, which can only be determined by clinical trials on patients.
Feasibility in terms of time, cost, samples, and infrastructure are vital to set a logistic time frame for the functioning and completion of the study. Finally, a study that does not adhere to ethical principles both for in-vitro and clinical designs, fails to answer clinically relevant questions. The principles of ethics are not restricted only to the handling of human participants, but also encompass the ethics followed in the methodology and reporting of results. The Indian Council of Medical Research (ICMR) has comprehensive guidelines for conducting experimental studies in India.[ 3 ]
The term Epidemiology refers to the study of the distribution and determinants of health-related states or events (including disease), and the application of these methods to the control of diseases and other health problems.[ 4 ] Erroneously in India, this science is often dissociated from dental clinical research and is regarded to be a practice under community dentistry. Hence research methods described under epidemiology have also not been used in answering many of our clinical research questions. David Sackett, in 1969, coined the term clinical epidemiology, which is the, “application, by a physician who provides direct patient care, of epidemiological and biometric methods, to the study of diagnostic and therapeutic processes, in order to effect an improvement in health.”[ 5 ] This concept identifies the clinician as the epidemiologist, which chiefly includes practitioners (general/specialist), students, and academicians, who are constantly involved in patient care. Almost four decades since this concept was introduced, our fraternity is waking up to this approach. It is important to note that knowledge of the disease process and treatment protocols constitute clinical knowledge. This forms only one essential part of clinical epidemiology. In order to understand the involvement of clinicians in clinical research, we need to be aware of certain disease manifestations in the community, with regard to the magnitude of the problem and measures to deliver dentalcare.
Consider this question being asked by the Head of Department of an institution, “What is the best endodontic regime for patients being treated in my department?” Traditionally, this question would be answered by schools of thought, textbook evidence, and findings reported in peer-reviewed literature. In reality, this simple question has the ability to raise meaningful research questions if we could apply this to the measurement iterative loop proposed by Tugwell et al .[ 6 ] [ Figure 1 ]. The measurement iterative loop breaks up the disease cycle into distinct component steps. It is iterative because, each step logically leads to the next, and thus comes back to the first step thus ‘closing’ the loop. Each step in the loop has the capacity to generate several research questions.
The measurement iterative loop
In this loop, the first step is to ascertain the burden of illness. The burden of illness (e.g., patients requiring root canal treatment) could be measured among the patients seeking dental care in the hospital or in a defined population. The former will provide an answer to the rate of occurrence of endodontic disease and the latter addresses the prevalence of endodontic disease, both of which would vary with place and time. The burden of illness could be subdivided into: (a) Unavoidable and (b) avoidable. Avoidable burden of illness comprises of disability, symptoms, and morbidity, for which efficacious caries preventive and intervention methods are present. The unavoidable burden of illness of disability comprises of symptoms and morbidity for which no efficacious prevention or cure exists. Eg if the tooth has been lost then root canal treatment is not possible.The focus on research in this area should be an effort to transfer the burden from unavoidable to avoidable.
Second is to identify and assess the possible cause of the burden of disease. The etiology and risk-factor assessment of a multifactorial disease like pulpal and periapical pathology in itself generates a lot of research avenues. This step also makes use of several traditional study designs to derive clinically significant conclusions. This step identifies the factors against which an intervention can reduce the burden of illness, for example, failure of primary endodontic treatment. To name a few obvious causes, inadequate cleaning and shaping, missed canals, and incomplete obturation. The risk factors in association to this failure could be: Vitality status of the pulp during initial endodontic treatment, amount of remaining tooth structure, and type of tooth.
Defining factors for causation also requires that there should be well-defined, specific, and reproducible definitions for both the disease state and the risk factors. Developing such criteria for defining disease and causative or risk factors contribute to increased diagnostic accuracy .
The third step of the loop is the most significant. Having identified the ‘intervenable’ factors, it is important to study if interventions against them will work. After identifying interventions, in vitro studies are carried out when necessary, and then the successful interventions are tried on humans. The initial trials should be to determine Efficacy . This means that it should be determined whether the intervention works if given in the right dose using the right methods, for the right duration, that is, Can it work in ideal circumstances ?
Once this is achieved, the intervention (preventive and restorative) methods are applied to the community, that is, patients seeking treatment for failed endodontic treatment or among the general population at a risk of developing failure of primary endodontic treatment. This step is Community effectiveness, which measures how well an intervention can work in real life . It assesses the benefit/harm ratio of potentially feasible interventions and estimates the reduction of burden of illness, if the program is successful. Community effectiveness is determined by five factors: (a) Efficacy , (b) Screening and diagnostic accuracy, (c) Evaluation of health care provider compliance, (d) Evaluation of patient compliance , and (e) Evaluation of coverage . To understand this better let us consider the question of treating symptomatic irreversible pulpitis with Mineral trioxide aggregate (MTA) pulpotomy in Department of Endodontics at a dental college and give hypothetical percentages of success for each factor and compute the community effectiveness.
Now community effectiveness can be computed using the Multiplicative law of combining probabilities (P),[ 7 ] considering the probability of each of these factors
Community Effectiveness = P (Efficacy 100% × diagnostic accuracy 90% × health provider compliance 80% × patient compliance 80% × coverage 90%) = 52%
After determining an effective treatment plan for the community/patients, the efficiency of the same needs to be evaluated. This step determines the relationships between costs and effects of options within and across the program. Cost could be a major deterrent in MTA pulpotomy. This could propel ingenious preparations to match commercially available MTA, or allocate funds to deliver this treatment to indicated patients. This is followed by the synthesis and implementation of MTA pulpotomy as a standard of care for indicated patients with irreversible pulpitis. This is done after integration of the feasibility of community effectiveness and efficiency. Any program implemented needs to be followed up with systematic documentation and monitoring. It should include markers for success and failure on the basis short-term, intermediate, and long-term treatment outcomes.
With success data in hand, the burden of illness should again be re-assessed, to ascertain any modifications required within the existing program.
Evidence-based practice is defined as, “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”[ 8 ] Individual clinical expertise is the proficiency and clinical judgment that is often a summation of clinical experience and clinical practice. This systematic clinical research in our field includes both in-vitro and clinical research, with equal importance. The sensible transition to clinical research by making use of the conclusions of in-vitro research will contribute evidence to various steps of the measurement iterative loop. It is often observed that the thrust for clinical research is feeble and as a result there is insufficient evidence from laboratory research translating to clinical practice. The ideal place to enable contribution to the best clinical evidence would undoubtedly be the institutional organization, which has the balance between clinical expertise from the teachers end and the requirement for research projects from the students’ end. The only missing link is a properly planned research , which can be fullfilled by employing the measurement iterativeloop.
The awareness of evidence-based dentistry is growing not only on the research/clinical front, but also from patients seeking quality dental care. Hence, the possibility of a research study being acknowledged in scientific literature is often driven by the relevance of evidence that a particular research study can deliver. There is a certain hierarchy termed as ‘Levels of Evidence,’ purely based on the reliability of information or from evidence derived from a scientific study,.[ 9 ]
There are five levels, and each level has sub-ranks as shown in Figure 2 .[ 7 ]
Levels of evidence
Case Series/Cross-sectional studies/Poor quality case control studies
Case Reports/Expert opinion/Literature review.
It must be noted, with caution, that the level of evidence is only a stratification based on the information that is obtained from each method, with minimal bias, and these levels in no way rank the study design. It is logical to perceive that study designs are chosen based on research questions. For example, even though Randomized Clinical Trials provide the best evidence, this study design is not meant to identify risk factors for occurrence of disease (determined by case-control study) or disease occurrence/prognosis (determined by Cohort study). Hence, levels of evidence are a logical ranking for evidence rather than a ranking for study designs.
With the understanding of the measurement iterative loop and the significance to generate relevant evidence for clinical practice, the research question should aim at focusing on one primary issue at a time. The method to identify and prioritize research questions is given in Figure 3 .
Method used to identify and prioritize research questions
A well-built research question should include four parts, referred to as the PICO format, which includes Patient/Population/Problem, Intervention, Comparison, and Outcome (PICO).[ 10 ]
Patient/population/problem — Defines the condition of interest. This is usually derived from the patients’ chief complaint in a clinical situation (in particular or on a larger population) or is derived from the problem faced in a particular material research.
Intervention [ or ‘ exposure ’- making it PECO for causation questions ]— It is important to identify what has been planned for the patient or the problem . Depending on the problem, this may include the use of a specific diagnostic test, treatment, medication or the recommendation to the patient, to use a product or procedure. If the problem measures the causation of a particular disease, then the etiological agent is assumed as the intervention.
Comparison — It is an alternative to the intervention under study.
Outcome(s) — This pertains to the result of the study preferably outcomes that can be measured accurately that are important to the patient.
The PICO format can be used to generate a research question for determining the causation of disease, diagnosis of a disease or therapy and prognosis of particular condition/disease. Examples for each are given in Table 2 .
Use of PICO format to generate research questions
Although the PICO format is best applied to intervention studies and experimental designs, research questions for all other study designs can also be formulated using this approach.
Both in-vitro and clinical study designs for various questions arising from clinical practice or knowledge can be determined by applying various sections of the iterative loop. Depending on the research question, the structure of each study design facilitates the derivation of appropriate answers. Prior to choosing the study design, there has to be a valid research question. The genesis of a research question should primarily focus on answering several aspects of a broader research interest. For example, if the research interest lies in stem cell research, then the best source of stem cells, ideal growth environment for stem cells, potential differentiation of stem cells into tissues, confluence of growth obtained by different processing methods, clinical application of laboratory-derived stem cells, storage of stem cells, potential for malignant transformation of stem cells, and so on, form the several aspects or avenues to generate research questions. The primary effort in research is not to focus on the research question, but to focus on your research interest . on study designs and its relevance in answering specific research question will be dealt with in detail in the subsequent articles of this review series on research methodology.
The Role of Biostatistics is often overlooked and ignored in the current research work in our speciality. Biological systems form a dynamic continuum and variation between the units forming the biological systems (people, teeth, bacteria, etc.) is the norm. On account of this variability within the systems, it is often difficult to differentiate between groups within the system. The science of biostatistics helps us to quantify and evaluate its variability within and between groups that make up the biological systems. Statistics is not absolute; it is a measure of the probabilities of occurrence of an event.
Biostatistics is less mathematics and more a method of determining the relevance of the research findings by application of statistical methods. This retains equal importance in both in-vitro as well as clinical research, because this statistical inference lays a foundation for the evidence deduced from any study. Hence the role of the statistician and the clinical researcher are equivalent in finding answers to any research question. The next part on research methodology focuses on understanding biostatics for dental research.
The research processes both in-vitro and clinical studies can be best summarized by the flow chart in Figure 4 .
Anatomy of a research study
The need for good research is to find the best evidence for clinical practice, for specific problems, and to address methods in reducing the burden of illness on a larger scale. Research studies in Endodontic and Restorative dentistry are two dimensional. The first dimension is the laboratory research, which provides the best evidence on material science and the second dimension is clinical research, which provides the best evidence in dealing with the burden of illness, with efficient clinical practice. This increases the avenues for research studies in several directions. With an increasing requirement to publish, articles with good clinical evidence stand a definite chance to find their place in scientific literature.[ 11 ]
The author would like to thank Prof. Peter Tugwell, Professor of Medicine University of Ottawa, Canada, Prof. Emeritus. Vic Neufeld, Faculty of Health Sciences, McMaster University, Canada and Prof. Manjula Datta, Retd Prof & Head of Epidemiology, The Tamilnadu MGR Medical university for having accepted to review the manuscript and for their valuable inputs in the preparation of the same and Chennai Dental Research Foundation, Chennai for their support.
Source of Support: Nil
Conflict of Interest: None declared.
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The following is a comprehensive list of dental definitions, dental conditions, dental topics, and general dental information to help you learn the importance of good oral health. Dental Associates offers every dental specialty, so it’s likely we have experience with anything listed on this page. You can also visit Our Services to learn more about the full range of dental services we provide you and your entire family.
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Objectives: This study aimed to provide visualized knowledge maps to show the evolving trends and key focal points of Class III malocclusion research through a comprehensive bibliometric analysis.
Materials and methods: Class III malocclusion research published between 2000 and 2023 was retrieved from the Web of Science Core Collection. VOSviewer was utilized to count the citation and publication number of authors, institutions, countries and journals. Co-occurrence, co-citation, and cluster analyses and burst detection were conducted using CiteSpace.
Results: A total of 3,682 publications on Class III malocclusion were included in the bibliometric analysis. During 2000-2023, both the annual publication count and citation frequency exhibited a gradual upward trajectory, with a noticeable surge in recent years. In terms of production and citation counts of Class III malocclusion research, the core journal is the American Journal of Orthodontics and Dentofacial Orthopedics. Furthermore, apart from the primary keyword 'Class III malocclusion', 'orthognathic surgery' was identified as keyword with the most frequency. The cluster analysis of cited references reveals that the research focal points have shifted to 'skeletal anchorage' and 'surgery-first approach'. Furthermore, the burst detection identified 'quality of life' as a potential research hotspot since it has recently gained increasing scholarly attention.
Conclusions: The current study provides scholars with the knowledge maps of evolving trends and prominent topics of Class III malocclusion research and a summary of research progress on various priorities during different periods. These findings are expected to provide a valuable guidance to facilitate the future research on Class III malocclusion.
Keywords: Bibliometrics; Class III malocclusion; Orthodontics.
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British Dental Journal volume 227 , page 113 ( 2019 ) Cite this article
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Kakudate N, Yokoyama Y, Sumida F et al. Practice-based research agendas priorities selected by patients: findings from a practice-based research network. Int Dent J 2019; 69: 183−191.
Study shows priorities differ with age and gender.
'Public involvement in research is defined as research that is done with or by the public and not to, about or for them' (Involve www.invo.org.uk ) and many grant funders now require evidence of public and patient involvement in research projects. The research agenda, however, may still be being set by academics and not by patients. Relatively little research is based in general practice.
Using a questionnaire with patients in 11 dental clinics in Japan, Kakudate and colleagues have attempted to find out which research topics would be important and relevant to patients. Involving patients 'may provide opportunities to produce research which is valid, relevant, acceptable, sustainable and innovative.'
Following a pilot study, a 31 item questionnaire, divided into 11 categories was developed (orthodontic treatment, regular dental check ups, prognosis of dental treatment, dental implants, tooth brushing, diet and food, aesthetic dental care, topical fluoride application, social health insurance, bruxism and miscellaneous) and was completed by 482 patients (87.6% response rate).
The most commonly selected research agenda was 'age specific care to maintain oral health' (n = 84), followed closely by topics related to toothpastes and brushing, the durability of restorations and questions relating to diet, caries and periodontal disease. The least popular topic related to the use of interdental cleaning aids. In patients <40, selection of toothpaste was the most popular topic. Only responders <30 listed the timing of wisdom teeth extractions and orthodontic as topics. Only those aged >60 listed the durability of restorations in relation to treatment available under the national health insurance scheme.
Statistically significant age and gender differences were noted. Younger patients rated orthodontic treatment, aesthetic dental care and fluoride applications more frequently than older patients. Older patients rated regular dental check ups, implants, diet and health insurance as more interesting than younger ones. Females rated aesthetics as more important than did males, who rated toothbrushing as more interesting than did females.
Responses may be different from within a different culture. However, these results clearly show that different age groups have differing priorities with regard to research priorities. If research is to be patient centred and relevant, then shaping research questions around actual patients' concerns, needs and values assumes greater importance. These results may 'help research funders identify future priorities that have the greatest impact on patients and the clinicians who treat them.'
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Hellyer, P. Which dental research topics are relevant to patients?. Br Dent J 227 , 113 (2019). https://doi.org/10.1038/s41415-019-0567-1
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This new tool is built on top of SQL, a programming language for database creation and manipulation that was introduced in the late 1970s and is used by millions of developers worldwide.
“Historically, SQL taught the business world what a computer could do. They didn’t have to write custom programs, they just had to ask questions of a database in high-level language. We think that, when we move from just querying data to asking questions of models and data, we are going to need an analogous language that teaches people the coherent questions you can ask a computer that has a probabilistic model of the data,” says Vikash Mansinghka ’05, MEng ’09, PhD ’09, senior author of a paper introducing GenSQL and a principal research scientist and leader of the Probabilistic Computing Project in the MIT Department of Brain and Cognitive Sciences.
When the researchers compared GenSQL to popular, AI-based approaches for data analysis, they found that it was not only faster but also produced more accurate results. Importantly, the probabilistic models used by GenSQL are explainable, so users can read and edit them.
“Looking at the data and trying to find some meaningful patterns by just using some simple statistical rules might miss important interactions. You really want to capture the correlations and the dependencies of the variables, which can be quite complicated, in a model. With GenSQL, we want to enable a large set of users to query their data and their model without having to know all the details,” adds lead author Mathieu Huot, a research scientist in the Department of Brain and Cognitive Sciences and member of the Probabilistic Computing Project.
They are joined on the paper by Matin Ghavami and Alexander Lew, MIT graduate students; Cameron Freer, a research scientist; Ulrich Schaechtle and Zane Shelby of Digital Garage; Martin Rinard, an MIT professor in the Department of Electrical Engineering and Computer Science and member of the Computer Science and Artificial Intelligence Laboratory (CSAIL); and Feras Saad ’15, MEng ’16, PhD ’22, an assistant professor at Carnegie Mellon University. The research was recently presented at the ACM Conference on Programming Language Design and Implementation.
Combining models and databases
SQL, which stands for structured query language, is a programming language for storing and manipulating information in a database. In SQL, people can ask questions about data using keywords, such as by summing, filtering, or grouping database records.
However, querying a model can provide deeper insights, since models can capture what data imply for an individual. For instance, a female developer who wonders if she is underpaid is likely more interested in what salary data mean for her individually than in trends from database records.
The researchers noticed that SQL didn’t provide an effective way to incorporate probabilistic AI models, but at the same time, approaches that use probabilistic models to make inferences didn’t support complex database queries.
They built GenSQL to fill this gap, enabling someone to query both a dataset and a probabilistic model using a straightforward yet powerful formal programming language.
A GenSQL user uploads their data and probabilistic model, which the system automatically integrates. Then, she can run queries on data that also get input from the probabilistic model running behind the scenes. This not only enables more complex queries but can also provide more accurate answers.
For instance, a query in GenSQL might be something like, “How likely is it that a developer from Seattle knows the programming language Rust?” Just looking at a correlation between columns in a database might miss subtle dependencies. Incorporating a probabilistic model can capture more complex interactions.
Plus, the probabilistic models GenSQL utilizes are auditable, so people can see which data the model uses for decision-making. In addition, these models provide measures of calibrated uncertainty along with each answer.
For instance, with this calibrated uncertainty, if one queries the model for predicted outcomes of different cancer treatments for a patient from a minority group that is underrepresented in the dataset, GenSQL would tell the user that it is uncertain, and how uncertain it is, rather than overconfidently advocating for the wrong treatment.
Faster and more accurate results
To evaluate GenSQL, the researchers compared their system to popular baseline methods that use neural networks. GenSQL was between 1.7 and 6.8 times faster than these approaches, executing most queries in a few milliseconds while providing more accurate results.
They also applied GenSQL in two case studies: one in which the system identified mislabeled clinical trial data and the other in which it generated accurate synthetic data that captured complex relationships in genomics.
Next, the researchers want to apply GenSQL more broadly to conduct largescale modeling of human populations. With GenSQL, they can generate synthetic data to draw inferences about things like health and salary while controlling what information is used in the analysis.
They also want to make GenSQL easier to use and more powerful by adding new optimizations and automation to the system. In the long run, the researchers want to enable users to make natural language queries in GenSQL. Their goal is to eventually develop a ChatGPT-like AI expert one could talk to about any database, which grounds its answers using GenSQL queries.
This research is funded, in part, by the Defense Advanced Research Projects Agency (DARPA), Google, and the Siegel Family Foundation.
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Across the 35 countries we surveyed, more have unfavorable views of China than favorable ones. The same is true when it comes to Chinese President Xi Jinping: People mostly lack confidence in him to do the right thing regarding world affairs.
But opinions vary widely across regions and across levels of economic development. For example, in the high-income European countries included in the survey, views of China and Xi tend to be broadly negative, while in middle-income nations in sub-Saharan Africa, views are significantly more positive.
Views tend to be among the most and least positive in the Asia-Pacific region – more positive in middle-income countries like Malaysia and Thailand, and more negative in high-income ones like Australia, Japan and South Korea.
A 35-country median of 35% have a favorable view of China, compared with a median of 52% who have a negative view. Opinions vary widely, from 11% favorable in Sweden to 80% favorable in Thailand.
In the 18 high-income countries we polled, views of China are, on balance, negative. There are three notable exceptions where opinion of China is either divided or net positive: Chile, Greece and Singapore. Among Singaporeans, those who are ethnically Chinese are particularly favorable (71%). A majority of Singaporeans who are not ethnically Chinese also see China favorably (59%).
In the 17 middle-income countries we polled, views of China are much rosier. Though three countries stand out for having more negative than positive views: India, the Philippines and Turkey.
Views of China have turned slightly more positive since last year in Argentina, Canada and Greece (+7 percentage points each).
Over the same period, favorable views have decreased significantly in Israel (-15) and Hungary (-7).
The sharp decrease in favorability among Israelis follows a number of Chinese policy positions related to the Israel-Hamas war. China was an early proponent of a cease-fire in Gaza , and Chinese Foreign Minister Wang Yi accused Israel of going “beyond the scope of self-defense” in the first days of the war. (The survey predated Xi’s calls for the establishment of an independent Palestinian state in his May meetings with Arab leaders .)
Jewish Israelis (25%) have much less favorable views of China than Arab Israelis do (61%). Among Jewish Israelis, this reflects an 18-point decrease in favorability since last year; among Arab Israelis, the decrease was 7 points.
In Hungary, the survey followed China’s offer for a security pact between the two countries but occurred before Xi’s May visit to Budapest .
We also see significant shifts in opinion in some of the countries not surveyed since before the outbreak of the COVID-19 pandemic :
In Ghana, the share who are unsure or decline to answer the question has dropped significantly since 2017, and in turn, both positive (+11) and negative (+7) views of China have increased. The same has also happened in Tunisia since 2019: Positive views have increased 5 points (from 63% to 68%) and negative views have increased 9 points (from 16% to 25%) while the share who decline to answer decreased significantly.
Younger people tend to have more favorable opinions of China than older people do. This has long been the case in the United States , and is also true in over half of the other countries surveyed.
Gaps are particularly large in Brazil, Chile, Mexico, Peru and the United Kingdom, where those ages 18 to 34 are around 25 points more likely than those 50 and older to view China positively.
Only in Hungary and South Korea is the pattern reversed, with younger people feeling less favorably toward China.
In most countries, views of China are not an ideological issue. But, in the U.S. and Israel, those who place themselves on the left of the ideological spectrum (“liberals” in the U.S.) have more favorable views than those on the right (“conservatives” in the U.S.).
In Bangladesh, Hungary, the Netherlands and Spain, those on the right tend to have more positive views on China than those on the left.
Few internationally have confidence in Chinese President Xi Jinping. A 35-country median of 24% express at least a fair amount confidence in the leader, while 62% have little to no confidence. However, opinion varies widely across high- and middle-income countries (49% and 12% confidence at the median, respectively), as well as across regions.
Views are least positive in North America and Europe: Clear majorities in each country surveyed there have little or no confidence in Xi.
In the Asia-Pacific region, Xi gets some of his highest and lowest ratings. Positive ratings tend to be more common in middle-income countries than high-income countries. For example, roughly half or more in Bangladesh, Malaysia, and Thailand have at least a fair amount of confidence in Xi. Conversely, in Australia, Japan and South Korea, at least eight-in-ten lack confidence in him. Middle-income India, where more lack confidence in Xi, and high-income Singapore, where most have confidence in Xi, are two notable exceptions to this pattern.
Views of Xi are more positive than negative in sub-Saharan Africa, especially in Kenya (64% vs. 33%) and Nigeria (59% vs. 30%). Notably, large shares in South Africa (33%) and Ghana (21%) refuse to answer or are unsure.
In the Middle East-North Africa region, views of Xi lean positive in Tunisia, but much smaller shares have confidence in him in Israel and Turkey. In Latin America, only around three-in-ten or fewer have confidence in Xi in every country surveyed.
Among countries last surveyed in 2023, opinions of the Chinese leader have become slightly less positive in South Africa (-9) and Israel (-6) and slightly more positive in Argentina (+6) and Hungary (+7).
Confidence has also fallen slightly in two countries last surveyed in 2022: Malaysia (-7) and Singapore (-6).
And, in the Philippines, last surveyed in 2019, confidence has fallen 13 points, from 58% to 45%.
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