Exploring the treatment journey of obstructive sleep apnoea: a scoping review on the perspectives of Chinese patients

Introduction

Background

Obstructive sleep apnoea (OSA) affects an estimated 1 billion people globally (1). Risk factors include advanced age, male gender, obesity, menopause, family history, and craniofacial or upper airway soft tissue abnormalities (2). OSA increases the risk of impaired daytime alertness, reduced quality of life, hospitalization, cardiovascular morbidities, and premature mortality (2). Continuous positive airway pressure (CPAP) therapy is the treatment of choice for OSA (3), while mandibular advancement devices (MAD) are recommended in patients who cannot tolerate CPAP or prefer alternate therapy (4). Surgical treatment is usually a second-line or adjunctive therapy for OSA along with CPAP or an oral appliance (5). Glucagon-like peptide 1 receptor agonists (GLP-1Ras) could significantly reduce the severity of OSA (6) and research is ongoing on various other pharmaceutical agents (7). Positional therapy has shown benefit over no intervention (8). Comprehensive lifestyle interventions including weight loss have been recommended for overweight or obese patients (9).

Rationale and knowledge gap

Despite the vast array of available treatment options, management of OSA remains challenging in practice especially with uptake and adherence to CPAP (10,11). While treatment engagement is multifactorial, emerging research suggests that race/ethnicity and cultural beliefs may play an important role in treatment engagement for OSA (12-14). Ethnicity refers to a group of individuals sharing a common racial and/or cultural background (15). A scoping review showed worse CPAP adherence in black/African American patients compared to white/Caucasian patients (14). Racial disparities in CPAP engagement and sleep health in general have been observed (12,16), but most research has focused on African American and Hispanic populations, leaving other groups under-researched. One important ethnic group are the Chinese population who despite having one of the highest prevalence rates (1) and increased severity of OSA compared to those of European descent (15), have correspondingly low CPAP acceptance (21%) (17) and adherence (44–67%) (17-19) rates. Chinese individuals are more susceptible to OSA at lower BMIs due to craniofacial differences which make them more vulnerable to the effects of weight gain (15,20) and greater burden of comorbidities, including diabetes, hypertension, and other metabolic conditions (21). It could be speculated that the global obesity epidemic in the Chinese population (22) further increases their risk of OSA and related comorbidities with significant implications for health systems. It is well established that there is a significant relationship between illness perceptions and beliefs and treatment adherence in chronic disease management like hypertension and asthma (23). A similar relationship may exist for OSA management, but little is known about how illness perceptions and beliefs, which include self-efficacy, and cultural and religious factors influence treatment engagement in Chinese patients.

Objective

Taken together, there is a need to better understand the treatment needs, experiences and perspectives of the Chinese patient population with OSA. As such, this scoping review aims to explore the current state of the literature and to synthesize patient-reported outcomes to better understand the perspectives of Chinese patients with OSA navigating treatments. We present this article in accordance with the PRISMA-ScR reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-299/rc) (24).

Methods

The review protocol is registered on the Open Science Framework (OSF) Inclusive Systematic Review Registration Form: (https://doi.org/10.17605/OSF.IO/SRTA9).

Inclusion and exclusion criteria

Publications meeting the following criteria were included in this review:

• Sample: adult patients (≥18 years) self-identifying as Chinese with OSA. OSA could be self-reported by the patient based on a prior diagnosis before study participation; or confirmed during the study. Multi-racial/ethnic studies conducted in countries/regions where the Chinese population is a minority and articles that did not specify the proportion of Chinese patients within the study sample were excluded.
• Phenomena of interest: patient experiences of various OSA treatments.
• Design: primary studies of all study designs investigating OSA treatment published in a peer-reviewed journal and written in English or Chinese.
• Evaluation: inclusion of a patient-reported outcome related to their OSA treatment at any stage of the treatment trajectory including beliefs and expectations; preference and acceptance; treatment experience; adherence and attrition, satisfaction and perceived efficacy.
• Research type: mixed (quantitative and qualitative).

Studies were excluded from this review if:

• Animal studies or cell lines were used as part of the study.
• Patient reported outcomes were not included as a measure of interest (i.e., only relying on biomarkers, physiological parameters or clinician-reported observations).
• Not primary research (e.g., reviews, clinical guidelines, white papers, case series, case reports).

Search strategy

Electronic databases (CINAHL, EMBASE, PsycINFO, Scopus and Medline) were systematically searched via Ovid on 28 Jul 2023, updated on 31 May 2024 and 21 Jun 2025 to identify articles. No date limits were applied; all databases were searched from date of conception. The complete search strategy can be located in Appendix 1. The search strategy followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Reporting Literature Searches in Systematic Reviews (PRISMA-S) checklist (25) (Appendix 2) and included the following major concepts: Obstructive sleep apn(o)ea; Chinese adult patient population; treatments included CPAP, surgical interventions, mandibular advancement device/splints, pharmacotherapy, positional therapy, complementary therapies, and lifestyle modifications; and psycho-social-behavioural factors. These concepts were mapped to the MeSH terms of the respective databases. Two Cochrane reviews on surgery (26) and drug therapy (27) were referred to for specific search terms.

Article selection

A total of 976 studies were retrieved for screening, of which 297 were identified as duplicates. Of 679 studies eligible for title and abstract screening, 585 were excluded due to not meeting inclusion criteria, and 94 were identified for full-text screening. Out of the 586 excluded 10 were conference abstracts deemed potentially relevant. For these abstracts we conducted a web search and contacted the corresponding/senior author, yielding two additional full texts. A total of 43 articles were selected. Update of the literature search in May 2024, along with manual searches of references lists of the included articles and related review articles, and a recommendation from one of the authors (P.A.C.), identified six more articles, resulting in 49 articles. The updated search in June 2025 identified three additional articles, totalling 52 articles selected for this review (Figure 1). The title, abstract and full text screening of studies were independently conducted by two reviewers (X.Z. and J.M.Y.C.) using Covidence (Veritas Health Innovation, Melbourne, Australia). Conflicts in decision making were resolved via discussion and the inclusion of a third reviewer on the team (Y.S.B.).

Figure 1 Literature screening and selection.

Data extraction

One author (X.Z.) extracted data using a standardized data extraction form to collect information relating to participant characteristics, study design, setting, country/region in which the study was conducted, article language, key findings, and patient-reported outcomes. The primary phenomena of interest were patient-reported outcome measures, which were operationalized as any information from the included studies directly reported by the patients on their experience throughout the treatment trajectory. Cross-checking of data extraction was then performed by a second author (J.M.Y.C.). Data extraction was facilitated by the NVivo 12 analysis software (QSR International). The details of each included study are summarised in Table S1.

Results

Study characteristics

Of the 52 included studies, most were conducted in mainland China (21/52, 40%), followed by Hong Kong SAR (17,28-38) (12/52, 23%), Taiwan region (39-48) (10/52, 19%), and Singapore (49-54) (7/52, 13%). Two (4%) studies (55,56) were based in the same international study involving sites in China. The majority of included studies (49/52, 94%) were published in English and three (6%) (50,57,58) were published in Chinese. Recruitment predominantly took place in a hospital setting except for three studies, which involved administering a screening survey at a bus depot (31) and surveying the elderly in community centers (17) or general community (59).

Twenty-six studies were interventional, comprised of randomized controlled trials (14/52, 27%), cross-over trials (36,51,60,61) (4/52, 8%) and single arm intervention trials (29,35,38,39,52,60,62,63) (8/52. 15%). Twenty-three studies were observational, comprising cohort (17,31,37,40,41,43,45-49,53,54,58,64-67) (18/52, 35%), case control (30) (1/52, 2%) and cross-sectional (18,50,57,67) (4/52, 8%) studies. The remaining three studies (6%) adopted a qualitative design using semi-structured interviews (42,44,68). The follow-up duration across 41 studies ranged from one night to 5 years with median follow-up time of 3 months. The remaining 8 studies did not specify follow-up duration (42,44,48,57,61,65,67,68) and 3 studies only specified range (49) or minimal follow-up duration (40,46) so they were not included in the median calculation.

The majority of studies investigated treatment with CPAP (29/52, 56%), followed by surgical approaches (39-41,45-47,54,62,64,66,69) (11/52, 21%), MAD/oral appliances (52,61) (2/52, 4%), lifestyle modifications/motivational interview (34,70) (2/52, 4%). Two studies (4%) investigated various treatment choices (57,65). One (2%) investigated alternative devices (nasal positive end expiratory pressure valve) (35), three studies (6%) involved a mix of treatment modalities (51,60,71), and two study (4%) investigated treatment delay without specifying treatment modalities (67,68).

Participant characteristics

The identified studies included a total of 16,828 adults (median sample size 102, with range, 10 to 4,097). For studies that reported a group mean for age (35/52, 67%), participants were 48 years with a range of 33.4 to 73.9 years. In another five studies, the median age range was between 35 to 61 years (5/52, 10%) (37,38,52,67,71). Eleven studies (21%) could not be included in this summary as the mean age was only reported for sub-groups (34,43,48-50,54,69,70,72,73) or only as a range (42). One study did not report participant age (32).

On average, 79% (range, 0–100%) of participants were male except for two studies which did not report gender distribution (32,36). One study (44) explicitly recruited female participants to explore their OSA experience. In two studies (64,69), while not exclusively targeting males, only male participants were recruited.

OSA severity across studies was heterogenous with 30 studies (58%) including all OSA severities, 2 studies including only mild to moderate OSA (4%) (52,61), 13 studies (25%) including moderate to severe OSA (40,44,45,50,51,54-56,71,72,74-76), 6 studies (12%) including only severe OSA (36,41,42,62,64,66) and 1 study (2%) including moderate to severe risk of OSA (49).

Patient-reported outcomes

Based on our synthesis, patient-reported outcomes were categorized into the following domains along the treatment trajectory: (I) beliefs about OSA and treatment; (II) treatment preference; (III) treatment acceptance; (IV) treatment satisfaction; and (V) treatment adherence (Figure 2).

Figure 2 Summary of findings and future research focus. CPAP, continuous positive airway pressure; HCP, healthcare professionals; MAD, mandibular advancement device; OSA, obstructive sleep apnoea; PEEP, positive end-expiratory pressure; PRO, patient reported outcomes; VAS, Visual Analog Scale.

Beliefs about OSA and treatment

Beliefs about OSA were captured in 10 studies (10/52, 19%) (Table S2). Two qualitative studies (42,44) identified themes about typical symptoms of OSA (e.g., snoring, choking, daytime sleepiness) and the impact on general health (e.g., decreased memory, hypertension, poor blood sugar control). However, participants did not necessarily link these symptoms to OSA and its consequences. Some participants believed that snoring was a normal occurrence and snoring was perceived as the preserve of men (44). The women in the study were unwilling to disclose their OSA status due to fear that they might be subject to ridicule as a result (44). Similarly fear of confirmed OSA diagnosis being disclosed to employers was a barrier to PSG uptake among bus drivers, despite confidentiality assurances from researchers (31). Relatedly, common reasons for not seeking help included the belief that treatment or testing is not needed or illness not serious enough for treatment [which was reported by 53.4% (65); 22.3% (57); 15.8% (50); 3.7% (38) of study participants] or being uninformed about the significance of untreated OSA (38%) (17). For women, the help-seeking experience has been described as a complex, time-consuming journey with “twists and turns and feelings of helplessness” (page 51) (44). Similarly trial and error for the “right” CPAP emerged as a theme with self-adjusting of comfort features of CPAP (e.g., temperature control) and self-seeking information due to insufficient information from professional personnel (42). Long scheduled wait-times for sleep assessment, feelings of uncertainty toward outcomes of CPAP, lack of consultation or support from medical staff, and the reliance on anecdotal information acquired from web searches or hearsay, were quoted (42,44). Three other studies identified barriers to help-seeking due to lack of awareness of snoring and tendency to attribute symptoms (e.g., tiredness) to other causes; normalization of symptoms particularly in the context of a family history of snoring (68), fear of infection [coronavirus disease 2019 (COVID-19) (67), severe acute respiratory syndrome (SARS) (31)] and inconvenience with transport during the Covid-19 lock down (67).

Treatment preference

Treatment preference was explored in six studies (6/52, 12%) (Table S3). Two studies utilized cross sectional surveys (65) and review of medical reports (53) and identified the most common choice was no treatment [38.4% (53) and 67.83% (65)], followed by CPAP [10.25% (65) and 34.8% (53)], and surgery [13.3% (53) and 15.23% (65)]. Oral appliances were chosen by 1.05% participants (65), with another study grouping them under various adjunctive treatments (53). Both studies reported treatment choice as a study outcome. However, one study simply asked what treatment was received without detailing the decision process (65). Another study (53) described a treatment pathway: starting with CPAP or adjunctive therapies and moving to surgery if nonsurgical options were declined. Four prospective studies reported patient preferences collected through participant questionnaires or interview for CPAP vs. positional therapy (51), different modes or types of CPAP (36,77), and different types of oral appliances (61). More patients preferred CPAP over positional therapy (51) (60% vs. 20%, while 20% preferred neither. A higher percentage of patients preferred one-piece over two-piece oral appliances (43.75% vs. 12.5%), while 43.75% had no preference) (61). Similar preferences were observed for simple/low-cost CPAP and traditional fixed CPAP (26.9% vs. 36.5%), while 36.6% reported no preference (77). However, another study reported preference for fixed CPAP over auto-CPAP (73.2% vs. 21.9%), while 2 patients (4.9%) discontinued treatment (36).

Treatment acceptance

A total of 22 studies (22/52, 42%) examined the treatment acceptance domain (Table S4). The majority of studies did not clearly provide a definition of acceptance. Four studies (30,43,48,53) used proxy measures to gauge acceptance with commitment behaviors such as the purchase of machines. Acceptance was operationalized in 20 studies (38%) as the proportion of patients progressing to treatment (17,18,30-32,34,35,37,38,43,48-50,53,57,58,65,74,76,77), revealing a median acceptance rate of 54.5%, with a range between 11.8% and 94.2%. However, two studies (2/20) (32,43) could not be included in the median calculation as the acceptance rate was reported for sub-groups only. Seventeen of the 20 studies reported acceptance to CPAP, two studies reported acceptance to a mix of treatment modalities (65) and one reported on a nasal positive end-expiratory pressure valve (35). Common reasons for declining or refusing treatment were intolerance or discomfort (17,30,48,57,74,76), fear of discomfort/pain (38), lack of benefit/trust in the treatment (65,74), financial reasons (17,38,48-50,57,65,74), inconvenience (17,50,65), and time constraints (49,65). Only one study reported the reasons for receiving treatment: frequent experience of breathlessness during sleep (69.8%); bedpartner or roommates intolerable of loud snoring (13.7%); suffered at least two traffic accidents/year (6.1%); irritability (4.7%); sexual problems (3.0%); or they had tonsillitis, nasal diseases, morning headaches, dry mouth or other frequently reported consequences of sleeping disorders (2.7%) (65).

Treatment satisfaction

Eleven studies (45-47,52,54,59,62,65,66,72,74) (11/52, 21%) reported treatment satisfaction as an outcome, and this was assessed with varied methods (Table S5). Satisfaction was operationalized using a range of questions: patient’s (54,66,74) or partner’s satisfaction (54); perceived effectiveness (65); facial appearance post-surgery (45,62,66); willingness to undergo the procedure again (46,47); overall experience (46,47); willingness to recommend the treatment to others (45,66); improvement on sleep quality, concentration (52) and partner’s perceived improvements in snoring (52,54). Visual Analog Scale (VAS) with varying scale and directions or binary outcome were collected in these studies. CPAP patients’ satisfaction was assessed in only three studies (72,74,76) (3/52, 6%), showing low mean VAS scores in both intervention and control groups (74), no significant difference in telemedicine and in-person groups assessed by Client Satisfaction Questionnaire (CSQ-8) (76), and one study reported satisfaction scores only for the CPAP titration night in the second study (72). Conversely, patients who underwent various surgical procedures reported higher levels of satisfaction. Over 70% of patients were satisfied with their post-surgery facial appearance (45,62,66); more than 75% patients would undergo the same surgery again (46,47), and all patients would recommend the treatment to others (66). The only study on MADs reported that the majority of patients (range, 69% to 78%) found improvement in sleep quality, concentration, and snoring (52). Symptom improvements were often used as a proxy for treatment satisfaction, with the Epworth Sleepiness Scale (ESS) being the most common tool (43/52, 83%). Most studies assessed symptoms except 4 studies (18,49,67,77). Mean ESS scores were available for both baseline and post-treatment for 14 studies (30,34,36,39-41,45-47,54,58,60,62,66) yielding a mean pre-treatment score of 12.0 (range, 9.2 to 20.9) and post-treatment score of 7.1 (range, 1.7 to 10.6). Thirteen of the 14 studies reported statistically significant improvement post-treatment. Improvements have also been assessed using VAS ratings for other metrics such as nose/airway symptoms (39,60,69,72) and snoring (40,41,46,47,54,61).

Treatment adherence

Thirty-one studies (31/52, 60%) captured adherence as an outcome (Table S6) with the majority (25/31) of the studies investigating CPAP adherence (17,18,28-33,36-38,43,48-50,53,55,56,58,59,63,73-76). One study investigated effect of dietician-lead lifestyle modification on CPAP adherence (34). Two studies investigated CPAP adherence among several other treatment modalities (57,65). One study investigated adherence to MAD (52), one study on CPAP vs. positional therapy (51) and the other on CPAP vs. MAD (71). Four hours of average nightly usage was a common cut-off for denoting CPAP adherence and was used in 22 of the 31 studies. Average nightly use ranged from 3.8 to 5.8 h/night in the first 30 days (28,29,36,55,56,74,76); 2.5 to 5.6 h/night in the first 3 months (17,28-31,33,56,59,74-76), 3.2 to 4.4 h/night over 12 months (17,34,55,56). Eight studies reported adherence across multiple follow-up periods, consistently observing decrease in adherence over time (17,28,29,36,55,56,74,76).

Ten studies (10/52, 19%) attempted to examine factors related to adherence from the perspectives of the patients, encompassing baseline symptoms or improvements (29,38,48,50,53,55,56,58,63,75); early CPAP experience or adherence (53,55,56), side effects (50,55,56), satisfaction (29), health beliefs (38) and psychological characteristics such as negative emotions and coping style (63) but consistent trends were not identified. Only one study interviewed patients directly to ascertain reasons for low self-reported CPAP usage. Reasons included difficulty acclimating during the titration night (27.3%), perceived inconvenience (18.2%), lack of perceived need or benefits from the treatment (11.8%), and various other factors including CPAP-related issues (e.g., noise and discomfort), financial constraints, dissatisfaction with treatment, and forgetfulness (18). Psychological characteristics including self-efficacy and outcome expectancy (74), and emotions and coping style (63) have been identified as possibly correlated with treatment adherence. Another study reported on reasons for attrition from CPAP including symptom resolution (13.9%); inconvenience (37%); lack of symptom improvement (19.1%); intolerance (17.3); partner complaining of equipment noise (9.3%) and equipment failure (3.5%) (65).

Discussion

This scoping review explored the state of the literature on the perspectives of Chinese-identifying OSA patients navigating through their treatment trajectory. Fifty-two articles with at least one patient-reported outcome measure were included for review.

Studies included in this review were predominantly comprised of male (79%) and relatively young patients (mean age 48 years). Current literature suggests OSA severity increases with age with menopause being a “turning point” in the prevalence of OSA among women (78). Older women with OSA appear to be underrepresented in the studies identified, raising questions about the generalisability of the results to this group. The only qualitative study on women highlighted perceptions of OSA as a male disease. OSA remains underdiagnosed and undertreated in women due to differences in clinical presentation, polysomnographic findings, and/or sociocultural factors (79). The traditional socio-cultural beliefs of women in a Chinese context and impact on gender appropriate OSA treatment should be further explored. Additionally, all studies identified were conducted in countries/regions where Chinese patients are the ethnic majority, leaving the influence of cultural, linguistic, and healthcare system differences on OSA treatment in migrant Chinese populations unknown, warranting further investigation.

Several barriers to disease recognition and treatment engagement identified in this review were potentially associated with patients’ health beliefs (e.g., beliefs that OSA treatment is unnecessary, lack of awareness of the health significance and normalization of symptoms) and gaps at the healthcare system level (e.g., reported long waiting times for diagnosis and inadequate support from healthcare profession). This aligns with literature from Singapore showing poor OSA awareness among the Chinese population (80) and literature from China indicating inadequate knowledge and low confidence about OSA management among healthcare professionals (81). Future research should focus on developing educational programs to increase OSA awareness and knowledge for both patients and healthcare providers.

The retrieved articles have more emphasis on biological factors influencing treatment adherence over patient perspectives and behavioural interventions. This aligns with existing literature, which has numerous reviews on CPAP adherence predictors over the past two decades but lacked systematic reviews on behavioral studies until a recent publication on the role of beliefs, cognition and personality on adherence (82). A fundamental strategy is to focus on individual behaviour or lifestyle, given their significant role in chronic disease management (83). Symptom recognition and perceived consequences of a disease are an integral part of frameworks for understanding illness self-management such as the Common Sense Model of illness self-regulation (23). Only a few studies included in this review attempted to investigate concomitant diseases as factors influencing treatment adherence (38,48,49,55,56,63), however they did not approach the issue from the perspective of associating comorbidities with beliefs and experiences related to OSA. Future research in particular qualitative methods could center on assessing patients’ perspectives (e.g., expectations, motivation, self-efficacy, coping style) from the onset of treatment through to maintenance, adopting a patient-centred approach to support behaviour change and to provide culturally sensitive care.

Patients’ treatment preferences appeared to differ from the sequence of best practice treatment offerings as recommended in clinical guidelines (84). CPAP is the treatment choice for OSA, followed by oral appliances for patients who are intolerant of CPAP therapy or prefer alternate therapy (4). Retrospective surveys identified the most common preference was no treatment, followed by CPAP and surgery (53,57,65) over oral appliances. Our review identified only 3 studies on oral appliances, compared to 11 studies on surgery, highlighting the need to explore why oral appliances might be less frequently used among this patient population. Previous reviews in both sleep and other chronic diseases have identified socioeconomic status as an influencing factor on health disparities (85) and health behaviour (86). Socioeconomic status includes age, gender, race, income, education, employment, insurance structure etc. (13,87), for example, Ruthberg et al. investigated the utilization of surgical treatment for OSA in the United States and identified multiple socioeconomic factors, such as income level, insurance status, and health literacy potentially influenced by language barriers, as factors that may influence decision making (87). Studies retrieved in this review lacked sufficient information on the impact of socioeconomical factors influencing treatment beliefs and decision-making. Additionally healthcare systems such as access and care pathways vary in the countries/regions the studies were conducted. Therefore, future research could further explore these identified gaps. We also identified heterogeneity in the definitions and tools for capturing treatment acceptance and satisfaction. Our synthesis highlighted gaps in understanding the full spectrum of illness experiences and its impact on patients’ health behaviours and treatment engagement.

There is growing evidence that racial/ethnic disparities exist in the management of OSA. The scoping review by Wallace and colleagues on CPAP adherence among minority groups in the US identified a majority of studies conducted in the Black and Hispanic population and concluded that little is known about the PAP adherence of other US minority groups (14). May and colleagues’ review on racial differences in CPAP adherence identified similar trend of lower PAP use in Black, Indigenous, and people of colour (BIPOC) (88). The most recent review by Johnson et al. identified particularly high rates of undiagnosed and untreated OSA among Asian (especially Chinese and Japanese), Black, and Hispanic groups (13). East Asians (Chinese, Koreans and Japanese) have higher prevalence of OSA at lower BMI levels and a greater burden of comorbidities, including diabetes, hypertension, and other metabolic conditions (21). It can be speculated that as one of the largest ethnic populations, the burden of OSA among Chinese individuals is likely to be particularly significant given the aging population and challenges of obesity. While all three of the aforementioned reviews (13,14,88) emphasized the multifactorial nature of these disparities, encompassing both micro- and macro-level factors, our review specifically focuses on patient-reported outcomes and perspectives. Our findings align with previous reviews in identifying the need for future research and culturally responsive interventions that address health beliefs, attitudes, knowledge, and psychosocial factors influencing disease management.

An important strength of this scoping review lies in its incorporation of both English and Chinese-language articles. While our search strategy was extensive and every effort was made to review all studies on perspectives of Chinese OSA patients navigating through treatment trajectory, we did not search the literature databases from China due to resource constraints within the institution. It is possible that articles from Chinese biomedical journals were missed. Secondly, although the Chinese population may share physiological similarities with other East Asian groups, this review did not include other East Asians, such as Japanese and Korean groups. Cultural and psycho-social differences may exist among these groups, suggesting that future research could expand the scope to include a broader range of East Asian populations and relevant databases. Furthermore, this review included studies from countries/regions with different healthcare models. For example, both Hong Kong SAR and Taiwan region have achieved near universal healthcare coverage, whilst China has a highly pro-rich distribution of healthcare expenditure and low levels of utilization among the poor (89), and the Singaporean health system has patient copayments as an integral feature of the framework, reflecting the emphasis on personal responsibility for health (90). We did not account for the difference in healthcare systems on outcomes in this review because this review aimed to focus on beliefs, attitudes, and behaviours. Nevertheless, it highlights the complexity in patient experience and health behaviour suggesting potential future research into different health care models that may influence the observed health behaviours and treatment engagement. This review primarily emphasized patient-reported outcomes and perspectives, focusing on beliefs, attitudes, and behaviours as key influences on treatment engagement. While these factors are shaped by broader environmental determinants, including healthcare models and system-level influences, such determinants were beyond the scope of this review. Future research and interventions should consider the role of environmental contexts, such as variations in healthcare access, delivery models, and systemic structures, to ensure comprehensive approaches to improving the treatment experience. Given the exploratory aim of this scoping review to map the breadth of literature on Chinese patient perspectives on OSA, we included studies across diverse methodologies to capture the full scope of evidence and identify knowledge gaps. Consistent with scoping review methodology (91) and PRISMA-ScR guidance (24), the optional formal assessment of methodological quality or risk of bias was not conducted, as the review sought to provide an overview rather than a detailed synthesis of study findings.

Conclusions

Emerging evidence indicates that the Chinese population exhibits a greater vulnerability to OSA at lower BMI with high prevalence and increased burden of comorbidities. This review identified challenges in treatment engagement within this population, underscoring the need for targeted interventions to improve treatment uptake and adherence. Patients play a pivotal role across all stages of the treatment trajectory, yet gaps persist in the current literature regarding the effective measurement of patient perspectives throughout their treatment journey. Addressing these gaps is important to inform the development of personalised care targeting better treatment outcomes and adherence. There is a notable evidence gap in understanding the experiences of women and migrants with OSA. These findings emphasize the importance of future research to focus on patient-centred approaches to identify the needs of these underrepresented groups and develop strategies that foster behaviour change and deliver culturally sensitive care.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-299/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-299/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-299/coif). X.Z. is employee of ResMed Pty Ltd. and declares sponsorship of PhD course from the company, and additionally holds ResMed stock or stock options. Y.S.B. declares research grants and support from the Australian Research Council, Charles Perkins Centre, The University of Sydney, and Australasian Epidemiological Association; editorial board for Sleep Health, Journal of Activity, Sedentary, and Sleep Behaviours, and Sleep Advances; founder and chair for Sleep in Women Working Group for the Australasian Sleep Association. P.A.C. declares research grant and support from ResMed Pty Ltd and SomnoMed, consulting for ResMed, SomnoMed and Sunrise Medical, and appointment to an endowed academic Chair at the University of Sydney that was established from ResMed funding. J.M.Y.C. declares consulting and funding grants from Australasian Sleep Association; associate editor for Behavioral Sleep Medicine; and review editor for Sleep, Behavior and Mental Health (specialty section of Frontiers in Sleep). The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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