Interventions to improve Cultural Safety in healthcare in CANZUS countries: a systematic mixed studies review of First Nations Peoples’ experiences

BACKGROUND: Assessing patient perspectives is fundamental to determining whether anti-racism and cultural training programs and services associated with an intervention achieve their intended outcomes, yet reviews frequently focus on health provider perspectives. This systematic review, therefore, aimed to investigate First Nations Peoples' experiences, as patients, of interventions to improve their Cultural Safety and experiences in secondary and tertiary healthcare settings. METHODS: American Psychological Association's PsycInfo (via EBSCOhost), Cumulative Index to Nursing and Allied Health Literature Complete (via EBSCOhost), PubMed, and Scopus (via Elsevier) were all searched from inception to 9 December 2025. Eligible intervention studies needed to report the experiences of First Nations' people as care recipients in secondary and tertiary healthcare settings. Eligible study countries were Australia, Canada, Aotearoa (New Zealand), and the United States of America (USA). General study quality was assessed using the Mixed Methods Appraisal Tool. Study quality was also examined with a modified version of the Aboriginal and Torres Strait Islander Quality Appraisal Tool to provide a First Nations perspective. Qualitative meta-aggregation was conducted to synthesize both qualitative and quantitative data. RESULTS: There were 22 reports (11 qualitative, 7 quantitative, and 4 mixed methods) of 20 eligible studies, including 2092 First Nations care recipients. Interventions and quantitative outcomes were heterogeneous, precluding meta-analysis. Four studies reported on cultural training for health professionals, with the remainder service-level interventions. The qualitative meta-aggregation resulted in six synthesized findings, which reflected the mechanisms by which these programs worked and their outcomes. Four synthesized findings described mechanisms. These included emotional and practical support; acknowledgement, respect, and support for culture; feeling accepted, heard, valued, safe, comfortable, and respected; and navigating treatment and the system. The two synthesized findings related to outcomes concerned perceptions of health services and, relatedly, impacts on health service access. Quality appraisal revealed no discussion of existing and newly created intellectual property considerations. Study limitations included undefined terminology, terms being used interchangeably, and a few studies from the USA and Aotearoa (New Zealand). CONCLUSIONS: Published intervention studies assessing First Nations care recipients' experiences appear to be increasing. Future interventions must clearly define the terminology in the intervention, use mixed-methods approaches, and report intellectual property considerations. TRIAL REGISTRATION: Systematic review: PROSPERO, CRD42024521218 (prospective, available at https://www.crd.york.ac.uk/PROSPERO/view/CRD42024521218).