A Review of Cultural Safety Initiatives in Sports and Arts Activities

What is Cultural Safety?

1.1

Cultural safety originated in nursing and midwifery practice in New Zealand in the 1980s. In response to the poor health status of the country’s Māori people, Irihapeti Merenia Ramsden, ONZM conducted pioneering research in the area, which defined cultural safety as,

This concept has attracted considerable attention worldwide and has grown to encompass a broader array of social groups, including those defined by age, gender, sexual orientation, socioeconomic status, ethnicity, religion, and differing abilities (De & Richardson, 2008).

In this evolution, considerable attention has been focused on the needs of Indigenous people. This reflects increased community advocacy and awareness regarding the complex and harmful impacts of colonisation, which is driving efforts to address the resulting intergenerational disadvantage. A report by the Lowitja Institute reflects this expansion in the concept and application of cultural safety concerning Aboriginal and Torres Strait Islander peoples (Mohamed et al., 2024).

Although the term “cultural safety” is used in this review, it is important to acknowledge that this is one of many interrelated terms such as “cultural competence,” “cultural responsiveness,” and “cultural awareness.” Additionally, cultural safety is seen as conceptually aligned with social inclusion and health equity as its scope has moved beyond interpersonal elements of healthcare provision to encompass the creation of culturally safe environments and consideration of structural elements of service delivery (Thompson, 2022).

Study Selection

9.1

Following the removal of duplicates, 334 citations were identified. After dual independent screening of all 334 titles and abstracts, 62 full text articles were reviewed in duplicate, of which 33 studies were found to meet all inclusion criteria (See Appendix 2 for PRISMA diagram).

Study Characteristics

9.2

The 33 included studies comprised six systematic reviews (de Lannoy et al., 2023; Gagliardi et al., 2022; Mansell et al., 2024; Miller & Walke, 2024; Pour et al., 2023; Williams et al., 2024), two narrative reviews (Austin & Vadiveloo, 2023; Frazer & Giles, 2023), and 25 primary studies.

Among the primary studies, nine focused on sports (Bennie et al., 2021; Brooks-Cleator & Giles, 2016; English et al., 2023; Gidgup et al., 2022; 2024; Rich & Breunig, 2022; Rich & Giles, 2015; Stronach et al., 2019; Whitau & Ockerby, 2019), 13 focused on the arts (Balla et al., 2022; Blanchet, 2024; Fanian et al., 2015; (Hadley et al., 2022); Latimer et al., 2018; (Lenette et al., 2022); Lines et al., 2021; Marchetti & Nicholson, 2020; Marchetti et al., 2022; Rieger et al., 2021; Robbins et al., 2017; (Whyte, 2020); Wilson et al., 2018), and three had a multifaceted focus (Doyle et al., 2016; (Flouris et al., 2016); Ollier et al., 2020). Fourteen of the primary studies were conducted in Australia and 11 were conducted in Canada.

The primary studies predominantly utilised qualitative methodologies, collecting data through yarning circles, semi-structured interviews, focus groups, and participatory workshops (Balla et al., 2022; Blanchet, 2024; Brooks-Cleator & Giles, 2016; English et al., 2023; Flouris et al., 2016; Gidgup et al., 2024; Hadley et al., 2022; Latimer et al., 2018; Lenette et al., 2022; Lines et al., 2021; Marchetti & Nicholson, 2020; Marchetti et al., 2022; Ollier et al., 2020; Rich & Breunig, 2022; Rich & Giles, 2015; Rieger et al., 2021; Robbins et al., 2017; Stronach et al., 2019; Whitau & Ockerby, 2019; Whyte, 2020; Wilson et al., 2018). Only four studies employed mixed-methods approaches (Bennie et al., 2021; Doyle et al., 2016; Fanian et al., 2015; Gidgup et al., 2022), and no purely quantitative studies were identified.

The participant groups across the primary studies reflect the origins of cultural safety in Indigenous healthcare, with 19 studies focused on Indigenous people. Several of these studies also specify the age and gender of participants, with six studies focused on Indigenous women (Balla et al., 2022; Bennie et al., 2021; Blanchet, 2024; Marchetti et al., 2022; Rieger et al., 2021; Stronach et al., 2019), four studies focused on Indigenous youth (Fanian et al., 2015; Latimer et al., 2018; Lines et al., 2021; Robbins et al., 2017), two studies focused on Indigenous men (Marchetti & Nicholson, 2020; Whyte, 2020), and one study focused on Indigenous girls/youth (Whitau & Ockerby, 2019). Six studies were focused on Indigenous people of multiple ages and genders (Brooks-Cleator & Giles, 2016; Doyle et al., 2016; Flouris et al., 2016; Gidgup et al., 2022; Ollier et al., 2020; Wilson et al., 2018). One primary study focused on people with disabilities (Hadley et al., 2022), another primary study focused on people from ethnic backgrounds (Lenette et al., 2022), and four primary studies focused on mixed groups (English et al., 2023; Gidgup et al., 2024; Rich & Breunig, 2022; Rich & Giles, 2015).

Further details about the study characteristics, as well as short summaries of some key findings, are presented in Tables 2–4.

Definitions of Cultural Safety

9.3

The results from the definition-focused portion of the review are presented first to give context to the other findings. Table 5 provides an overview of the most cited cultural safety definitions and concepts. The full list of the definitions used, and the definitions of related terms, is provided in Appendix 3.

Of the 33 included studies, 16 provided an explicit definition of cultural safety (Austin & Vadiveloo, 2023; Balla et al., 2022; Brooks-Cleator & Giles, 2016; Frazer & Giles, 2023; Gagliardi et al., 2022; Lenette et al., 2022; Marchetti & Nicholson, 2020; Marchetti et al., 2022; Miller & Walke, 2024; Ollier et al., 2020; Pour et al., 2023; Rich & Breunig, 2022; Rich & Giles, 2015; Rieger et al., 2021; Robbins et al., 2017; Wilson et al., 2018). Additionally, four studies provided definitions of related terms, such as cultural sensitivity, cultural competence, cultural humility, culturally appropriate programmes, and strengths-based approaches (Gidgup et al., 2024; Lines et al., 2021; Rich & Breunig, 2022; Rieger et al., 2021).

Common Elements Used When Defining Cultural Safety

9.4

Among the definitions of cultural safety used, the most frequently occurring themes were:

• Ensuring that there is no assault, denial, or challenge to individuals’ identity (including, but not limited to, age or generation, gender, sexual orientation, occupation, socioeconomic status, ethnic origin, migrant experience, religious/spiritual beliefs or disability) (Austin & Vadiveloo, 2023; Balla et al., 2022; Brooks-Cleator & Giles, 2016; Gagliardi et al., 2022; Lenette et al., 2022; Ollier et al., 2020).

• Shared knowledge and experiences of learning, reflexivity, dialogue, and intentional listening (Balla et al., 2022; Marchetti & Nicholson, 2020; Marchetti et al., 2022; Miller & Walke, 2024; Robbins et al., 2017)

• Recognising and addressing inequities rooted in colonial histories and institutional discrimination (Austin & Vadiveloo, 2023; Marchetti et al., 2022; Ollier et al., 2020; Pour et al., 2023; Rich & Breunig, 2022; Rieger et al., 2021).

• Acknowledging and reducing power imbalances (Brooks-Cleator & Giles, 2016; Lenette et al., 2022; Marchetti et al., 2022; Ollier et al., 2020; Rich & Breunig, 2022; Rieger et al., 2021).

• Creating a safe environment that is spiritually, socially, and emotionally supportive for people to share their stories and receive care (Austin & Vadiveloo, 2023; Balla et al., 2022; Frazer & Giles, 2023; Ollier et al., 2020; Rieger et al., 2021; Wilson et al., 2018)

• Ensuring that the recipient, and their communities, determine what works and what is respectful and inclusive of their culture (Brooks-Cleator & Giles, 2016; Gagliardi et al., 2022; Miller & Walke, 2024; Ollier et al., 2020; Rich & Breunig, 2022)

• Ensuring that healthcare providers and facilitators have knowledge and understanding about other cultures and cultural protocols (Frazer & Giles, 2023; Marchetti & Nicholson, 2020; Marchetti et al., 2022; Pour et al., 2023; Rich & Breunig, 2022; Robbins et al., 2017; Wilson et al., 2018)

Other mentioned elements included achieving social justice outcomes (Lenette et al., 2022) and health professionals’ responsibility to protect clients from risks or harm (Ollier et al., 2020).

Key Features of Culturally Safe Practices

9.5

Drawing upon the key principles outlined above, culturally safe programmes share several important features. Successful initiatives were designed with strong community involvement, making them relevant and inclusive (Bennie et al., 2021; Gagliardi et al., 2022). Common features included using participants’ preferred languages, hosting activities in community-based settings, and involving facilitators who reflected participants’ cultural and social norms (Gagliardi et al., 2022). These programmes also worked to remove barriers to participation (Bennie et al., 2021; Gagliardi et al., 2022). Flexibility and respect for local cultures were essential, for example the Ironbark programme successfully established a supportive programme framework for both the Elders who participated and their communities (Gidgup et al., 2022).

Leadership of Indigenous people and the role of Elders were particularly significant in creating culturally safe spaces (Whyte, 2020). Elders provided cultural guidance, shared traditional knowledge, and strengthened programme relationships (Brooks-Cleator & Giles, 2016; Whyte, 2020). Programmes that addressed intergenerational trauma, grief, and systemic inequities were especially effective (Marchetti & Nicholson, 2020; Pour et al., 2023).

Challenges and Areas for Improvement

9.6

While most programmes captured in the review showed promise, some also faced challenges. Insufficient funding and staffing made maintaining programme quality and adapting to participants’ needs difficult (English et al., 2023). Standardised Western frameworks often failed to meet the cultural needs of Indigenous communities, highlighting the need for culturally relevant content and greater involvement of local leaders (Brooks-Cleator & Giles, 2016; Frazer & Giles, 2023). Efforts to promote inclusivity were sometimes hindered by resistance within organisations, particularly in areas like sports/recreation (Rich & Giles, 2015). To overcome these barriers, programmes demonstrated the importance of working closely with Indigenous communities throughout programme lifecycles (Miller & Walke, 2024). Co-design approaches prioritising community leadership and respecting cultural protocols were shown to improve outcomes and foster cultural safety (English et al., 2023; Lines et al., 2021).

Impact of Cultural Safety Programmes: Sports Programmes

9.7

Culturally safe sports programmes created environments that promoted self-determination, empowerment, and cultural connections. Participation in sports improved physical and mental health, self-esteem, and confidence among Indigenous women, enabling them to assume leadership roles within their communities (Stronach et al., 2019). For youth, sports programmes reinforced cultural ties and supported holistic well-being by addressing spiritual, emotional, mental, and physical health while strengthening connections to ancestry and the wider community (Frazer & Giles, 2023; Pour et al., 2023).

Programmes for older adults, such as Ironbark, a PA initiative targeting Aboriginal and Torres Strait Islander people aged 45 and over to improve their health and well-being, have been positively received for their cultural relevance, emphasis on relationship-building, and PA promotion (Gidgup et al., 2022, 2024). Community events integrating cultural celebrations have further supported health promotion and increased participation in these programmes (Miller & Walke, 2024). Moreover, addressing racism at all levels of competition, and fostering leadership of Indigenous people within community clubs, were found to be essential for supporting Indigenous athletes and strengthening community spirit (Mansell et al., 2024).

Impact of Cultural Safety Programmes: Arts Programmes

9.8

Culturally safe arts programmes have reported benefits for participants, particularly within Indigenous communities. By creating supportive spaces for self-reflection, emotional expression, and personal growth, these initiatives address the holistic needs of individuals while promoting cultural reconnection and belonging (Blanchet, 2024; Marchetti & Nicholson, 2020; Robbins et al., 2017; Whyte, 2020). For instance, the Dreaming Inside programme, an arts-based programme for incarcerated Aboriginal and Torres Strait Islander men in NSW, utilised creative writing to facilitate cultural reconnection and enhance well-being. Participants reported improved self-worth, confidence, a sense of belonging, and emotional well-being through the opportunity to express and process emotions in a culturally safe space (Marchetti & Nicholson, 2020).

Similarly, the Forum Theatre programme was an arts programme that used games and image work to create a short play reflecting an oppressive situation. It employed an Indigenous strengths-based approach to reframe complex topics (e.g. suicide prevention) into actionable wellness interventions, through collaboration with community partners and ongoing leadership and guidance from Indigenous community members (Lines et al., 2021). For young people, arts programmes offered opportunities to develop skills in areas like music production, visual arts, and spoken word (Fanian et al., 2015). These activities fostered strong relationships with peers, facilitators, and their communities, which, in turn, contributed to a sense of extended family and cultural belonging (Fanian et al., 2015; Robbins et al., 2017).

Overall, employing strengths-based approaches fostered resilience, self-determination, and identity exploration through artistic expression. Creating culturally safe spaces further enabled participants to navigate the interconnected physical, emotional, and spiritual dimensions of well-being (Austin & Vadiveloo, 2023; Hadley et al., 2022; Latimer et al., 2018; Williams et al., 2024). These findings underline the importance of trust and collaboration for success.

Two arts-focused initiatives surfaced unexpected insights. In the Talking Circle sessions, physical pain emerged as the predominant theme, aligning with the types of physical discomforts that youth commonly report in national surveys. However, when participants had the opportunity to express their pain through painting with an Indigenous artist in a culturally safe environment, emotional pain became more evident. Emotional pain often overlapped with aspects of physical, spiritual, and mental pain (Latimer et al., 2018). For some of the incarcerated men in the study by Whyte (2020), the correctional system was their first exposure to cultural access, which the author reflected “speaks to the greater dialogue regarding the impact of colonisation on community health as a whole” (Whyte, 2020, p. 59).

Statement of Key Findings

10.1

This rapid scoping review aimed to synthesise knowledge about the impact of cultural safety initiatives in sports and arts programmes in Australia, New Zealand, and Canada and to identify and describe how studies defined cultural safety. A comprehensive literature search identified 33 relevant articles comprising 8 reviews and 25 primary studies. Most primary studies (n = 19) focused on Indigenous people.

Of the 16 studies providing an explicit definition of cultural safety, key themes from the definitions encompassed recognising and respecting individual identities, including age, gender, culture, and life experiences (Balla et al., 2022; Marchetti & Nicholson, 2020); the importance of shared knowledge, open discussions, and mutual understanding (Balla et al., 2022; Lines et al., 2021); acknowledging colonial histories and systemic discrimination as barriers to equity, including through Indigenous-led programmes (Mansell et al., 2024; Rieger et al., 2021); reducing power imbalances and allowing communities to shape programmes (Gidgup et al., 2022; Miller & Walke, 2024); and understanding cultural practices, including adherence to cultural protocols and involving Indigenous facilitators (Marchetti & Nicholson, 2020; Whyte, 2020).

Positive impacts of arts-based initiatives centred on addressing holistic needs and promoting cultural reconnection and belonging. Similarly, sports-based programmes promoted self-determination, empowerment, and cultural connections. Furthermore, sports participation improved physical and mental health, self-esteem, and confidence, particularly among Indigenous women. Key challenges for initiatives and programmes included insufficient funding and staffing, inappropriate use of standardised Western frameworks, and organisational resistance.

Comparison of Findings with Related Research

10.2

The definitions of cultural safety drawn from the included studies show that considering the critical nuances of the definitions may have important implications. For example, Austin and Vadiveloo (2023) describe the duality of cultural safety as both an ethical framework and an intended outcome, emphasising the need to be mindful of its overarching intent and conscious that in making spaces safer, it is important to be cognisant of imposing the organiser’s values and beliefs on the activity, which can result in participants losing agency and power. Such situations can reinforce, rather than diminish, power structures inherent in colonisation (Frazer & Giles, 2023). This underlines the importance of thoughtful self-reflection and reflexivity in reference to one’s positionality in guiding cultural safety planning and practice, as highlighted in Ramsden’s seminal definition (Papps & Ramsden, 1996). Relatedly, a recommendation of multiple studies in this review was the need to ensure that sports and arts activities are co-designed with, and, where able, delivered by representatives of the groups they seek to include. This appears critical in addressing hidden biases of those outside of these groups.

Two studies offered powerful manifestations of this concept. First, Latimer et al. (2018) used artistic expression to explore how Indigenous children and youth express pain, and concluded that “Indigenous cultures often conceptualise health issues very differently from Western medicine…Youth reported high rates of physical pain and missed school due to pain, but primarily shared emotional and mental pain experiences in their artwork” (Latimer et al., 2018, p. 11). Second, the study by Lines et al. (2021), which examined strength-based approaches to wellness aimed at youth, included elders, families, adult learners, and toddlers. This underlined the importance of community connections and relational accountability, suggesting that more limited approaches, for example those where only youth are included, may inadvertently neglect this key ingredient.

Notably, 19 of the 25 primary studies focused on Indigenous people, including 6 on Indigenous women and 5 on Indigenous youth. In contrast, few of the included studies focused on other groups who may also benefit from cultural safety practices, for instance people with disability and from non-majority ethnic backgrounds. Although one review focusing on PA promotion for immigrant women reported positive findings, there were relatively few studies within this review (Gagliardi et al., 2022). Furthermore, no studies were identified addressing the needs of other groups like LGBTQIA+, gender-diverse individuals, and/or those from minority religious groups. Explanations for this could include limitations in the review scope, disruptions to programmes arising from the COVID-19 pandemic, and publication lag. Further exploration of cultural safety initiatives addressing the needs of these groups is warranted.

However, a relatively large volume of research on Indigenous people does not obviate the need for further research focused on this group. The review of Pour et al. (2023) concluded that “mainstream psychological wellbeing methods, Rules, dos and don’ts continue to operate using colonial ideologies when providing services to First Nations youth…It is imperative that the “colonial lens” is removed and culturally safe practices are embedded…” (Pour et al., 2023, p. 406). The study of an arts programme in Victoria, Australia by Austin and Vadiveloo (2023) emphasised the importance of engaging Indigenous people in facilitator and leadership positions: “the basic principle of ensuring that there is a Welcome and then ongoing Acknowledgement of Country is useful but ultimately insufficient in cultivating culturally safe collaborative space for First Nations young people working with a white facilitator on stolen land” (Austin & Vadiveloo, 2023, p. 66).

Future avenues of research could include, but are not limited to, exploring how cultural safety definitions and terminology vary across target populations (e.g. culturally and linguistically diverse (CALD) communities, people with disability and LGBTQIA+); examining how cultural safety is approached theoretically by different academic disciplines; focusing on activities beyond sports and arts; and more targeted primary and review research examining specific groups or disciplinary perspectives.

Strengths and Limitations of the Review

10.3

This is the first known review focusing on cultural safety in sports and arts settings. The review applied robust dual independent study selection methods using explicit and pre-determined criteria; comprehensive searching of nine databases by a specialist librarian; and collaboration with the review commissioners on review approach and interpretation, reflected by co-authorship. Given the breadth of the concept of cultural safety, an in-depth exploration of how cultural safety was defined and operationalised across the included studies was another strength of the review.

Review limitations are primarily related to adjustments in the scope of the review to accommodate a rapid review time frame: limitations to the English language, a small number of countries with shared characteristics, and a 10-year time frame. While some relevant evidence may have been found in earlier years, the review focused on more recent evidence to identify current trends and due to limited resource availability. In addition to different sectoral approaches to “cultural safety” across populations, there are also many ways to view cultural safety from various academic disciplines; this aspect was beyond the scope of the present work.

Furthermore, quality appraisal was not undertaken – noting this is not routine in scoping reviews (Munn et al., 2018). In addition to considerable variation in study design across the included literature, various underlying research paradigms were represented owing to the nature of the topic, and differing study designs led to the inclusion of very large and very small sample sizes. In this context, it can be argued that quality appraisal was unlikely to add value to the interpretation of review findings.

Definitional Themes and Their Application

11.1

For organisations in a position to implement insights from this review, the findings can provide a foundation for advancing cultural safety as a core element of health promotion and community well-being strategies. The review highlights critical definitional elements of cultural safety, including the importance of shared knowledge, reflexivity, and dialogue, addressing systemic inequities rooted in colonial histories, and fostering environments free from identity-based assault or denial. These elements can be used to develop and refine organisational definitions of cultural safety. For instance, VicHealth used the findings of this review to refine its current definition to “cultivating an environment where individuals feel respected, valued, and supported in their cultural identity, with systems fostering equity by actively addressing power imbalances and embracing cultural differences to minimise harm and racism within Victoria.”

Policy implications include embedding these themes into organisational frameworks, co-designing programmes with communities to reflect their lived experiences and cultural protocols, and, where possible, employing staff or programme leaders who share participants cultural backgrounds. The findings underscore the importance of integrating shared learning and dialogue mechanisms into partnerships with local government, sports and arts organisations, and community groups. Such approaches reflect organisations’ commitment to fostering equity, trust, and mutual respect among diverse stakeholders. Finally, the review’s emphasis on reducing power imbalances and acknowledging colonial histories reinforces the need for policies and practice that promote self-determination and equity.

Opportunities for Operationalising Cultural Safety Principles

11.2

There are several ways to operationalise cultural safety principles identified in the review for organisations. Practical steps may include:

• Resource allocation: Providing targeted funding to support community-led programmes that prioritise cultural inclusion and connectedness. These programmes can improve mental health, social cohesion, and overall well-being by addressing barriers to participation for marginalised groups.

• Capacity building: Offering training, resources, and networking support for stakeholders to develop cultural competence; understanding of cultural protocols; and skills for self-reflection. This aligns with the review’s finding that knowledge and reflexivity are key to fostering culturally safe environments.

• Community engagement: Enhancing identification and relationships with underrepresented community groups, ensuring that programmes address their needs and priorities. This engagement needs to be more than “one off” projects. Rather, work needs to be ongoing and undertaken with intentional consideration of long-standing forms of oppression and the need for iterative, reflexive approaches.

Addressing Barriers and Facilitators

11.3

The review identifies several barriers to implementing cultural safety, such as resistance within organisations, insufficient funding, and reliance on Western frameworks. Overcoming these barriers involves adopting a strengths-based co-design approach that prioritises community leadership and cultural relevance. Facilitators such as Indigenous leadership, relational accountability, and recognition of intergenerational trauma are essential for creating sustainable and impactful initiatives. We acknowledge that cultural safety is a complex phenomenon with individual and system-level characteristics and drivers. This review focused on the practical manifestations of cultural safety practices. While the wider system and other dynamics are critical for building and scaling cultural safety practices, exploration of this aspect was beyond the scope of the present work. Of note, the context of this review was to inform a long-term strategy based around system transformation (Victorian Health Promotion Foundation, 2023). Therefore, deeper exploration of system implications of this review is an important next step for both policy and research.