BACKGROUND: Randomised controlled trials (RCTs) conducted early during the pandemic showed that awake prone positioning (APP) significantly reduced the risk of intubation among adults with COVID-19 acute respiratory distress syndrome (ARDS), but more recent studies have questioned this benefit. We hypothesise that the effects of APP may vary with the national Power Distance Index (PDI), a measure of hierarchy in local culture. OBJECTIVE: To conduct a meta-analysis examining the effects of APP in adults with COVID-19 ARDS and examine whether effects differ between nations with a PDI less than 80 versus at least 80 (low versus high deference to authority). DESIGN: Systematic review and meta-analysis of RCTs. DATA SOURCES: Cumulated Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, Embase, Medline and Scopus were searched to November 2024. ELIGIBILITY CRITERIA: All RCTs that compared APP with standard care in adults with COVID-19-related ARDS or Acute Hypoxaemic Respiratory Failure (AHRF) were included. RESULTS: Twenty-two RCTs were identified with 3615 patients having valid data. APP reduced the risk of intubation [relative risk (RR) 0.80, 95% confidence interval (CI), 0.72 to 0.90]. Effects were greater in nations with a PDI at least 80 (RR 0.67, 95% CI, 0.54 to 0.82), and there was equipoise in nations with a PDI less than 80 (RR 0.89, 95% CI, 0.75 to 1.05). Intubation rates in the high PDI nations decreased from 32.3% (n = 512) with standard care to 21.2% (n = 508) with APP. The reduction in intubations with APP was less pronounced in nations with low PDI, from 20.1% (n = 1012) with standard care to 17.1% (n = 1084). The risk of mortality reduced with APP (RR 0.86, 95% CI, 0.74 to 0.99). Fidelity of APP, specifically, adherence to the recommended duration, was higher in nations with PDI at least 80 (P = 0.04). CONCLUSION: APP reduces the risk of intubation and mortality, but the significance of this benefit varies with the cultural context. Effects are strong in nations with a higher PDI, where intubation rates are lower and adherence to APP higher.