“ I would just like to see more acknowledgement,respect and services for the people who are in between,just Métis people ” : recommendations by Métis women to improve access to health and social services in Victoria,Canada

Introduction

Métis Peoples account for over a third of the Indigenous population in Canada (Statistics Canada, 2017). Nested within 17th-century fur trade relationships, Métis Peoples’ identity blossomed into a distinct cultural and social orientation that continues to thrive today (Macdougall, 2017). While the origins of their ancestors were mixed, Métis scholar Brenda MacDougall (2017) reminds us that Métis people are not, as subsequent generations formed communities with distinct languages and traditions, separate from that of their First Nations and European relatives. Since the emergence of Métis communities in Canada, the settler government has implemented assimilative and racist colonial policies to make way for incoming settlers and development (Fiola, 2012; Iseke, 2010; Thistle, 2019). These political efforts have had detrimental impacts on Métis Peoples’ identity and life ways, including connection to land, governance, and kinship systems. As a result, Métis Peoples experience severe disparities in health determinants and outcomes compared to the non-Indigenous Canadian population (Smylie, 2009, Smylie et al., 2008).

Available literature highlights major gaps in access to culturally safe health and social services for the 90,000 Métis Peoples residing in British Columbia; where they feel comfortable, safe, and are able to be openly Métis (Auger, 2019; Wesche, 2013). Nestled within the unceded Coast Salish Territory of the Lekwungen and W̱SÁNEĆ nations, Victoria is home to over 6,500 self-identifying Métis people, whose families have thrived and contributed to the urban landscape for over two centuries (Goulet & Goulet, 2018). While Métis account for 38% of the Indigenous population in the Greater Victoria area (Statistics Canada, 2017), no literature exists to our knowledge on Métis Peoples experiences with accessing health and social services in Victoria.

To address the Métis health service gap, this paper will describe the ways that we, as researchers, have engaged with self-identified Métis women, two-spirit, and gender diverse people who live in or receive health and social services in Victoria, British Columbia. This paper provides recommendations for improving health and social service access for the Métis community in Victoria. Expanding on research conducted in Ontario, this paper is a call to action for policy makers and service providers to work towards closing a culturally safe service gap for Métis Peoples living across Canada (Monchalin et al., 2019).

Methods

This research expands on multiple years of exploring Métis Peoples’ experiences with health and social services in urban settings. It continues to be Indigenous-led and community-driven at all stages. It was initially nested in a project entitled Our Health Counts Toronto (OHC), a longitudinal cohort study co-led by the Well Living House (WLH) and Seventh Generation Midwives Toronto (SGMT) in 2015 and 2016 (Monchalin, 2019). Upon learning from OHC that Métis people in Toronto needed health care services but did not receive them, Author 1 conducted an in-depth, follow-up study in 2018 and 2019 for their doctoral research project with WLH and SGMT (Monchalin, 2019). This doctoral research involved conversations with 11 self-identified Métis women living in and/ or accessing health and social services in Toronto. Métis women in Toronto provided wholistic and practical recommendations for improving access to health and social services, including (1) Métis presence, (2) wholistic interior design, (3) Métis specific or informed service space, (4) welcoming reception/front desk, and (5) culturally informed service providers. The use of the term wholistic will be used throughout this paper to reflect wholeness (Baskin, 2016). When we use the term holistic in this paper, we are referring to the coding method by Saldaña (2015).

Following this doctoral research, Author 1 was hired at a university in Victoria and had conversations with Author 2 —a member of the Métis community in Victoria—about a similar lack of health service access for Métis in both cities. Building on the Toronto research, Author 1 and Author 2 wanted to determine if Métis women in Victoria had similar or different experiences and recommendations, with the goal of improving health service access on the island. Author 1 and Author 2, along with Author 5, received an Insight Development Grant from the Social Sciences and Humanities Research Council to further explore and understand access to health and social services for Métis people in Victoria. Ethics approval was obtained from the University of Victoria. Prior to contacting participants, consent and guidance was received by a local and prominent Métis Elder living in Victoria who informed the project goals, recruitment plan, and interview guide.

Recruitment

To increase project interest and for community members to see themselves reflected within recruitment materials, we contacted a local Métis artist in Victoria to feature their artwork on the recruitment poster. The artist provided the research team with multiple image options, and they chose the artwork that the Métis Elder believed best reflected the local Métis community. The recruitment poster was then shared on the Facebook group titled, Métis Nation of Greater Victoria (n.d.). The poster informed potential participants to contact Author 4 for more information to participate. Author 4 screened each potential participant either through email or by phone to ensure that they met study criteria. Criteria included that the participants self-identify as Métis; were 19 years old or older; self-identify as a woman, two-spirit, and/ or gender diverse; and lived in and/ or accessed health and social services in Victoria within the last 12 months. If the participant met all criteria, a date and time to meet over Zoom was arranged. The recruitment goal for this study was reached within one week of first sharing the poster.

One-on-one conversations

Author 3 and Author 4, who are Métis research assistants on the project, conducted interviews with each participant over Zoom, applying a conversational interview method (Absolon, 2011). This conversational method facilitated the emergence of each participant’s story in a style and form that reflected their knowledge and experience and avoided the externally imposed structuring of a more formal interview guide. Gathering the stories through a conversational method fostered both relational connection and flexibility, and is aligned with Métis ways of gathering and sharing knowledge through storytelling and informal kitchen-table conversations (Flaminio et al., 2020; Gaudet, 2019).

The research team was initially provided with funding to hold conversations with 15 participants. However, due to COVID-19 public health measures, social distancing requirements, and having conversations held over Zoom, the team was able to conduct additional conversations. As the interviewers did not have to physically travel to meet with participants, we were able to allocate funds to cover the costs of interviewing more participants. For example, while we initially budgeted for $50 honorariums; travel savings allowed us to increase participant honorariums to $95 honorarium, paid through e-transfer.

The interview guide was adapted from Author 1’s doctoral research; Author 2 and the Métis Elder on the project, in addition to the recent pandemic, updated and informed the interview guide to better reflect Victoria Métis community contexts. Ten open-ended questions guided the conversations that centred around the following themes: (1) Métis identity, (2) experiences with health and social services, (3) racism and discrimination, (4) COVID-19, and (5) recommendations for improving access to health and social services. This article focuses on the theme of recommendations for improving access to health and social services in Victoria.

Making meaning and returning to community

Following participant consent, all the conversations were electronically recorded over Zoom and transcribed verbatim and identifying information was removed. Following Métis scholar Catherine Richardson’s (2016) teaching about how stories are medicine, Author 2 and Author 4 worked together to assign each participant with a local plant medicine name in the Michif language. Participants were asked for their consent to include direct quotes in the analysis and all, but one gave consent. While each participant approved their assigned plant medicine name, those who consented were also given the option of using a name of their choosing that would accompany each of their quotes.

Interviewers wore headphones and conducted interviews in private to ensure the confidentiality of conversations. A total of 24 Métis women, two-spirit, and/ or gender diverse participants were interviewed during the winter of 2021; conversations were approximately 1-hr in length. Before the coding process began, Authors 1, 2, 3 and 4 reviewed the transcripts to identify major themes. Once these authors came to consensus about the individual themes, Author 4 mailed the transcripts to participants for verification and/or corrections. To ensure rigour and validity, participants were asked if the identified themes appropriately reflected their experience. All participant verifications, corrections or deletions were fully integrated into the transcripts. Participants received a thank you note designed by local Victoria Métis artist Lynette La Fontaine, along with a COVID-19 appropriate face mask. We gifted participants face masks from two designers: one by Métis artist Lynette La Fontaine and the other by Anishinaabe artist Lesley Hampton.

Once all of the transcripts and themes were returned and updated, a holistic coding method (Saldaña, 2015) was applied by Authors 1, 2, 3, and 4 using NVivo software (QSR International, 2018) to interpret the larger themes and to assist with meaning-making of the conversations. Following this, a final thematic analysis (Braun & Clarke, 2006) was undertaken by the first four authors.

Results

Five cross-cutting recommendation groupings emerged from the analysis and were woven together with many overlapping themes. The five recommendations to improve health service access in Victoria are: (1) warm and inviting service spaces, (2) Métis specific Cultural Safety Training, (3) Indigenous specific clinic, (4) wholistic or integrative service delivery, and (5) non-judgemental service providers.

Discussion

This research demonstrates that Métis women, two-spirit and gender diverse people carry practical solutions for improving access to health and social services for the Métis community in Victoria, British Columbia. These recommendations are directed at creating health and social service spaces that are culturally safe for Métis. Cultural safety can only be claimed when the people who receive the care, identify it as culturally safe (National Collaborating Centre for Aboriginal Health [NCCAH], 2013). For the Métis women, two-spirit, and gender diverse participants in this research, a safe health service space is one that is warm and inviting, has local Indigenous artwork, provides services through a wholistic lens and recognizes the physical, emotional, spiritual, and mental connections, has service providers that understand Métis Peoples’ histories, who are non-judgemental, and trauma informed.

Some of these recommendations echo those shared in previous service access literature (Monchalin et al., 2019; NCCAH, 2013). For example, Author 1’s doctoral research findings as well as a 2013 NCCAH fact sheet about culturally safe health care for Métis patients align with many of the Victoria recommendations. Specifically, both recommend the incorporation of Indigenous artwork in health service spaces. While the Toronto study highlighted the importance of having locally relevant Métis artwork, the Victoria study emphasized the value of local Indigenous artwork to acknowledge and honour the territory. This preference reveals the importance of avoiding pan-Indigenous approaches when providing culturally safe services. Furthermore, Métis women in Victoria highlighted that, while it is important to have Indigenous artwork, it cannot be a replacement for providing safe and friendly care. The NCCAH (2013) fact sheet also stresses that “cultural safety involves deep systemic change and is much more than interior design” (p. 7).

When asked about which traits a health service provider should possess, participants stressed the importance of having service providers who are non-judgemental, trauma-informed, willing to listen, and who will believe Métis women and not minimize their experiences. Similarly, Métis women in Toronto spoke to the importance of non-judgemental service providers who would listen and possess an awareness of issues surrounding power, privilege, and oppression in health care (Monchalin et al., 2019). Firestone and colleagues (2019) found a similar recommendation when evaluating a programme called Niiwin Wendaanimak, a health service for urban Indigenous people experiencing homelessness. Results reveal that clients who accessed the programme felt a sense of safety due to health service providers being trauma informed, resulting in them being non-judgemental (Firestone et al., 2019). Trauma has been found to negatively impact individual health and how individuals respond to health interventions, which can result in delaying service access (Shimmin et al., 2017). This demonstrates the critical importance of implementing a trauma informed approach when attempting to improve health service delivery for Métis.

Both the Victoria and Toronto findings highlight the importance of having service providers who identify as Indigenous, and who hold knowledge and understanding of Indigenous Peoples’ histories. Métis women in both Victoria and Toronto also underscored the need for cultural safety training to educate service providers about Métis Peoples unique experiences. This contrasts the common pan-Indigenous approach to cultural safety training currently offered in Canada. Wylie et al. (2021) explored how to improve cultural safety training in Canada and found that: “Local Indigenous community members felt that [cultural safety] training needed to be specific to their communities and needs, rather than general information about Indigenous Peoples and histories” (p. 328). Community specific training may result in improved health and services as the specific contexts and experiences of diverse Indigenous Peoples is considered during screening, diagnosis, treatment, and support. Nevertheless, the Victoria recommendations highlight how cultural safety training must be evaluated to keep service providers accountable. Churchill and colleagues (2017) echo this statement, arguing that the impact of cultural safety training must be evaluated “both in the short-term and long-term to accurately assess the extent to which the cultural safety training program improves how Indigenous peoples are treated by health care providers” (pp. 8–9).

Another recommendation from both Victoria and Toronto participants was having an Indigenous or Métis specific clinic. In Victoria, participants spoke to the need for an Indigenous specific clinic with Indigenous health care providers. Toronto results also demonstrated that existing services should incorporate a Métis specific space within the service (Monchalin et al., 2019). One significant difference between the two cities was that Métis women in Toronto shared that SGMT was an ideal culturally safe health service space (Churchill, 2015). Whereas the Métis women in Victoria did not share an exemplary health service where the majority felt safe. This signals the critical need for a culturally safe Métis health service space in Victoria.

Despite these aligning recommendations, challenges persist in putting these needs into action. For example, a Yellowhead Institute Report lead by Jewell and Mosby (2020) highlights the lack of progress with accomplishing the Truth and Reconciliation Commission’s (TRC) Calls to Action released in 2015. TRC Call to Action number 23 states that all health care professionals must complete cultural competency training. However, this call to action has become a checkbox on service providers to-do list (Jewell & Mosby, 2020, p. 12). Wylie et al. (2021) highlight how cultural safety training is often delivered online, which comes with limitations when trying to initiate behavioural and attitudinal changes. Wylie and colleagues state that, while online cultural safety training is an excellent first step, cultural safety training should be delivered in multiple modalities and integrated throughout service providers careers. These researchers also reveal that, to appropriately inform their practice, service providers require training that is specifically tailored to their roles and responsibilities (Wylie et al., 2021).

To act on these recommendations, health resources and funding needs to be made accessible to Métis communities (Monchalin, 2019). Métis specific funding will provide support for Métis people in leading the development of specific cultural safety training that is both designed and led by the community, in addition to developing an Indigenous specific clinic that is accessible for Métis in Victoria. Acknowledging the need for Métis specific funding, the Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls (2019) states:

We call upon all governments to fund and to support culturally appropriate programs and services for Métis people living in urban centres, including those that respect the internal diversity of Métis communities with regards to spirituality, gender identity, and cultural identity. (p. 211)

In the meantime, existing health and social services in Victoria must begin to act on the recommendations provided by Métis women, two-spirit, and gender diverse people in this research. This can include allocating funds to making services warm and inviting through attainable undertakings, such as incorporating local Indigenous artwork, calm lighting, plants, and comfortable chairs; engaging with resources developed by Métis people to educate staff and service providers, such as making the books From the Ashes: My Story of Being Métis, Homeless, and Finding My Way by Jesse Thistle, or Halfbreed by Maria Campbell mandatory readings; and if not yet completed, having staff and service providers enrol in available cultural safety trainings. Finally, both mainstream and Indigenous specific health and social services in Victoria can create awareness on eligibility, informing the Métis community of what and how their services are available and accessible.

Strengths and limitations

While our sample was random, the recommendations may not be representative of the entire Métis community in Victoria as we only shared the recruitment poster on the Facebook group, Métis Nation of Greater Victoria (n.d.). Despite this limitation, COVID-19 stay-at-home measures created travel savings, which allowed us to allocate funds to conduct additional interviews. At the same time, while COVID-19 created flexibility for conducting conversations, it only allowed those who had access to a phone or computer to participate. Another observation made by the Author 1 was that, due to COVID-19 and participants having one-on-one conversation from their homes, this impacted their recommendation responses around the physical aspects of a service space. Author 1 found that participants in Toronto often drew inspiration about an accessible service space from where the in-person interview took place. This research in Victoria may have been impacted participant responses given they were at home. Despite this possible limitation caused by COVID-19 stay-at-home protocols, the Métis women, two-spirit, and gender diverse participants thought of unique and creative recommendations to make health and social services in Victoria more inviting. Further, this research contributes to the limited literature surrounding access to health and social services for Métis People, and is the first of its kind regarding the Métis community in Victoria. While the Métis community in Victoria is unique, these recommendations have shown to have significant overlap with recommendations made in Toronto (Monchalin et al., 2019), and may be applicable in other urban Canadian contexts.

Conclusion

Recognizing the diversity among Métis communities across Canada, and the need for a locally tailored approach to culturally safe service delivery, this research demonstrates that Métis Peoples experience major gaps in access to culturally safe health and social services in urban settings. At the same time, this research demonstrates that Métis women, two-spirit and gender diverse people carry practical solutions for improving access to health and social services for the Métis community.