Medicine, Faculty of
Obstetrics and Gynaecology, Department of
DSpace
UBCV
Scott-Fiddler, Piper
Master of Science - MSc
University of British Columbia
Métis clients seeking family planning services in British Columbia often encounter mistreatment, shame, and barriers to accessing contraception and abortion care. This study comprises two parts aimed at comprehensively exploring their experiences. In Part 1, a qualitative investigation was conducted to understand Métis clients' encounters with family planning care access (Aim 1 and 2). Through analysis, an overarching theme emerged, encapsulating the essence of their experiences as "Feeling lost in a system that does not value relational care." Within this overarching theme, five key sub-themes were identified: "Searching for a consistent healthcare provider: 'I’ve never gone to the same doctor twice,'" highlighting the lack of continuity in care and mistreatment from healthcare providers; "Prioritizing care despite costs," revealing the financial, emotional and physical challenges faced by Métis clients in accessing abortion and contraception services; "Jumping through hoops to find information," indicating the difficulties in navigating complex healthcare systems; "Feeling shame in family planning care due to legacies of trauma," addressing the deeply ingrained cultural and historical factors influencing perceptions of reproductive healthcare; and "Needing Métis-specific family planning services," emphasizing the importance of culturally tailored and community-responsive care. In Part 2 of the study, the concept of Métis-specific services was further examined through an eight-person community conversation. This community conversation aimed to deepen the understanding of Métis perspectives and preferences regarding family planning care (Aim 3). The community conversation generated three additional emerging themes: "Acceptance from our Elders and health care professionals," highlighting the significance of cultural validation and support from trusted sources; "Communication: ‘There is a huge disconnect,'" emphasizing the challenges in effective communication between Métis clients and healthcare providers; and "Cultural Safety: Could the answer be Métis-Specific Services?" prompting reflection on the potential benefits of culturally tailored healthcare services.This research sheds light on the multifaceted challenges faced by Métis individuals in accessing family planning care in British Columbia and elevates the importance of developing culturally relevant and inclusive healthcare services that address the unique needs and preferences of Métis communities.
i BRIDGING STORIES: EXPLORING MÉTIS EXPERIENCES IN ACCESSING FAMILY PLANNING SERVICES by Piper Scott-Fiddler BA, Simon Fraser University, 2022 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in The Faculty of Graduate and Postdoctoral Studies (Women+ and Children’s Health Sciences) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) October 2024 © Piper Scott-Fiddler, 2024 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled: Bridging Stories: Exploring Métis Experiences in Accessing Family Planning Services submitted by Piper Scott-Fiddler in partial fulfilment of the requirements for the degree of Master of Science in Women+ and Children’s Health Sciences Examining Committee: Dr. Gillian Hanley, Women+ and Children’s Health Sciences, University of British Columbia Supervisor Dr. Sarah Munro, Department of Health Systems and Population Health, University of Washington Co-Supervisor Dr. Brittany Bingham, Division of Social Medicine, University of British Columbia Supervisory Committee Member Dr. Helen Brown, School of Nursing, University of British Columbia Additional Examiner Additional Supervisory Committee Members: Dr. Sheona Mitchell-Foster, Department of Obstetrics & Gynaecology, University of British Columbia Supervisory Committee Member iii Abstract Métis clients seeking family planning services in British Columbia often encounter mistreatment, shame, and barriers to accessing contraception and abortion care. This study comprises two parts aimed at comprehensively exploring their experiences. In Part 1, a qualitative investigation was conducted to understand Métis clients' encounters with family planning care access (Aim 1 and 2). Through analysis, an overarching theme emerged, encapsulating the essence of their experiences as "Feeling lost in a system that does not value relational care." Within this overarching theme, five key sub-themes were identified: "Searching for a consistent healthcare provider: 'I’ve never gone to the same doctor twice,'" highlighting the lack of continuity in care and mistreatment from healthcare providers; "Prioritizing care despite costs," revealing the financial, emotional and physical challenges faced by Métis clients in accessing abortion and contraception services; "Jumping through hoops to find information," indicating the difficulties in navigating complex healthcare systems; "Feeling shame in family planning care due to legacies of trauma," addressing the deeply ingrained cultural and historical factors influencing perceptions of reproductive healthcare; and "Needing Métis-specific family planning services," emphasizing the importance of culturally tailored and community-responsive care. In Part 2 of the study, the concept of Métis-specific services was further examined through an eight-person community conversation. This community conversation aimed to deepen the understanding of Métis perspectives and preferences regarding family planning care (Aim 3). The community conversation generated three additional emerging themes: "Acceptance from our Elders and health care professionals," highlighting the significance of cultural validation and support from trusted sources; "Communication: ‘There is a huge disconnect,'" emphasizing the iv challenges in effective communication between Métis clients and healthcare providers; and "Cultural Safety: Could the answer be Métis-Specific Services?" prompting reflection on the potential benefits of culturally tailored healthcare services. This research sheds light on the multifaceted challenges faced by Métis individuals in accessing family planning care in British Columbia and elevates the importance of developing culturally relevant and inclusive healthcare services that address the unique needs and preferences of Métis communities. v Lay Summary Métis clients attempting to access family planning services in British Columbia report experiences of mistreatment, shame, and inaccessibility to contraception and abortion care. My two-part study explored these experiences. Part 1 identified the overarching theme "Feeling lost in a system that does not value relational care," which includes five key themes: “Searching for a consistent healthcare provider,” “Prioritizing care despite costs,” “Jumping through hoops to find information,” “Feeling shame due to legacies of trauma,” and “Needing Métis-specific family planning services.”. Part 2 explored Métis-specific services through an eight-person community conversation, revealing three themes: “Acceptance from Elders and healthcare professionals,” “Communication: ‘There is a huge disconnect,’” and “Cultural Safety: Could the answer be Métis-Specific Services?” vi Preface The work presented in this thesis is original work conducted by master’s student, Piper Scott-Fiddler (PSF). I completed this thesis work under the supervision of Dr. Sarah Munro and Dr. Gillian Hanley with addition to my committee member Dr. Brittany Bingham. Chapter 2: The qualitative investigation that I conducted is embedded in a 4-year CIHR funded study which explores Indigenous people’s experience accessing contraception and abortion care in British Columbia. I have received ethics approval from UBC Behavioral Research Ethics Board to conduct this study, as part of the Story Project (Ethics # H21-01171). The study in my thesis investigates the Métis individuals who participated in the Story Project from July 2023 to November 2023 (n = 16). My research questions focused on the stories of the participants when accessing contraception and abortion care in British Columbia, as well as what good models of contraception and abortion care look like from the Métis perspective. Our research team included my supervisor Dr. Sarah Munro (SM), Aleyah Williams (AW), Miranda Kelly (MK), Danette Jubinville (DJ), and Bimbola Olure (BO) who assisted with interviews and analysis. Our team designed recruitment materials for all Story participants using graphics illustrations designed by Ocean Hyland. All interviews were conducted by myself, Miranda Kelly, and Dr. Munro. All interviews were recorded on Zoom. Each interview was transcribed verbatim by a third party transcription service, Advanis. Bimbola Olure and I conducted analysis with mentorship from my supervisor Dr. Sarah Munro. Our analysis followed constructivist grounded theory, following analysis, I authored the chapter with continuous feedback from Dr. Sarah Munro. vii Chapter 3: I created and led an activity named the Kitchen Table Talk using integrated knowledge translation (iKT) and Kitchen Table methodologies with the guidance of Dr. Sarah Munro. The activity included one virtual collaborative conversation which was conducted and recorded over Zoom followed by the development of a graphic to depict the key elements of the conversation. I worked with Jessie Mead (JM) from the agency Fuselight Creatives who listened to the recording after the activity. I sent JM key themes and elements that I highlighted through note taking and we worked together on revisions after the initial draft. I received ethics approval from UBC Behavioral Research Ethics Board to conduct this study, as part of the Story Project (Ethics # H21-01171). viii Table of Contents Abstract ........................................................................................................................................................ iii Lay Summary ................................................................................................................................................ v Preface ......................................................................................................................................................... vi Table of Contents ……………………………………………………………………………………………………viii List of Tables ................................................................................................................................................. x List of Figures .............................................................................................................................................. xi List of Abbreviations ................................................................................................................................... xii Acknowledgements ..................................................................................................................................... xiii Dedication ................................................................................................................................................... xv Chapter 1: Introduction ……………………………………………………………………………......…… 1 1.1 Thesis Aim and Objectives ....................................................................................................... 1 1.2 Thesis Overview ....................................................................................................................... 3 1.3 Definition of Family Planning Services in British Columbia ................................................... 6 1.4 Barriers to accessing family planning services for Indigenous clients ..................................... 8 1.5 Structure of Thesis .................................................................................................................. 12 1.6 Critical Frameworks and Methodology .................................................................................. 13 1.7 Positionality Statement ........................................................................................................... 22 1.8 Conclusion .............................................................................................................................. 22 Chapter 2: Experiences of Métis Clients Accessing Family Planning Care in British Columbia: A Qualitative Investigation ............................................................................................................................. 23 2.1 Purpose .................................................................................................................................... 23 2.2 Research Questions ................................................................................................................. 23 2.3 Methods................................................................................................................................... 24 2.4 Results ..................................................................................................................................... 34 Chapter 3: Coming Together at the Kitchen Table: Métis Perspectives on Developing Better Access to Family Planning Care in British Columbia: A Community Conversation ................................................. 68 3.1. Purpose ................................................................................................................................... 68 3.2 Methods................................................................................................................................... 68 3.3 Results ..................................................................................................................................... 76 3.4 Conclusion .............................................................................................................................. 85 Chapter 4 Discussion and Conclusion ........................................................................................................ 86 4.1 Discussion ............................................................................................................................... 86 ix 4.2 Conclusion ............................................................................................................................ 101 References ................................................................................................................................................. 103 Appendices ................................................................................................................................................ 108 Appendix A Recruitment Poster ................................................................................................. 108 Appendix B Social Media Square ............................................................................................... 109 Appendix C Community Facing Interview Guide ...................................................................... 110 Appendix D Preliminary Codebook for qualitative investigation (Chapter 2) ........................... 111 Appendix E Final Codebook for the qualitative investigation (Chapter 2) ................................ 143 Appendix F Full Interview Guide ............................................................................................... 150 Appendix G Email Script for Member Checking ....................................................................... 154 Appendix H Resource Guide ...................................................................................................... 155 Appendix I Revised Topic Guide for Kitchen Table Talk .......................................................... 156 Appendix J Trauma-Informed Research Approach .................................................................... 160 Appendix K Invitation Email Template for Kitchen Table Talk ................................................ 163 Appendix L Email Template with Zoom Link and Agenda ....................................................... 164 Appendix M Matriarch and Knowledge Keepers Values in Research Graphic Facilitation ...... 165 x List of Tables Table 2.1 Summary of key themes and subthemes …………………………………………….36 xi List of Figures Figure 1.2. Patient-Centred Access to Health Care Framework (Levesque, 2013) ……………..15 . Figure 1.3. Accessibility Framework for Indigenous peoples accessing Indigenous primary healthcare services (Davy et al., 2016) ………………………………………………………….16 Figure 2.1 Illustration of Key themes …………………………………………………………...67 Figure 3.1 Kitchen Table Talk Infographic ……………………………………………………..79 xii List of Abbreviations FNHA, First Nation Health Authority iKT, integrated Knowledge Translation IUD, Intrauterine device KT, Knowledge Translation MNBC, Métis Nation BC xiii Acknowledgements I would like to express my deepest gratitude to my mentor and supervisor, Dr. Sarah Munro, thank you for your continuous support throughout my thesis and the program. Your guidance and expertise afforded me an invaluable experience by providing me with extensive research training. Your patience and encouragement allowed me the positive space to grow. Your leadership continues to inspire me and I am very appreciative for my time that I have spent with you. To my co-supervisor and committee member, Dr. Gillian Hanley, and Dr. Brittany Bingham and the supervisory committee chair, Dr. Lori Brotto, thank you for your encouragement and the guidance that allowed me to successfully conduct my research and complete my thesis. I am grateful for my teammates from the Munro Lab, who continuously provided their unwavering support through out the WACH program, my research project and thesis writing process. All of your mentorship, and comradery mean the world to me. To the Story research team, my thesis would not have happened without all of you. Danette Jubinville, Miranda Kelly, Samantha Martin-Ferris, Evelyn George, and Aleyah Williams, you all made significant contributions to my research and supported me through endless questions. To Bimbola Olure, thank you so much for being my guiding light through analysis, your expertise is invaluable and I cannot thank you enough for being a part of my research with me. It truly would not have been possible without you. xiv To the community members who participated in the research. Thank you for your stories with us, this work would not have been possible without you all. xv Dedication My deepest appreciation to my friends and family, who continually supported me through my education journey and never doubted my abilities. To my mother, Meighan, your resilience, selflessness, and unwavering belief in my abilities have inspired me to overcome challenges and pursue excellence. Your love has shaped me into the person I am today. To my father, Brian, although you passed before you could witness this academic milestone, your encouragement to be bold has guided me throughout my pursuit of knowledge and played a significant role in shaping the person I have become. Your ridiculous sense of humour and love lives on with me, driving me forward with every challenge I face. To my siblings and their partners, Peter, Sydney, Geoff, Nathalie, and Bryce thank you for cheering me every step of the way, you have all been a constant source of motivation that have allowed me to reach this milestone. I am a very proud aunt to my nieces and nephews, Emerson, Jack, Levi and Hazel. I extend my heartfelt gratitude for bringing joy, and laughter into my life. Your smiles, hugs, beautiful drawings, and constant questions remind me of the importance of curiosity, creativity, and wonder. To my friends, your friendships truly enrich my life in countless ways. Whether it was lending a listening ear during moments of doubt or celebrating my achievements with endless enthusiasm, you have been my pillars of strength throughout this journey. I will cherish you all forever. xvi To my partner, Colin, your positivity, encouragement, and love propelled me forward and fueled my determination to succeed. Your consistent presence, whether in quiet moments of study or in joyous celebrations of achievement, has been a source of comfort and strength. To my aunt, Barb, thank you for your constant support and guidance that led me into health service research. Your belief in me has been pivotal in shaping the path that has led me to this moment. As I reflect on the countless conversations we shared about the importance of compassionate care, I am reminded of the profound influence you have had on my journey. 1 Chapter 1: Introduction 1.1 Thesis Aim and Objectives My thesis will answer the following question: What are models of culturally safe family planning care for Métis Peoples in BC? Research Questions: 1. What are Métis clients’ experiences of accessing contraception and abortion services in BC? 2. Have Métis clients encountered racism and stereotypes in accessing these services and what did those experiences involve? 3. What are the characteristics of good access to contraception and abortion care for Métis clients? Conducting this research, I will amplify the voices of Métis women and gender diverse individuals, by acknowledging the ignored knowledge and stories to be heard and used as evidence in the health service research context. I will identify themes that illustrate Métis clients’ experiences accessing family planning care in British Columbia. I will identify characteristics of access that are important to Métis clients from across British Columbia and engage with community members to inform better models of accessing family planning care through design and practice. This research will advance Métis-specific health service research and contribute to 2 the limited data available, empowering policy development and Métis voices to create meaningful change. My thesis is embedded in a CIHR-funded study investigating access to contraception and abortion care (family planning services) for Indigenous clients across British Columbia called The Story Project: Improving Access to Family Planning for Indigenous Peoples through Storytelling. My work is a sub-study that highlights Métis clients of care experiences in accessing family planning services within British Columbia. For the purposes of my thesis, I define the term Métis as “a person who self-identifies as Métis, is of historic Métis Nation Ancestry, is distinct from other Aboriginal Peoples and is accepted by the Métis Nation” (1). The term client of care is an individual who has received family planning services in British Columbia at any point in their reproductive lifetime. Individuals who self-identified as Métis, received family planning care in British Columbia and at least 18 years of age at the time of the study were eligible to participate in this research. I use the terms “woman” and “women” only where they are used in the existing literature, to be consistent with authors’ definitions. In this thesis, I recognize individuals who have female reproductive organs may identify with a different gender. Wherever possible, I describe study participants as Métis clients of care. My project aims to be inclusive of all genders and I have consulted with Métis communities and the Story Project co-investigators to ensure that language is appropriate and inclusive. 3 1.2 Thesis Overview On February 3rd, 2022, Taanishi Kiiya: the Métis Public Health Surveillance Program Baseline report was published. Created by Métis Nation BC (MNBC) and the office of the Provincial Health Officer, the report provided testimonies from Métis individuals that “If we talk about intergenerational trauma, we also need to talk about intergenerational healing, and we should also talk about reproductive justice as intergenerational.”(2). Colonization has policed and criminalized Indigenous people’s sexuality and their rights as lifegivers for generations, resulting in Indigenous people experiencing forced sterilization, reproductive coercion, discriminatory treatment in hospitals while giving birth and having their children taken away from them (2–5). Although many individuals think of these actions in the past tense, in recent years, Indigenous people have reported unsafe sexual and reproductive healthcare services (2–6). Abortion access and safety Experiences such as inequitable access, racism, and coercion often create a barrier around accessing family planning services (4–7). Historically, Indigenous people were almost 3 times more likely to travel over 100km to access an abortion clinic compared to a non-Indigenous woman (7). Additionally, it should be recognized that the burden goes beyond distance, time, and money (7). The impact on Indigenous clients’ emotional and physical well-being was reported as a major expense to access an abortion (7). Hospital-based procedures and services are a necessity for individuals who live in rural and remote communities and may be the only point of care accessible to them in a reasonable amount of time (7). Some clients forgo this option due to multiple appointments, the use of anesthesia, and privacy issues, as in a smaller community there is a higher risk of having confidentiality compromised (7). 4 Since mifepristone was introduced into the Canadian healthcare system in 2017, there has been a rapid increase in the availability of medication abortion across Canada (8). In Ontario, for instance, mifepristone medication abortion accounts for roughly 30-50% of all abortions in that province, depending on the region, and this rate is likely similar for British Columbia (8). However, it is not clear from the available data where medication abortion providers practice in British Columbia, how many medication abortions they provide annually, how this new option ensures care closer to home for Indigenous people, and what the experiences are of people who access medication abortion (7). Clients in smaller communities may forgo an abortion option closer to home due to the risk of a confidentiality breach, resulting in clients negating a safe experience (6). A safe experience is defined in many ways, but Monchalin et al., (2019) heard testimonials of from eleven Métis women (9), among whom one expressed that it relates to the formality of their care relationship: “I would prefer to have my health care provided over a cup of tea any day, as opposed to having the formality . . . that comes with going into . . . a medical office. It just can feel really oppressive.” In this context, there is a pressing need to understand how these significant shifts in abortion access have impacted Indigenous Peoples, from their own perspectives. Countering Anti-Indigenous Racism The In Plain Sight report (2020) identified health care professionals may use stereotypes of Indigenous clients seeking healthcare, including perceiving Indigenous clients as being “irresponsible/non-complying”, “less capable to take responsibility for their healthcare”, and “less worthy” of care. The report highlighted specifically that Métis people are hesitant to seek 5 required care and change within the British Columbia health system needs to happen in order for Métis and other Indigenous clients to “receive the same level of care other British Columbians are afforded.” The In Plain Sight report (2020) highlights the inclusion of all Indigenous voices (Inuit, Métis, and First Nation), but it is unclear what proportion of participants represent Métis peoples in the report. The report included data collection from over 9,000 survey responses from the Indigenous Peoples Survey and Healthcare Workers Survey. Only the Indigenous Peoples Survey identified that 10% of respondents were Métis whereas the Healthcare Worker Survey only identified when a worker identified as Indigenous. Monchalin et al. (2019) identified culturally informed service providers as a key recommendation to improve Métis women’s access to health and social services. When considering distinction-based services such as Métis-specific family planning services, there are minimal options for Métis clients to access in British Columbia. Many Métis clients feel misplaced between Western and First Nation options – they do not feel accepted by First Nation or Pan-Indigenous healthcare services yet do not feel comfortable in Western healthcare – resulting in an additional barrier (4,5,10). Identifying and Addressing the Knowledge Gap According to the 2021 Statistics Canada Census, over 290,000 people in BC identified as Indigenous. Nearly 97,900 of the individuals identified as Métis in BC, which corresponds to 2% of the population in British Columbia, while over 125,100 individuals identified as status First Nation (4,5,11). Based off of this census, there has been growth of the Indigenous population from 2016 to 2021 (270,585 Indigenous people to 290,210 Indigenous people) which demonstrates the rapid growth of all three populations within British Columbia (11). As health service research increasingly focuses on health and wellbeing of Indigenous populations, reports 6 of this research, like In Plain Sight, offer limited information describing how each Indigenous population has participated to these studies. As a result, there is minimal evidence to explain the experiences of Métis people accessing contraception and abortion care through distinctions-based and strengths-based approaches. Only as of recently has Métis Nation BC been able to conduct research that has created Taanishi Kiiya (2021) which describes Métis experiences accessing healthcare in British Columbia as well as, recommendations to improve the experiences and quality of care. However this report included minimal literature and data on family planning care. Based on this knowledge gap, this is a pivotal moment for community-led research to understand, what are models of culturally safe family planning care for Métis Peoples in BC? 1.3 Definition of Family Planning Services in British Columbia In terms of this thesis, family planning care is defined as contraception and abortion care. Indigenous communities have longstanding evidence of traditional medicines that were used as contraceptive and abortifacients (4). Administered by the grandmothers, mothers, and aunties, the traditional knowledge was passed down intergenerationally where reproductive knowledge continued to allow Indigenous people to space their births which made survival easier to move along with animal herds (4). I will be defining contraception and abortion care based on the British Columbia and Canadian context. An abortion is the ending of a pregnancy in the early stages of gestation (12). If the pregnancy is less than 10 weeks, clients of care seeking an induced abortion have the choice of 7 two options, a medication abortion, and a procedural abortion (12–14). If the pregnancy is between 10 weeks and 24 weeks, clients are provided options for procedural abortion. While these methods are free, safe, and legal in Canada, there are key differences between the two options, including where to access the abortion (primary care vs. a facility or hospital), side effects, length of the abortion, and the ability to bring a support person. Although uncommon, clients in Canada seeking abortion after 24 weeks typically access care in the United States (12–14). Contraception is defined as preventing pregnancy through the utilization of a device, prescribed medicines, or surgery (15,16). In Canada, clients have access to prescription hormone-based contraceptives including oral contraceptive pills, intrauterine devices (IUDs), injections, vaginal rings, and subdermal contraceptive implants, as well as over the counter emergency contraception (16-20). Non-hormonal contraception includes barrier methods such as condoms, diaphragms, cervical caps, and sponges, as well as the prescription copper IUD, and permanent methods including tubal ligation and vasectomies (16,18). While “birth control” is often used as a synonym for contraception, I use the term “birth control” only in quotations when citing the existing literature or by participants as an outdated term. “Control” pushes underlying histories of eugenics and forced sterilization endured by minorities due to racial ideologies held by eugenicists (19). “Birth” is also inaccurate as the purpose is to prevent conception and does not account for the individuals who use contraception for other purposes such as menstrual suppression and regulation, or treatment of fibroids (20). 8 1.4 Barriers to accessing family planning services for Indigenous clients A range of factors disproportionately impact Indigenous clients’ equitable access to family planning services broadly, and culturally safe services in particular. In terms of logistical considerations that affect access to family planning services, distribution of abortion providers is uneven throughout Canada (21,22). As approximately 60% of Indigenous people live in rural areas of Canada, this creates a greater chance of financial hardship when trying to access services as travel is an out-of-pocket cost (23). Delayed access to care is also a heavy barrier; in a qualitative investigation focusing on 64 Canadian people who accessed a medication abortion in 2017, participants reported their choice based on personal and logistic convenience (24). One participant illustrates the convenience based on not requiring a ride after a procedural abortion as they were not sure if this was possible for them. So, with access to a medication abortion it reduced the risk of delayed care as this participant may have had to wait until they could secure a transportation (24). Unfortunately, clients of care who are required to travel long distances to access an abortion are statistically less likely get an abortion (21,22). If clients are able to seek family planning services in their community, there can be a lack of awareness of which healthcare providers are considered “trustworthy” (21,22). Results of a qualitative investigation revolving around 16 women’s experience accessing abortion services after 2005 in White Horse, Yukon describe participants requiring an average of six appointments in order to receive an abortion. This risked participants interacting with “anti-choice or unsupportive clinicians” and enduring their unwanted pregnancy longer which was described as needing a longer period of emotional recovery (25). LaRoche and Foster (2020)’s qualitative investigation, discuss a number of their 64 Indigenous and non-Indigenous participants highlighting misinformation from clinicians surrounding regulatory changes to the universal coverage of mifepristone and 9 misoprostol (24). Although most participants did not feel judged or stigmatized through these experiences, participants required using a lot of self-advocacy in these situations which made it frustrating (24). By living in a smaller community there is a higher risk of a breach in confidentiality as access to healthcare providers and services is limited (21) and there are risks with community members seeing a client enter a clinic in order to receive care. As there is a shortage of family physicians and nurse practitioners in British Columbia, there is even less availability of healthcare providers in rural areas resulting in clients having to take what services they can get (26). Surveyed healthcare providers reported their peers using outdated practices in terms of contraception counselling such as advising their clients to “take a break from the hormones”(21,22,27). This has manifested through practices like refusal of prescribing, and refusal of referral to a healthcare provider who can deliver the required care. Even if a client were to get access to an appointment with a healthcare provider, clients feel rushed and are unable to receive adequate family planning counselling as there is limited time per appointment (22). Indigenous women and gender diverse individuals endure considerable inequities in sexual reproductive health (SRH) services (23). These inequities have been longstanding as in the wake of colonization, Indigenous people’s reproductive rights were heavily targeted and continue to be (23,28). Challenges related to accessibility of contraception and abortion care are related to the ongoing colonial and intergenerational trauma experienced by Indigenous populations in Canada (23,28). In current reports, Indigenous clients spoke on their fear of visiting hospitals or giving birth in a healthcare facility caused by concerns of their children being removed from their care (29). This statement is supported by a British Columbia report, In Plain Sight (2020), where 10 witnesses in the healthcare system recounted experiences in which Indigenous clients were mishandled by healthcare providers and experienced bias and anti-Indigenous racism. The report shares an account of one healthcare provider stating, “people like her [Indigenous woman in care] should be sterilized” (3). Traditionally, Indigenous women held the knowledge of medicine which was passed down the matrilineal line, including contraceptives and abortifacients (23,28). Today, Indigenous clients face a disconnect between their traditional teachings and the western care settings in which Indigenous rights and knowledge are dismissed (4). Understanding the range of barriers to accessing appropriate healthcare is critical to improve cultural safety, cultural relevancy, and de-stigmatized family planning services.(21,23) The limited existing literature suggests that access is not just an individual challenge involving logistical considerations (travel, cost, availability of services and information). The scientific evidence to date has focused primarily on this narrow definition of access, with the exception of more recent studies involving patients and led by Indigenous scholars. Building on this knowledge base, I aim to explore how access barriers to family planning healthcare are nuanced and require attention to role of colonial and intergenerational trauma, and listening to clients themselves. 11 1.4.1 Lack of Métis Voices in Health Service Research (Challenges and Opportunities) Historically, Métis representation has been lacking in the context of health service research (2,4,28,30). Although Métis individuals may participate in studies, there is minimal Métis-specific representation in crafting and implementing any recommendations that arise in said studies (30). In the context of Métis women and gender diverse individuals, there is limited literature that is specific to these populations in the British Columbia context and across Canada (4,28,30). One issue that arises is the complexity of the Métis identity. Colonialism has erased and forcefully removed Métis identity, leaving an entire population without many components of their culture (28,30). Métis women and gender diverse individuals held and continue to hold the responsibility for the well-being and overall health of their families and communities (4). There is a pressing need to amplify the voices of Métis people, their traditional knowledge, and their recommendations for their communities (28,30). Métis Nation BC and the British Columbia’s Ministry of Health published Taanishi Kiiya (2021) which leverages voices and concerns of the Métis communities as well as future priorities. They identified: 1) “Improved Métis health and wellness through upholding Métis self-determination”, 2) “Fully realized mental health and wellness for Métis people”, and 3) “Collaborative, robust, self-determined Métis health information systems” (2). As an updated surveillance report will be published every three years until 2030 to update these priorities, there is opportunity to highlight and engage with community members’ stories (2). This engagement 12 will elevate culturally appropriate recommendations of safe models of family planning care for Métis clients in British Columbia. 1.5 Structure of Thesis In this chapter, I have provided an introduction, overview of the relevant literature, and stated my objectives to explore the experiences of Métis women and gender diverse individuals in accessing family planning services in the province of British Columbia. In chapter 2, I provide the results of analysis of sixteen interviews with Métis women and gender diverse individuals. I will present themes focusing on the dimensions of access for contraception and abortion care that I generated during analysis. I detail the data collection and analysis through constructivist grounded theory, a Two-Eyed Seeing, and distinctions-based approach in order to find emerging themes that represent the Métis peoples’ experiences in accessing contraception and abortion care in British Columbia. Through this chapter, I seek to answer my first and second research questions. In chapter 3, I describe a knowledge translation activity, consisting of a Kitchen Table conversation and graphic facilitation to build a Métis-specific access to family planning care framework off of an existing Indigenous adaptation of Levesque’s access to care framework (31,32). In order to detail the meaningful recommendations generated in this activity, I use a Métis Kitchen Table Talk methodology as a means of knowledge sharing amongst the 13 community members and integrated knowledge translation principles (iKT) (30,33). In this chapter I seek to answer my third questions. In chapter 4, I integrate, situate, and analyze results of my qualitative investigation. Through this process of reflection, I will establish my work within the current body of available literature. 1.6 Critical Frameworks and Methodology Through my thesis chapters, I follow a Two-Eyed Seeing and distinctions-based approach bridging storytelling methods, an Indigenous adaptation of Levesque’s Patient-Centred Access to Healthcare framework, Métis Kitchen Table methodology, constructivist grounded theory, and integrated knowledge translation principles (10,31,32,34–39) . I provide an overview of each of these frameworks and methodologies in the sections below and why I selected them, with explanations for how I use them in my thesis . 1.6.1 Accessibility Framework for Indigenous peoples accessing Indigenous primary health care services Levesque’s Patient-Centred Access to Health Care Framework (Figure 1.2) incorporates five stages that address health service and health service user attributes that play a role in access to care (32). 1) Approachability: Refers to the ability of the user to recognize services available. 14 2) Acceptability: Refers to the ability of the user to seek services based on personal socio-cultural factors that affect how the user will decide if they will access the service. 3) Availability and accommodation: Refers to the ability of the user to access services based on the location, distance, and timely availability of the service. 4) Affordability: Refers to the ability of the user to access a service based on costs. These costs can be direct or indirect costs to the service such as transportation, childcare, time and the cost of the service 5) Appropriateness: Refers to the suitability of the service to the user, including satisfaction and quality of the service from the users’ perspective. 15 Figure 1.2. Patient-Centred Access to Health Care Framework (Levesque, 2013) https://creativecommons.org/licenses/by/2.0/ Davy et al., (2016) built off of Levesque et al., (2013)’s model of access to health care in order to conceptualize factors that reduce Indigenous clients from accessing primary care services. Although Levesque’s framework addresses many barriers of access for Indigenous clients, Davy et al., (2016), highlighted a few additional considerations. 1) The healthcare system in its entirety affects access and acceptability of care, thus access must be looked at with the broader context in mind. 2) Many Indigenous services function on a tight budget, so limited funding has resulted in a reduction in services for Indigenous clients. 16 3) A non-linear representation of the Levesque framework (Figure 1.3) accurately demonstrates the relationships between access and accessibility by allowing for factors to be represented in with a more in-depth interrelatedness. Figure 1.3. Accessibility Framework for Indigenous peoples accessing Indigenous primary health care services (Davy et al., 2016) https://creativecommons.org/licenses/by/4.0/ I apply Davy et al., (2016)’s adaptation to the development of my KT activity (Chapter 3) questions to discuss barriers and facilitators in accessing family planning care in British Columbia from a Métis perspective, in order to create a Métis-specific access to family planning care framework. I selected this framework as this considered additional barriers and facilitators that are specific to the perspectives of Indigenous clients accessing care. 17 1.6.2 Two-Eyed Seeing Approach The Two-Eyed Seeing approach is a theoretical framework that acknowledges the contributions of both Indigenous and Western “ways of knowing” (10). The concept was developed in 2004 by Albert Marshall, a Mi’Kmaq elder (10). Two-Eyed seeing allows for essential characteristics of both Western and Indigenous perspectives to be used together in order to tackle the gaps and questions relating to the health of Indigenous communities and their individuals (10). Historically Indigenous ways of knowing have been dismissed and deemed “unscientific.” A Two-Eyed Seeing approach allows for a positive acknowledgement of the importance of Indigenous ways of knowing while also ensuring both perspectives have equal consideration and no one worldview dominates the other (10). In terms of my thesis, this approach is used in my qualitative investigation (Chapter 2). I bridge the western perspective of family planning care and traditional knowledge of Métis communities in order to understand the context of Métis clients accessing family planning care in a western healthcare system. I chose this methodology as it allows for me to understand the relationships of Métis clients accessing contraception and abortion care through the Western healthcare system while trying to incorporate their knowledge and culture into the services. I demonstrate this through elevating the strengths of both Indigenous and Western knowledge through my analysis in Chapter 2. 1.6.3 Distinctions-based Approach A Distinctions-based Approach requires the understanding and acknowledgement that pan-Indigenous strategies to health do not meet the needs of all Indigenous people due to the fact that pan-Indigeneity does not acknowledge “the distinct histories, interests and priorities of First Nations, Métis and Inuit people” (34). This approach is used through out my qualitative 18 investigation (Chapter 2) and knowledge translation activity (Chapter 3) through the development of questions, analysis, and recommendations. By understanding the history, culture, and priorities of the Métis community in British Columbia, I give richer and more specific accounts and recommendations tailored to improve the health of Métis people (34). I use this approach through building relationships with Métis chartered communities in order to follow the individual processes of each community. As well, introduce myself through my distinct histories as a Métis and mixed settler woman to participants in order to build connection through our ways of knowing. I chose this approach as it allows for specificity of results and recommendations for one Indigenous population rather than generalizing the results to form recommendations for Indigenous people as a whole. My use of this approach can be seen throughout my thesis and reflects my goal to challenge traditional Western paradigms of health service research. Governance, which I define as Métis communities being able to have authority over themselves, such as decisions about Métis affairs including health, political, cultural, and economic matters is an important piece of Métis culture which is demonstrated through our histories fighting the erasure of our people. I believe that taking an approach that acknowledges our beadwork, family, sashes and the lands where we come from elevates the voices of not only the present generations but the generations who were not able to speak as they had to hide through identifying as Scottish, Italian, Irish, French and English. This method is highlighted in my efforts to understand data governance processes within every chartered community I engaged, engage in member checking with participants to ensure they approve the final version of their story, and use collaborative techniques distinct to Métis culture (e.g. Kitchen Table Talk). 19 1.6.4 Storytelling Storytelling methods have been shown to be an effective way of to collect oral data in a culturally safe and appropriate way (35–37,40). In order to stay true to my promise of community collaboration with Métis community members and elders, I honour “the importance of oral-tradition and traditional ceremonies” (35–37). Storytelling is both “relational and reciprocal”, rather than a traditional western interview methods where the interviewer asks questions and the participant answers, storytelling allows for the interviewer and participant to share each others’ experiences and learn from one another (35,36). I use this methodology through my qualitative investigation (Chapter 2) interviews, this allows for a holistic exchange of knowledge between the participants and myself. I chose this methodology for this reason, in order to build meaningful recommendations, relationality and reciprocity is required. I incorporate a Two-Eyed Seeing approach with storytelling in order to investigate western and Indigenous ways of knowing at the same time with equal consideration (10,35,36). 1.6.5 Integrated Knowledge Translation (iKT) Integrated Knowledge Translation (iKT) is used in my knowledge translation activity (Chapter 3). Integrated Knowledge Translation combines community participatory research and knowledge transfer from Western perspectives of health (33,37). This approach acknowledges that successful knowledge use requires the engagement of potential knowledge partners (33,37). Meaningful engagements in the context of my knowledge translation activity includes Métis community members from all across British Columbia, and active members in Métis Nation BC to ensure the knowledge translation is culturally appropriate, and relevant to the Métis 20 community in British Columbia (33,37). I chose this methodology due to the “grass roots” approach as in order to create recommendations of good models of family planning care it requires community members and clients seeking abortion and contraception care to be involved at every point as this will create “real-life” recommendations that are useful from Métis perspectives. 1.6.6 Métis Kitchen Table Methodology Traditionally, the kitchen table plays a vital role in Métis culture; it is a space of social gatherings and teachings (30,38,41). It is where our families and ancestors have passed down knowledge and became a space of action (30,38,41). In recent years, Métis scholars have begun to advance Métis-specific methodologies in order to work with Métis-specific perspectives. Métis Kitchen Table methods are defined as: “a safe space to gather for dialogue, knowledge sharing, eating, drinking tea, and learning from a Métis worldview.” (38). The goal of this methodology is to create a space that is informal and collaborative, resulting in community engagement, reciprocal relationality, and knowledge development (30). In terms of my thesis, I use this methodology in my knowledge translation activity (Chapter 3). By creating a Métis-specific space, we foster Métis-specific knowledge transfer and build relationships within community further strengthening the experience. I chose this approach to ensure that I was taking a Métis-specific approach in order to create a safe space for individuals to co-generate recommendations that optimize Métis clients of care experiences accessing contraception and abortion services. 21 1.6.7 Constructivist Grounded Theory Constructivism acknowledges individuals build their reality through their relationships and their meanings of the relationships through experience and their mental processes (39,42,43). A constructivist perspective to research allows space for the participants’ and researchers’ interpretations to co-create knowledge (39,42,43). Early iterations of the method, which pre-dated constructivist grounded theory, posited that reality is objective and that any ‘emerging’ themes would be ‘discovered’ without the interpretations of the researcher (39,42,43). Constructivist approaches address the generation of knowledge through agency, power, and action which are found in feminist theory. This is a reaction to the absence of these ‘conceptual families’ in positivist approaches to grounded theory (39). Constructivist grounded theory (CGT) is a methodology that combines constructivism and grounded theory centering the importance of the meaning participants hold to their experiences, and social processes in relation. In collaboration, the researcher’s role as an interpreter in data collection and analysis generates explanations of patterns to explain the phenomenon. Data collection and analysis are conducted simultaneously to ensure that emerging themes and insights can be further explored through additional data collection (39,42,43). I use CGT throughout my recruitment, data collection, and analysis (Chapter 2). This methodology is effective in the context of my study as it is an adaptable method alongside the number of methods I use through out the qualitative investigation, allowing for a deeper engagement with community and their stories. I engaged in constant reflection of my role as a researcher in how I interpret the data as well an in-depth interpretation from my perspective of a Métis woman who has accessed family planning services in British Columbia. 22 1.7 Positionality Statement I am a white-passing Métis woman and proud member of Métis Nation BC. Although I have connections to my community, it does not discount for my privilege of being able to pursue a graduate degree. I do my best to ground myself in community, I acknowledge that my perspectives come from a place tainted by colonialism. My voice and research can be impactful, so to ensure that my work is meaningful and community-oriented, my actions and words will be wholeheartedly collaborative with community itself, as well as other collaborators involved in the work I do. 1.8 Conclusion In response to these gaps in the literature, my thesis explores Métis clients’ experiences accessing family planning services in British Columbia. I aim to answer three research questions: 1. What are Métis clients’ experiences of accessing contraception and abortion services in BC? 2. Have Métis clients encountered racism and stereotypes in accessing these services and what did those experiences involve? 3. What are the characteristics of good access to contraception and abortion care for Métis clients? By answering these questions through a qualitative investigation and a knowledge translation activity in order to generate recommendations that will optimize Métis client’s access to safe models of family planning care. 23 Chapter 2: Experiences of Métis Clients Accessing Family Planning Care in British Columbia: A Qualitative Investigation 2.1 Purpose In this chapter, I introduce the results of my qualitative investigations to understand the experiences of Métis clients accessing family planning care in British Columbia. My research objectives were to: a) Investigate experiences of Métis clients’ of accessing contraception and abortion services and b) Investigate the experiences of Métis clients encountering racism and stereotypes in accessing these services. 2.2 Research Questions 1. What are Métis clients’ experiences of accessing contraception and abortion services? 2. Have Métis clients encountered racism and stereotypes in accessing these services and what did those experiences involve? 24 2.3 Methods 2.3.1 Study Design My study design was guided by three critical frameworks: a Two-Eyed Seeing approach, a distinction-based approach, and Storytelling methodology. I also used flexible constructivist grounded theory techniques to guide my data collection and analysis. My thesis was embedded in a larger study (The Story Project: Improving access to family planning care for Indigenous peoples through storytelling). The Story Project aims to investigate the experiences of Indigenous clients accessing contraception and abortion care in British Columbia. The broader STORY team consists of Indigenous and settler scholars as well as clinicians and community members. The research team for this specific thesis, which focused on a sub-sample of Métis clients, consists of members of the Story Project team: • Principle investigator and my co-supervisor, Dr. Sarah Munro (SM), a settler-ally researcher who is an assistant professor at University of Washing in the Department of Health Systems and Population Health with over 15 years of experience in qualitative research. • Co-Principal Investigator, Miranda Kelly (MK), born of Stó:lō and mixed settler ancestry, is trained as a full-spectrum doula and has over 10 years of health system leadership encompassing Indigenous People’s health planning, policy, education, and research. • Research Manager, Aleyah Williams (AW), a mixed-settler public health research, certified with a Master of Public Health and Project Management experience, uses her 5 years of experience working with Indigenous organizations, and contraception and abortion health service research to implement trauma-informed research practices. 25 • Research Coordinator Bimbola Olure (BO), born in Nigeria is a formally medical doctor who recently graduated from UBC’s Reproductive and Developmental Sciences MSc program. She is formally trained in trauma-informed qualitative practices. • Graduate Student Evelyn George (EG), a Nbissing Anishnaabe/French-Canadian Registered Midwife who is trained in trauma-informed qualitative research practices. • Graduate Student myself, Piper Scott-Fiddler (PSF), born of Métis and mixed settler ancestry who is trained in trauma-informed qualitative research practices. My approach to using Two-Eyed Seeing included embracing two perspectives throughout my research: the western ideologies of family planning care, and the Métis and Indigenous knowledges and histories that encompass traditional family planning care (10). As storytelling is a form of culturally relevant oral data collection, it allows for reciprocal knowledge exchange between the interviewer and the participant. In turn, oral storytelling supports a Two-Eyed Seeing approach to bridging western and Indigenous worldviews (35,36). My distinction-based approach was incorporated heavily in the recruitment process. Data collection consisted of gathering and exchanging stories with Métis participants. Recruitment was conducted specifically with Métis organizations and Métis chartered communities in order to connect with potential participants in a way where Métis participants were introduced to the project through their communities. SM, MK, and I conducted one-on-one interviews with Métis participants over phone and Zoom. The interview questions included probes to explore participants’ insights on access, using language and terms from the “Accessibility Framework for Indigenous Peoples Accessing Indigenous Primary Healthcare Service” adapted by Davy (31). This framework describes features which prompted participants to discuss access in a greater depth. These 26 features included: individual healthcare users’ ability to perceive, reach, pay, seek, and engage in healthcare, and the system’s approachability, acceptability, availability, affordability, and ability to engage with healthcare users (31). To guide the analysis of my interviews, I used principles of constructivist grounded theory. Constructivist grounded theory acknowledges the roles of the storytellers (participants) and the interviewers (researchers) in co-developing knowledge based on the participants perceived experiences and the understanding of the knowledge perceived by the researcher (39,42). It is a flexible approach that can be adapted and integrated with other qualitative methods. Throughout my conduct and analysis of interviews, I was able to be reflexive on my own positionality of being a white-passing Métis woman who has accessed family planning services. Through out this process, I elevated participants autonomy by asking their preference of interview style (remote or in-person) as well as reminded them prior to the interview that cameras were optional in order to reduce power imbalance and anxiety around confidentiality (44). Prior to commencing the interview, I began with a Land Acknowledgment and introduced myself through my ancestry and histories. I followed this practice with inviting the participant to introduce themselves in a similar manner. By sharing histories there is reciprocity in the process, it allowed me to centre myself in community and for the participants and I to share a sense of being together. This allowed for a collaborative co-generation of knowledge between me and the participants. 2.3.2 Setting and Participants For this thesis, women, Two-Spirit, and gender diverse individuals who identified as Métis, were age 18 or older, and who were interested in discussing contraception and abortion care were 27 eligible to participate in an interview and be included for analysis. We excluded individuals who did not reside in British Columbia and those who were not comfortable conducting the interview in English. 2.3.3 Participant Recruitment The recruitment materials were designed under guidance of Dr. Munro, co-principal investigator Danette Jubinville, and the Matriarch and Knowledge Keepers advisory circle (The MACK). Artwork included on the materials was designed by Indigenous artist Ocean Hyland. Recruitment material included a poster, and social media square, and a write-up to send via email. Materials are attached as appendix A, and B. I recruited Métis women, Two-Spirited and gender diverse individuals through multiple streams of engagements. Through chartered community engagements I was invited to talk with community leaders and introduce the community facing interview guide to ensure transparency to community (attached as Appendix C). With their support, I circulated the poster on private community Facebook groups such as Métis Women British Columbia (MWBC), emails to members, and via physical posters circulated in community spaces. This included Chartered communities, the Kelowna Métis Association (KMA) and the Waceya Métis Society. The poster was also published in Métis Nation BC’s “Lii Noovel Métis Citizen Newsletter,” which is circulated to citizens monthly via email. 2.3.4 Eligibility Screening As the majority of the recruitment posters were circulated on secured online platforms or community spaces with vetted members, I had limited risk of recruiting ineligible, fraudulent 28 participants. Nonetheless, our team used a simple screening process to ensure that participants met the basic inclusion criteria for the study. The research manager (AW) would confirm their name, age, and self-identification at Métis via a brief phone or Zoom call. Once we confirmed eligibility, the secondary screening would be conducted by an interviewer (PSF, EG, or SM) during the demographic questions section where we asked participants to confirm their age, self-identification, and geographic region. All eligible participants were invited to schedule an interview after having one week to review the consent form. Any ineligible participants were not invited to schedule an interview. 2.3.5 Sample Size I sought to interview participants using purposeful and theoretical sampling until I reached informational redundancy. In terms of this project, informational redundancy as reaching a state where information is being repetitive to prior data which can sufficiently explain the phenomenon (45). Purposeful and theoretical sampling allowed for the research questions to be adequately answered through participant recruitment that demonstrated a sample with diverse experiences that are encompassed by age, socioeconomic status, identity, and sexuality (45). It was decided by myself and Dr. Sarah Munro that I had reached informational redundancy which meant we were not seeing any new ideas being expressed that could be coded as additional themes. I reached data saturation at the 16th participant (PPID #126) and had sufficient breadth and depth of rich data to explain the phenomenon of access to family planning services among Métis clients in the context of BC. As this was a qualitative investigation, I did not require a sample size or power calculation. Based on literature using similar methodologies, studies suggest that 15-20 participants is adequate to achieve saturation (45). 29 2.3.6 Data Collection My data collection consisted of one-on-one interviews that were 60-90 minutes in length. I completed all interviews by phone or video conference (Zoom). I offered participants an in-person interview option, but all participants preferred one of the remote options. Remote options ensures accessibility for individuals in remote and rural areas from all across British Columbia to participate(44). This also addresses potential power imbalances between the interviewer and the participants (44). Studies have highlighted that remote interviewing provides more privacy as participants can turn their cameras off and allows for participants to be an environment that is considered safe to them (46). This allows for participants to feel safer and share information on sensitive subjects such as contraception and abortion care more comfortably (46). The interview guide was first developed by Dr. Sarah Munro and Danette Jubinville and was then peer reviewed and revised by the MACK to ensure that questions were culturally safe, trauma informed, and addressed topics that were important to Indigenous clients. The guide included open-ended questions with probes to discuss how the participants and their communities interpret their experiences of accessing family planning care in British Columbia, what characteristics of good access to family planning care look like and their experiences with racism and stereotypes in the healthcare system. The guide was designed to allow participants’ stories to set the pace of the interview. The full interview guide is attached as Appendix F. Before the interviews were conducted, participants were asked a series of demographic questions including their age, pronouns, Indigenous identification, nation, or ancestry, if they had status or citizenship, gender, sexual orientation and the first three digits of their postal code. All 30 demographic questions were optional, and participants were encouraged to opt out of questions if preferred. All interviews with participants were recorded (audio only) and after the completion of each interview, they were downloaded to Dr. Munro’s SharePoint Drive under their participant identification number. During the interviews and afterwards, I wrote memos of any themes and thoughts that would come to mind, which was important for my analytical process, for data saturation, and developing initial themes and relationships. Data were collected from July 7th, 2023, to November 21st, 2023. All audio files were transcribed by Advanis transcription service. 2.3.7 Data Analysis While my analysis was iterative and began during data collection, I conducted my coding after all interviews had been transcribed. I coded all transcripts in collaboration with a research coordinator (BO), who is a recent Master of Science graduate trained in qualitative methodology. The analysis of transcripts followed the principles of constructivist grounded theory (39). We began with an inductive analysis, in which we read the same sub-set of transcripts from the interviews in duplicate and began to conduct open coding to identify themes to create an initial codebook. From there, we discussed our separate findings and created a second, refined codebook to guide focused coding. At this stage we used in NVivo (ver. 12) to conduct focused coding. Using the software allowed us to create additional codes to explain the phenomenon, which resulted in more defined categories of codes with subcodes. We met regularly to discuss 31 our interpretations and shared our codebooks (Attached as Appendix D and E) and coded transcripts with Dr. Munro, who provided detailed feedback, suggestions, and questions. To ensure participatory interpretation, each participant who consented on receiving their interview transcript was emailed over their password protected transcript. This is for the purpose of member-checking, a reflexive process that allows participants to review their story where they can edit, remove, and add to the document. Each participant was emailed the same prompts: 1. How accurately does the transcript capture your thoughts and experiences? 2. Is there anything else that could be added to the transcript to capture your experiences better? 3. If there is anything you would like removed, what would that be and why? This was meant to be a 10-minute activity to generate trustworthiness of the codebook generated. The email script is attached as Appendix G. 2.3.8 Rigor and Trustworthiness I used multiple strategies in order to ensure rigor and trustworthiness. This included memo writing, which allowed me to track emerging themes from each participant’s interview and form comparisons among participants. I shared several of these memos by email with Dr. Munro for suggestions of how to refine my analysis, and with fellow Indigenous graduate student EG for peer feedback. Based on initial coding, myself, NPA Munro, and BO went through multiple stages of revisions and reflection to conclude a final codebook. 32 2.3.9 Protection of Human Participants Ethics and Consent Under the Story Project, our team received ethics approval from University of British Columbia’s Behavioural Research Ethics Board in order to conduct this study (Ethics #H21-01171). All prospective individuals who were interested in participating contacted the research manager (AW) to be introduced to the interviewers (PSF, MK, SM), and team involved, given a consent form to review, an interview guide, welcomed to ask questions and via email confirm that they met the study requirements. Between the initial contact and the scheduled interview, prospective participants were given at least one week in order to consider if they would like to continue and provide written consent. Participants who wanted to continue but were unable to provider written consent were given the opportunity to provide consent verbally with the interviewer after going over the consent form. This option was given in order to make the study more accessible to participants who were unable to sign the form electronically or print the consent form and email over a picture. All participants were encouraged to ask questions about the study and their participation prior to the interview commencing. Participants were also reminded that their participation was voluntary, and they could stop the interview at any point of the interview and withdraw from the study. Privacy and Data Protection Any digital files with identifiable information were stored on Dr. Munro’s SharePoint Drive which is maintained on a University of British Columbia server. All files were stored in password protected folders as well as the files themselves were password protected when possible. 33 All recruitment materials used (posters, social media posts, and write-ups) were approved under ethics (H21-01171). All participants were given a numeric identifier (e.g. Participant 135 or P135) and stored in a password protected excel spreadsheet with personal information. Outside of this document, all participants are referred by their participant IDs. Any participants who reached out to me initially were connected to the research manager (AW) via email to ensure the potential participants could receive all information about the study, the consent form and have time to consider if they would like to continue before having an interview scheduled. Compensation At the completion of the interview, participants were provided with a $100 electronic transfer to compensate for their time and a gift sent to their homes in plain packaging (valued at $25) that contained tobacco ties, medicinal teas, and salves produced by Indigenous makers in order to give thanks and appreciation. All honoraria and gifts were sent by the research manager (AW). Trauma-informed reflection and practices. Through my process of data collection and analyses I think there is a lot of actions through my interview and recruitment style where I have been focusing on my relationality to the work and with the people. I incorporated a reflection process after each interview where I reflect on my "self-critical consciousness and understanding of our position, interaction, socialization, and values" that storytelling creates (47). I began journaling to reflect on interviews where at the beginning I restricted myself as a researcher. My journey of interviewing Métis clients was an uplifting and celebratory experience for the participants who have talked about how the interview empowered them, but it also brought me to a space where I connected more to my culture as well as a family member who I have never met. This experience brought me closer to 34 my father and a side of my family I never thought I would meet. It was at this moment that I could really feel the line between the participants and myself soften. I grounded myself and the interview space using decolonial practices. This entailed connecting ourselves with the land through acknowledging where we were and discussed our families and histories. This allowed us to share a common connection grounded in ‘ways of visiting’ with each other. This elevated the experience of sharing stories as the “meaning that visiting, both with the land and with relatives, was also a method of survival, of dialogue and deliberation, of decision-making, of responsibility, of celebration, and of sharing and caring for our relatives”(30). This brings us back to our traditions, it’s a blood memory. 2.4 Results I interviewed 16 Métis clients of care for this study. Participants ranged in age from 20 to 69 years. Six participants each resided within the Fraser Health Authority and Interior Health Authority catchments, three participants lived within the Northern Health Authority catchment, and one participant lived in the Vancouver Island Health Authority. Fourteen participants used “she/her” pronouns and two participants used “she/they or they/them” pronouns. Twelve participants identified as heterosexual, two participants identified as bisexual, one participant identified as pansexual, and one participant identified as lesbian. Most participants self-identified as Métis (n=14) whereas two participants self-identified as Métis and First Nation. Thirteen participants had Métis citizenship from Métis Nation British Columbia, one participant had First Nation status, and two participants did not have citizenship or status. Interviews ranged from 30 minutes to 90 minutes with the average interview length being around 60 minutes. All interviews 35 were conducted via the Zoom application. One potential participant was excluded from the interview as they did not meet the eligibility criteria, one participants withdrew after reviewing the consent form and scope of the study, and three potential participants were lost in follow-up. 2.4.1 Qualitative Analysis and Key Themes Summary of themes My analysis of qualitative interviews resulted in five inductive themes, all united under the overarching theme of "Feeling lost in a system that does not value relational care”. This can be described using this participants’ dream of what their family planning care experience would look like. “I think, in the ideal world, it would be something, it would be somebody that, well, went through that process with you, whether that’s just supporting or guiding you through what options there were and then providing that follow-up.” (PPID 125) All key themes and subthemes can be found below in Table 2.1. 36 Table 2.1 Summary of key themes and subthemes 1 Searching for a consistent healthcare provider: “I’ve never gone to the same doctor twice” • There is limited availability of family practitioners. • Relationality with a consistent provider builds better connections. • Pharmacists have become a consistent healthcare provider. • “There was absolutely no follow-up" • Feeling “more like a number than a human being” • Experiencing reproductive coercion 2 Feeling isolated in family planning care due to legacies of trauma • Worrying about confidentiality 3 Prioritizing care despite the costs 4 Jumping through hoops to find information 5 Needing Métis-specific family planning services • Wanting more culturally relevant options • Looking towards Indigenous services (FNHA) for infrastructure examples • Dreaming of safe and welcoming healthcare spaces 2.4.2: Searching for a consistent healthcare provider: “I’ve never gone to the same doctor twice” Within this theme, I describe six sub-themes: 1) There is limited availability of family practitioners. 2) Relationality with a consistent provider builds better connections. 3) Pharmacists have become a consistent healthcare provider. 4) “There was absolutely no follow-up" 5) Feeling “more like a number than a human being” 6) Experiencing reproductive coercion 37 My first sub-theme describes the participants’ experiences in their struggles trying to find a consistent healthcare provider and as a result it has impacted their accessibility to family planning services. I will discuss how the lack of a consistent healthcare provider affects participants through various costs. My second sub-theme describes the importance of building relationships between the client and a consistent healthcare provider. I will discuss how the participants feel this phenomenon would improve their accessibility to family planning services. My third sub-theme describes a shift in participants relying on pharmacists rather than the traditional practitioner route in light of the new British Columbia policy. I will discuss how this policy has increased accessibility and participants comfortability in accessing family planning services. My fourth sub-theme is exemplified by the experience of a participant who did receive follow-up care after having a procedural abortion. In responding to interview questions regarding follow-up care after an abortion, many participants described that they received none or a minimal amount. For participants who had not had an abortion, many did not know of any follow-up care offered. Many participants voiced that without follow-up care they were lost and felt that their emotional hardship would have lessened with proper follow-up care. My fifth sub-theme describes participants’ experiences in the British Columbia healthcare system where participants felt forgotten, mistreated, and judged. 38 My sixth sub-theme describes participants’ experiences accessing contraception and abortion care. Reproductive coercion is the interference of an individual’s right to choose how, when and if they want to be pregnant. I discuss participants’ experiences of various instances of reproductive coercion and the effects of reproductive choice being taken away from them by individual actors and by the medical system. There is limited availability of family practitioners. Many participants highlighted the lack of accessible family doctors in their area which has resulted in participants accessing family planning services through various clinics, virtual care, or traveling longer distances to access care. Participants describe having a family doctor in terms of being secure. The lack of having a consistent provider makes them feel invisible and anxious, as they do not know where they are going to access care in the future. “I would say finding a provider because I always, like I said, I bounced around to wherever I could go, so because I couldn’t go back to the same person, it was just really tricky, because like I said, I like to be able to go online and book an appointment and work it into my schedule. I always try to plan ahead, but always, it would end up being a few days out or for my [contraception prescription] package being at the end of it, right? Then even after you get the prescription from a doctor, then they have to send it. Then it could take up to 48 hours or whatever for it to be ready for pickup, so I definitely remember being stressed out several times that I had cut it down to the line and couldn’t find a doctor, couldn’t get a prescription, couldn’t make it to an appointment, whatever. It was definitely a huge source of stress for quite a few years.” (PPID 113) “Yeah. I’ve actually thought about this a lot more lately because my husband and I are thinking about getting pregnant, so I’m trying to plan ahead. Now it’s like the reverse problem, you know? I’m realizing that we don’t have a family doctor. There’s no consistent people we can talk to. We’re not prioritized because we’re young and healthy, so yeah, it definitely makes me feel, I’m very frustrated by it, but also, I’m somebody who I feel really 39 nervous around doctors, typically. I’ve had a few kind of weird experiences where I just felt very uncomfortable.” (PPID 113) One participant highlights the fluctuation of doctors in her area which has resulted in access to family planning services being inconsistently available. Being unsure of the availability of certain services results in a gap of information that reduces accessibility. “I think it [abortion referral pathways] could look that way. I don’t know necessarily through the sexual health clinic, but there are two nurse practitioners on staff, so I imagine that they would be able to make that referral, if needed. I don’t know if they provide those services in Prince Rupert. I know a friend, she had gone for a—what’s it called?—a D&C at some point, and she was required to go to Terrace, which is an hour-and-a-half drive from Prince Rupert. I don’t know if that procedure is sometimes offered here. Sometimes they are. Certain services sometimes are, sometimes aren’t just based on the doctors that are in town or travelling in town. I’m not sure exactly, but I think another route could be, obviously, if someone has a family doctor here, but I’ve heard that about 40 percent of people in Prince Rupert don’t have a family doctor. I think, too, one of the services available through Northern Health, like, a lot of people access different virtual clinics, and Northern Health has a virtual clinic. There are some other private ones as well that are covered by MSP, so I imagine it would be a matter of getting a referral that way.” (PPID 109) A few participants hesitated to disclose that they had a family doctor because they acknowledged how difficult it was to obtain one. One participant in particular even relaxed after disclosing when I acknowledged I had a family practitioner. “Yeah, I know. Yeah, I don’t shout it too loud.” (PPID 124) “I'm lucky to have a family doctor.” (PPID 111) 40 Relationality with a consistent provider builds better connections. Building relationships with a provider was highlighted by participants as a vital piece in making their family planning care experiences comfortable and easy. Participants described reasons why relationality creates consistent services and how they can feel more accessible. Although this participant is at a different phase of family planning care where she is looking to get pregnant, this participant highlights the history she has with her practitioner which the participant describes as “everything.” This consistency allows for the participant to receive more personalized care as she trusts her practitioner’s medical knowledge in her body. “Well, it’s everything. Like, she knows my body not just right now but what’s happened in the past, before my pregnancy, after my pregnancy. Let’s say we’re trying to have another. She is part of the family planning, with the medical perspective.” (PPID 124) Another participant describes yearning for a doctor with whom they can build a lifetime relationship. The participant describes the reluctance they feel when accessing care from a specific provider in their local walk-in clinic. Although the participant has seen this provider consistently, becoming a permanent client is not an option which makes her feel uncomfortable to discuss reproductive health concerns. “I feel like, well, he’s not willing to take me on as a family doctor, so I don’t even wanna go to him for things like my changing period. It would be nice to have someone a little bit I feel more of a connection with or a relationship.” (PPID 126) 41 Pharmacists have become a consistent healthcare provider. A few participants described leaning on their local pharmacy to access contraception care, this concept is described by participants describing their relationships with their local pharmacists. Many of the participants do not have access to a regular healthcare practitioner so, they illustrate the importance of their pharmacists as a healthcare provider for their family planning care needs. “Um, I think, for myself, I would probably go to my pharmacist because, at this point, he is the person that I think knows the most about my medical needs. He takes a lot of time to understand what my needs are and talks about lots of different options, and it always is from a very safe, non-judgmental place.” (PPID 125) Some participants described their appreciation of pharmacists being able to provide prescriptions for contraception as this allows for better accessibility to contraception care. “I’m thankful that kind of thing is available easily at the pharmacy now.” (PPID 126) “Well, nowadays, you can go to pretty much any pharmacy, or you can go to pretty much any clinic here in Abbotsford and receive birth control. I think that’s a huge step in and, again, allowing our young people to make decisions for themselves and to have that protection, if they so choose to, above and beyond the normal, “Let’s go and buy a prophylactic,” right? Again, it’s not just for women to have these, because I don’t believe it’s just the women’s, it should be just a woman’s decision to be contraceptive or have contraceptive.” (PPID 123) 42 “There was absolutely no follow-up" One participant describes their experience in accessing a medication abortion at a hospital. In addition to the trauma suffered from their sexual assault, the abortion was a difficult experience to undergo without any check-up. “Actually, I had to do it at the Kamloops hospital. I was sexually assaulted. I mean, you’d go up there, and it was just like, ‘Go home. Take the two pills,’ but I don’t know. I just felt like there was no checkup afterwards. I get that it was just like taking the two pills, and it should just be easy, but I mean, it was just everything surrounding that was pretty traumatic in and of itself, and then just not having, yeah, not having anybody kind of checkup to see how you’re doing afterwards is really hard.” (PPID 119) Another participant who had an ectopic pregnancy while using an IUD describes the lack of follow-up care required resulted in a traumatic experience with unanswered questions, and the feeling of being alone through out the process. “It was terrible. There was absolutely no follow-up care, except for blood tests that they did afterward. There was no kind of psychological support. There was not even any support in terms of family planning afterwards or anything. I had to research myself that losing one fallopian tube doesn’t necessarily decrease your chances of getting pregnant by too much, but I had to find that out for myself through Google. There was no follow-up. I was very traumatized laying on the floor, thinking I was going to die, and then having the surgery happen and really like, ‘You’re on your own’ sort of thing. I would have really appreciated some follow-up. In fact, I still would appreciate follow-up. The second time where it was such a traumatic experience physically, emotionally, yeah, I would have really appreciated some good follow-up even by any healthcare professional would have been really appreciated.” (PPID 105) 43 One participant reflects upon the experiences of follow-up care she has received through out different healthcare procedures but how after receiving an abortion, she did not receive any follow-up care. “No, I have never received follow-up care at all. I have received home care and follow-up care for every other procedure that I've ever had, except for that, actually.” (PPID 122) Many participants describe either not knowing of any supports or not receiving any support in little words as there wasn’t much to say about a service that did not exist for them. “There is none. There's no support groups. There is no community spaces to talk about it, nothing.” (PPID 111) “No. No.” (PPID 117) “I don’t know of anything like that” (PPID 126) Feeling “more like a number than a human being” Participants described their experiences of health care providers allowing their own biases to affect the care of clients. This demonstrates instances of stigma that translated into mistreatment and feeling judged by the provider resulting in feeling unsafe throughout the experience. “After that, after I had been out of that home and in a safe space where I could make my own decision, I went for the abortion. It was, the guy who got me pregnant came, brought me to the hospital, and he was sitting in the waiting room. The nurse that was attending went and said, ‘Are you here with anybody?’ I said, ‘Yes,’ and she said, ‘Is it the father?’ I said, ‘Yes,’ and it was like, ‘Why are you asking me?’ She left the room, got him, forced him to come in. I didn’t want him there. I did not know him well enough. He was my best friend’s 44 cousin, so he wasn’t, I didn’t want him in there. I was in this vulnerable position. He didn’t want to be in there. That nurse made him, and she said, ‘You’re gonna watch this.’ I was screaming because it hurt, and it was incredibly, um, it felt shameful and embarrassing” (PPID 117) Another participant discusses the option of an abortion being taken away from them due to the fact that their pregnancy diagnosis was missed by their local hospital two months prior making an abortion inaccessible to them due to their gestation time and location. “No, I was 18 and one day when I went into my doctor’s office. I had been in the hospital two months prior for about a week’s stint, and they were treating me for stomach ulcers. One day after my 18th birthday, I went into the doctor’s office because I thought I had a lump in my intestines. Clearly, I wasn’t paying attention in science class. I said this to my doctor, and he looked at me and said, ‘Oh shit, you’re pregnant.’ I just started freaking out at that point. ‘I’m 18.’ I’m like, ‘No, this can’t be.’ He got me to do a urine sample. He came back and said, ‘Yes, you’re pregnant.’ I burst out crying, super emotional. He shared with me at that time that because of the information I had given him, it seemed that I was probably about four months pregnant and that abortion was not an option.” (PPID 125) One participant recounted their past abortion history being used against them at a time when they were trying to conceive. The participant felt the need to explain that their current pregnancy was wanted, because the provider decided to make assumptions and proactively refused abortion services if needed. “One time, out of those three times, the first three times, I was living in Fort St. John, and I was pregnant. This was when I had my son, actually, when I was 24. I went to the doctor, and she must have looked at my chart or something. I went for a pregnancy test, and it came back positive. The first thing she said to me was, ‘Don’t ask me for abortion because I don’t give one,’ and I was like, ‘Actually, I wasn’t. I’ve been trying. If you notice, I’ve had two miscarriages, but thanks anyways.’ That was the only time that I was accosted like that, I guess, from a doctor or a healthcare professional at all.” (PPID 122) 45 One participant concluded the discussion of their lifetime experiences accessing family planning services in their local clinic with this final line as they described how they could only use the word “icky” to illustrate the atmosphere of the clinic and the treatment from their healthcare provider as they feel rushed through the doors and cannot bring up more than one health concerns due to the appointment being so short. “It just feels so, I don’t know. The only word I can think of is icky. Yeah, it’s not warm. It’s not inviting. It’s just sort of another, I don’t know. You feel more like a number than a human being. I guess that sort of encapsulates it.” (PPID 125 ) Experiencing reproductive coercion Participants described their experiences with reproductive coercion caused by health providers’ biases in their treatment. “I was a foster kid, and it [birth control] was kind of forced upon me by my doctor. I understood this doctor just by subtle comments, like microaggressions, that she didn’t think very highly of Indigenous people. As a girl then, a young girl trying to understand sex, she didn’t give me a great deal of information.” (PPID 104) Other participants experienced reproductive coercion by being forced to carry their pregnancy to term. This coercion was related to pressure by their surrounding support systems due to religious and cultural beliefs. Participants were denied access to abortion services by their families, partners, and healthcare provider. “I did not want to keep—my son doesn’t know that—I didn’t want to keep my son. My mom knew that, and she denied me getting any help with it. She worked in the medical field. She was a nurse. My dad was on his way to becoming a doctor. I had all of this over here that 46 was denying my rights that I wanted. I had no safe space, so I would like to advocate for that safe space for people.” (PPID 117) When this participant was asked about any pressures to keep a pregnancy, they disclosed their physician would not support their access to an abortion based on their partner’s desire to keep the baby. This was an unintended pregnancy, the participant previously discussed having a child with autism before this event and was not planning on another child as they did not have capacity. “It was a very abusive relationship, so I went to the doctor to see if I was pregnant, and I was. My partner was with me, so I had asked what my options would be for abortion then. Essentially, the doctor told me that … because my partner didn’t want me to have an abortion, therefore he wouldn’t support me in getting the abortion. My doctor wouldn’t, just because of the situation that I was in. I couldn’t really go up to the hospital and get it done anyways, so it was, yeah. I had a kid with him.” (PPID 119) As a result, the participant was forced to give birth and made the decision to give up their child. This was their “only option” in order to sever all ties with the abusive partner. “I mean, my decision seven months before that was that I wanted to abort, and that option was not given to me, so my only option at the end of the day when we went into the hospital was basically signing over all of my rights to her and to him and his family.” (PPID 119) 2.4.3: Feeling shame in family planning care due to legacies of trauma In addition to the health system barriers participants experienced, they also encountered internal and external stigma related to accessing contraception and abortion services, due to legacies of trauma from colonialism. 47 This led participants to feel isolated in their family planning experiences. One participant described their communities’ beliefs in terms of family planning care, although they don’t talk about contraception, it seems to be accepted enough as it has become more normalized over the years, but she defined that the community had a strict belief that abortions were unacceptable. “Yeah, birth control good to go. Abortions, no don’t do it” (PPID 124). Two forms of stigma exemplify participants’ experiences within this theme: internalized stigma and community stigma. When participants were asked about their use of contraception care and abortion, most participants reflected upon experiences that were decades old that varied from their teens to early twenties. Participants spoke of their internalized stigma through terms like “shame”, “humiliation”, “weird”, and “uncomfortable.” Some participants expressed internalized stigma through emotions. “And I wasn’t sexually active till I was 17 anyway, so even going on birth control at a younger age for period issues but still feeling shameful, I wasn’t using it for other purposes.” (PPID 116) “I didn’t really tell a lot of people about the abortion because, again, stigma, and you don’t go around telling people because that’s weird, but yeah.” (PPID 119) One participant described a traumatic experience of accessing abortion care as someone who was raised in a fundamentalist church household. Not only did they have internalized feelings from their upbringing but also, they had feelings of shame and humiliation from negative interactions 48 with the health care system when accessing the abortion. Although the abortion was 30 years prior, the same feelings came up again in the course of their interview. “I mean, I’m still crying about it this many years later, which is 30 years later. It’s still raw for me. I still feel that shame and that humiliation. Just it gave me a lot of negative feelings about myself and just about interactions with people and added to the trauma that I’d already gone through, and it’s just there’s so much there that it’s, like, if your cup is full and you’ve got more stuffing dumped in, it’s like you can’t deal with all of those things, so it’s just one more unnecessary thing to have to deal with in this big glass of trauma, right? It’s like even just picking it out, I don’t know how to do that, so the emotional cost was massive.” (PPID 117) When participants were asked about resistance to abortion and contraception in their communities, they described various instances of anti-abortion actions. “I can say, within the community, it is looked down on, abortion. Contraception is still kind of iffy. Abortion, certainly because of religious – I’m not trying to be insulting towards religious people. I get that they have beliefs. I am not because of the trauma that I went through and the trauma that my father went through, but it [abortion] is definitely shameful, horrible, “you don’t do it” thing, and it is definitely because of religion.” (PPID 117) “Well, there’s still, there’s a giant stigma, and I live in a small community, still. That’s, it’s just not, it’s still not, and I know, ugh, it’s still not what we do. You’re not supposed to have an abortion.” (PPID 124) One participant describes the harsh reality of community trying to control a woman’s choice through advertisements on the Highway of Tears. The advertisement reflects the continuum of colonialism that continues to impact Indigenous women and gender diverse individuals in our communities. The participant described the advertising as a “power imbalance.” “Yeah, so the biggest thing that's kind of like a slap in the face is driving along our highway and there's several anti-abortion signs. One of them doesn't even make sense. I recently saw an anti-abortion one, and it was like, ‘Men, you have to protect the baby and the mother.’ I was thinking about that. Well, it's also sitting across from the ‘Keep Highway 16 safe,’ 49 Highway of Tears side, and I'm like, what is the power balance there? Right? Telling men that they need to step up takes so much autonomy away from women and women knowing what they need in their body. Then as well, there's several anti-abortion protests along our highways and in our communities. It's actually really disheartening because there's many people who would do it. There's Fundamentalist Christian groups that will schedule days where they will all kind of gather along the sides of our highway and protest abortions, so I don't know. I just often think about that power imbalance of having that while living along the Highway of Tears.” (PPID 111) A few participants describe the intersectionality of having their “big Métis families” involved in their family planning decisions, and the impact it does or would have on the quality of their access to family planning care. This participant is describing how to have culturally safe care, healthcare providers need to acknowledge the importance of involving family and community within family planning care as it is a ‘big family discussion’. “Um, it [bringing culture into family planning care] is important to me. It is important to me. You know, I want the elders to respect my choices, so that is important. It is important for my parents to be involved sometimes, unfortunately, in those decisions, but it is important to have those traditions. I want it all to be like a family thing when either we’re looking to adopt or not looking to have a child right now. I just, I love that whole family involvement thing, so I think to be culturally safe is, yeah, I love that it’s a big family discussion.” (PPID 124) Another participant echoes the above participants feelings through discussing how they live in an area where many of her community members live with local First Nation communities on their reserves. She describes through her community members that she understands that the importance of family connection in health care is discussed through various Indigenous cultures and defines is an encompassing piece of ‘Indigeneity’. 50 “I think if physicians and healthcare providers are understanding that, that that’s what Indigeneity is about is making sure that the family connection is understood and that we can rely on, um, that they will rely on their family members to support them through anything, whether it’s just through family planning or it’s through abortions or whatever entails in all that process. I think the physicians, nurses and physicians need to understand that, that there is a cultural connection, a family connection that’s maybe a bit tighter than they’re used to experiencing, with Indigenous people.” (PPID 114) Finally, one participant discusses the need to go back to the “traditional understandings of what that family unit meant”. This further describes the importance of family, community and traditional knowledge in order to learn and receive family planning care. “I actually think that we as Métis people or we as a Métis nation, I think we need to go back to that grounding of family and do some teaching around what is family, what is the understanding of family, why do we create new beings, what is the purpose of new beings because we didn’t, I guess if we go back, and it was sort of what I’ve been taught a little bit from my knowledge-sharers is that, yes, we added to community, but we only added to community when we needed to add to community, right, because if you had too much people in community, there wasn’t enough food. There wasn’t enough shelter. There wasn’t enough anything, so I guess going back and looking at those traditional understandings of what that family unit meant and what piece of community was that family because I think, for Indigenous people, we’ve got away from that real concept of what kinship is. We call each other relatives. We call each other family, but we’re not looking after each other, and there’s a difference between all of that. I think we’ve really got away from that kinship, so understanding what that is for Indigenous people and understanding how beautiful to bring a child into a world where we as, I guess, in the settler world or whatever, we say it takes a village. Absolutely, we need to get back to that village raising, not individual parent raising because that’s not the way we were designed as people. We wonder why our children sometimes are—and this is my own person-, my own—we wonder why sometimes our children are flawed. I think it’s because we haven’t really gone back to that full circle moment yet of kinship.” (PPID 123) To further deepen the understanding of the phenomenon, one sub-theme is used to describe an additional perspective related to the overall theme: 51 1) Worrying about confidentiality Worrying about confidentiality Throughout the interviews, participants’ stories emphasized how privacy and confidentiality impacts their experiences in accessing contraception and abortion care at different life stages. One participant’s story centered on their discomfort in accessing family planning services in their small town when they were younger. In the local public health unit, the participant had to interact with a nurse who was the parent of one of her peers at school. Although she understood that the nurse was held to confidentiality standards, a question was in the back of her mind: “Are they gonna talk about me at the dinner table?” (PPID 125) Many participants hesitated to access family planning care at a particular healthcare space because the physical environment did not ensure others would not see and hear them. This resulted in participants avoiding specific services, traveling to a neighboring community to access care, and one participant verbalizing that they would go to a private service if they needed an abortion in order reduce the risks to their privacy and confidentiality. “My goodness. I don’t know. Unfortunately and, oh, I hate to say this, but if there was a private service, because I would hate to go through the public right now.” (PPID 124) This participant shared a sexual assault experience where they “denied themselves” access to care as their local healthcare spaces are not safe, and they were not confident that their privacy and confidentiality would be maintained in their small community. 52 “There's been times where I've went to a neighbouring community where they've got self-checkout or it’s on a shelf where I don't have to be like, ‘Hey, everybody. This is what I'm buying just so you all know,’ right? It's just not, it's not safe to access that, so I think that that's really another layer there. I think within that, even say that they do put it on the shelf, well, you still have to go pay at the counter where people buy children's toys or whatever, right? They're not upheld to the same level of confidentiality as the actual pharmacist is……. One of the things that I had a lot of anxiety about after was like, ‘I should probably go get the morning-after pill and go follow up with a practitioner’ because I didn't know what happened, but I didn't do that because there was so much shame around those other folks hearing, ‘This is what happened to me. This is what I need,’ because the community members in that room will definitely go out and say, ‘Guess what I heard?’ Right? It was never a safe space, so I denied myself access to that and access to a rape kit because of not having that safe space. I think the first thing that we really need to do that's foundational here is creating those safe spaces where there's a little bit more confidentiality.” (PPID 111) Another participant discusses the change in processes of their local health unit since Covid-19 where clients seeking care have to wait outside which impacts client’s capacity of discreteness. “Now that door is actually locked, so you have to knock, and you have to sit outside of that area some more in the communal hospital space. Well, you have to sit and wait. Somebody comes to the door and asks your name. Then you sit outside, and then you go in, so if you were even trying to be discreet about getting birth control, like the condoms—I think they have lube there, too; I don’t know exactly—you would have to say, ‘I’m here because I want to pick up some free condoms.’ I think that’s a huge barrier to accessing that type of birth control in our community right now.” (PPID 125) In addition, this participant described how their personal experience in working and accessing the Depo Provera shot at the local needle exchange was a positive experience due to private location and her trust and knowledge of the staff, which provided a sense of confidentiality. When asked about an example of a safe place to access family planning care, the participant re-introduced the “needle exchange” as their staff are kind, maintain privacy, and provide good care. 53 “At this point, I would probably say our needle exchange downtown again just because I have worked with the staff there before. I haven't for years, but I do feel that that location is the most accepting of everybody no matter what services they're asking for. I also think that they have a no-questions-asked policy.” (PPID 122) This resulted in her referring her social work clientele to the facility in order to access family planning services. “So I would tell my clients to go to the needle exchange if they wanted more privacy because it's such a low barrier and nobody's going to see you there or talk about it,” (PPID 122) In addition to the space lacking privacy, a participant discussed the lack of options in healthcare providers in a small community of 8,000 people which resulted in switching to a different pharmacy. “Again, because we live in a small town, and not only did I know the pharmacist, but I knew a lot of the people that worked behind as a pharmacy tech, right, so one of them at the time was my mom’s cousin’s daughter. I chose even not to go to that pharmacy for my regular medication because I didn’t want this person to know what I was taking.” (PPID 125) 2.4.4: Prioritizing care despite the costs This theme was evidenced by a participant reflecting on prioritizing birth control even when they could not afford it, resulting in having to take a loan from a family member and paying them back in monthly instalments: “The IUD cost $300. I asked my brother for the money because, at the time, I wasn’t working, and there’s no way that I would have been able to afford it otherwise.” (PPID 119) This participant felt especially appreciative that they had a family member who could loan them the money as the upfront costs of an IUD was a barrier. This concept is described by participants’ recollections in their struggles to afford contraception and 54 their behaviour in avoiding their ideal methods because of the cost. Multiple participants observed that contraception was prohibitively expensive before British Columbia implemented their contraception coverage program. For instance, one participant described their experience in struggling to afford the upfront costs of an IUD because the monthly cost of birth control pills was not an option due to side effects. “Yeah, so it was really difficult to afford birth control because I wasn’t able to handle birth control pills. I had severe side effects with it, so the only option for us were IUD. At first, we start, we use copper IUD, but because my periods were so heavy, it was I ended up extremely anaemic, so I had to have that removed.” (PPID 105) Unfortunately, the participant had to have their method removed, but referenced the IUD at a later point in the interview describing how she only chose the copper IUD based on its lower price relative to the hormonal IUD, not because it was the best method for her. “That’s why I started on, initially, my very first birth control was the copper IUD because it was an economic thing. It was the cheapest option for the IUDs,” (PPID 105) Many participants described the cost of contraception being “expensive” and that, while they couldn’t afford it, they would accept the cost because avoiding pregnancy was a priority. “It was expensive because it wasn’t covered under health care, or I might have gotten it covered but had to pay $300 out of pocket and then submit the receipt to get the money or not.” (PPID 116) “I have benefits, and it still cost, benefits don’t cover an IUD. That cost me $300. I mean, $300 is cheaper than having a kid, but also, that’s a lot of money to come out of my pocket right now.” (PPID 119) 55 “so I was paying for all of my prescriptions—birth control being one of them—out of pocket at full expense. It wasn’t that I didn’t, I’ve made it a priority because it was a priority to me, but we had no money.” (PPID 125) “I think, generally, when I’ve had long-term partners, they’ve been very supportive, like my partner now and my previous partner, yeah, just supporting in the way they can. I think part of that has been financial, too, around the costs of contraception because being on the pill, I mean, is quite expensive when you don’t have coverage for it. Yeah, I’ve had them offer to cover partial costs of contraception in the past, and that’s been really helpful.” (PPID 109) Another participant reflects deeper on their lifetime costs to “protect yourself” from unplanned pregnancy. In the interview she sat with this thought for a few seconds and took a deep breath, seemingly stunned, in reflecting on that lifetime cost. “Everything, we could get locally, but yeah, an IUD, those types of costs for it, you know, that is $500. Then there’s the monthly cost of prescription. I think it was, like, $40. You know, you think about that since you’re 16 to, actually, I don’t have the brain power right now to do the math, but it’s a lot that you’re spending to protect yourselves or to help you in your family planning.” (PPID 124) In addition, the term “cost” can be described as out of pocked costs such as travel. This theme goes beyond the monetary impact and describes the emotional and physical impact participants endured. One participant describes the inaccessibility of family planning services based on locality, as described by one participant: “The women’s clinic is very, very far away from me. I think it would be three buses away, so that’s not very accessible.” (PPID 105) Participants describe their experiences of depending on others for rides. The distance to services has a huge impact as cost for transportation such a cab or transit would be too much based on the distance, the time off from work to access the service, and the emotional cost of coordinating travel. Many participants described living in rural areas where, in order to access a clinic-based procedure 56 such as an IUD placement or a procedural abortion, they depended on a second person to get them to and from the service provider. Although contraception services are available, participants may or may not be able to take on the financial burden of travel. For instance, one participant relayed that public transit was not an option as it would take too much time. After her planned ride fell through, the distance necessitated that she take an expensive Uber to and from the IUD procedure, a cost she was not expecting. “As for the service, it was, I believe she [the clinician] was located close, well, over an hour from where I lived. Originally, my partner had decided that he would drive me just because we had heard, afterwards, there could be cramping or discomfort, so he had offered to drive, but then the morning of, he got pulled into work and wasn’t able to. I did have to take an Uber, I think, there. I just didn’t have time to get there on public transit, so it was quite expensive because I think the drive, it was over an hour there and over an hour back.” (PPID 109) Another participant describes that they would have not been able to access an abortion without the driver (person who got them pregnant) due to lack of financial resources. But this necessity came at an emotional cost as the participant’s experience was worsened with the individual being forced into the room during the participants’ abortion. This reduced the participants’ comfort and safety. “there was travel, and again, if I didn’t have to have that ride, that experience would have never happened. That guy came in with me and made the situation worse, because I could have had a cab or something, but unfortunately, I didn’t have the financial resources to do that.” (PPID 117) 57 Although this participant is from an urban city centre, they describe their struggle to access contraception care. They have to travel via bus to access walk-in clinics, however if the walk-in clinic is full, they take another bus to a different location. This experience illustrates the relationship between inaccessibility of care based of lack of providers and lack of centrally located services. It highlights that the time required to access the service can be just as lengthy and impactful as that for participants in more rural areas. “Then you think about if you have to go to a walk-in clinic, you have to take time off work, so sometimes I’ve missed a whole day of work waiting all day in a walk-in clinic just to see the doctor just to get the prescription for the IUD and then having to take off another day of work to try to find someone to do the insertion, so that’s two full days missed of work. Sometimes you’re waiting in the walk-in clinic all day, and they’ll say, ‘Sorry. We’re at capacity.’ Then you have to – then you’ve missed the whole day of work, and you still don’t have a prescription, so I’ve had that as well. I don’t have a car, so I bus. That takes quite a long time, especially if the walk-in clinic is far away. There’s a lot of costs involved.” (PPID 105) 2.4.5: Jumping through hoops to find information Participants struggled to access information on contraception and abortion services, and their experiences suggested there is an overall lack of accessible and pertinent information. When asked if they knew someone safe and knowledgeable who they could ask about accessing family planning services, one participant reflected: “It just seems like you have to jump through a bit of hoops to find the answers that you need.” (PPID 115) The participant goes on to describe how they not only did not have someone like that in their lives but also there are broad challenges in accessing family planning services. They describe how the lack of information and lack of appropriate services are rooted in anti-Indigenous racism: 58 “Yeah, I think it’s just the lack of information. Like, we don’t know where to go. We don’t know what’s out there. Then sort of the worry that you’re going to be treated poorly or kind of brushed off, I feel like a little bit that’s a female concern because, oftentimes, pain for females is not taken seriously, in my experience and in my family’s, and then also being Indigenous as well, so there’s a lot of concern with that. I’ve never ever known of a healthcare system that is actually inclusive of Indigenous people.” (PPID 105) Another participant reflects on their resistance to access information from a provider because they worried the conversation would be a negative experience. Instead, they relied on internet resources. They felt they did not have consistent, trustworthy sources that they could access and questioned the scientific reliability of internet sources. In addition, they described the phenomenon of “gate keeping” based on a lot of family planning service information being greatly accessible if you are in the field. “No, I don’t [feel knowledgeable about options of contraception and abortion]. I feel like it would be nice to go in and have a thorough conversation with a professional about potential options that I could choose, but I do rely on Google quite a bit, and as far as the internet goes, you don’t, nothing that you read is ever 100 percent. Like, you always have to use your critical thinking to ensure that it’s a reliable source, so no, I feel like it’s, unless you’re doing the research and then go through seminars or meetings, it’s just hard to access the information. Sorry. That was a really roundabout answer, but no, I don’t feel that knowledgeable in it.” (PPID 115) After asking how people in their community usually access an abortion, the participant shared that they did not know and elevated the importance of having information quickly and easily available. “That, I believe, it’s either, I don’t know. There’s not enough information that is, that I can, and that’s the thing. I look, and I keep up to date with things, so if I can’t recall like that, we’re lacking. We’re very much lacking in that quick-and-easy knowledge for people.” (PPID 117) 59 One participant describes that people in their community rely on first-hand experiences from their family members when learning and making choices about method of contraception, as those real-world accounts are trustworthy information. “Through their aunts and their sisters and their friends, it’s still through that women connection like you said, in our family, because I didn’t know about some of these options” (PPID 124) Following the end of the interview, one participant circled back and asked me for information on Indigenous health services as they did not know where to find them (PPID 115). This demonstrates the lack of information accessible to clients seeking care. I referred them to the study resource guide that we send to all participants after the interview is complete. Please see the complete resource guide in Appendix H. 2.4.6: Needing Métis-specific family planning services This theme describes participants’ vision for Métis-specific services after being asked how they would change the healthcare system for family planning services. This theme is described by three sub-themes: 1) Wanting more culturally relevant options 2) Looking towards Indigenous services (FNHA) for infrastructure examples 3) Dreaming of safe and welcoming healthcare spaces 60 The first sub-theme, wanting more culturally relevant options, entails distinction-based services – services that are culturally tailored to Métis clients. Within this concept, I discuss how access to culturally relevant care increases a participant’s willingness to engage with the services due to feeling more comfortable and seen. The second sub-theme describes participants’ suggestions from real life examples. This concept is described by participants’ perspectives on the First Nation Health Authority’s programs and infrastructure. The third sub-theme describes the ideal care environment desired by participants, encompassing both the physical outlook and interactions with healthcare providers: “Things from lighting to seating to smells to even just art and representation.” (PPID 116) Wanting more culturally relevant options Many participants described a need to receive culturally tailored services involving Elders, knowledge keepers, and full spectrum supports. This tailored care would combine traditional teachings of Métis knowledge with western knowledge for a decolonized approach to family planning services. “I think it’d be great if, um, because I don’t believe that these teachings should just lay on Indigenous people, I think if we were able to have knowledge-keepers that provided information about decolonizing sexuality to healthcare providers, that’d be pretty decent, and have it on a regular basis. If they’re regularly educating about sex, they should have understanding of what culturally-safe conversations feel like, but I would say it’s still five 61 years away till we have those, till it’s completely awake in a place where it’s much more safe.” (PPID 104) “if I knew that there was a Métis-specific, directed opportunity to see somebody, I’d probably take the drive. I think we need to focus, again, and look at First Nations-, Métis-, Inuit-specific-centered care, and where in Abbotsford or whatever city, how do we get an arm of that so that’s Indigenous-specific to First Nations, Métis, and Inuit.” (PPID 123) One participant supports the above participants’ commentary by acknowledging the need to access care that has holistic qualities. This allows for a wide range of care options to support a Métis client’s healthcare journey from start to finish. “I would actually love to see those two sides come together with a little bit more of a holistic medical field kind of a thing, yeah, like a centre where it’s Métis people, and elders are in there. It’s just, yeah, having doulas and midwives, but then also not putting all of your eggs in that basket, that there’s going to be doctors and still have the option of going to a hospital and having your birth in that way and just—I don’t know—I think just mental health resources and counselling and doctors and nurses and family doctors and just all of the things in one building to be able to access right from, yeah, like, it comes to stitches or anything else like that. Like, if it was actual medical stuff to your mental health to any kind of social work aspect as well all kind of working together, because I think there’s a huge disconnect between the medical field and the social work field, especially when it comes to Indigenous peoples. I think it needs to be smushed together.” (PPID 119) Following the conversation, the participant described the excitement and happiness they would feel not only accessing Métis-specific services but seeing Métis healthcare workers in healthcare. Being able to see representation would make them feel more comfortable and know that Métis people are seen and allowed to be seen with cultural accessories like a sash. “That in and of itself, even if they weren’t treating me, if I just saw that in a hospital would make me absolutely giddy. That is the one thing that I would just love to see is little, mini sashes on Métis people wherever I go so that I can find them.” (PPID 119) 62 Looking towards Indigenous services (FNHA) for infrastructure examples When participants were asked about what kind of services they would like to see, some used FNHA as an example as they favoured the way some of their programs were developed as well as the overall infrastructure. “I do know that status folks can access support through FNHA, and then there was also the doula grant for if you kept a pregnancy, but there’s no Métis-specific reproductive care.” (PPID 111) “I think that would be good, and I think if you had a Doctor of the Day that was, like, if Métis Nation had regional doctors or tele-doctors or telehealth, I think that would be hugely beneficial.” (PPID 116) One participant prefers the specificity of FNHA in delivering broad spectrums of care to a specific group. This allows for more culturally tailored care as it focuses on the First Nation cultures and traditional knowledge in British Columbia. To have something similar would mean Métis-specific healthcare where the Métis population is acknowledged as having their own cultures and histories that play a role in the way they receive care. “I love the idea of the First Nations Health Authority. Again, with the way that the medical system pan-Indigenizes everyone as if we all had the same culture is probably one of my biggest bitches about everything. I hate it so much, so I think just having offices that are actually Métis specific with Métis workers in it.” (PPID 119) Dreaming of safe and welcoming healthcare spaces Participants describe examples of “safe and welcoming spaces” based on their real interactions within spaces in British Columbia healthcare settings. The definition of “safe and welcoming 63 spaces” is a broad concept that participants envisioned through cultural safety, utility, design, layout, and interactions with staff. Many participants mention the terms “white walls”, and “sterile” to describe a clinical setting which is what they would like to veer away from if not required for the procedure or care. Participants mention bringing “warmth” into the spaces with different elements such as rugs, different styles of seating, coloured walls, the smells, and plants. “Yeah, just kind of more windows, more nature. My naturopath usually has, there’s usually kind of that calming music, too.” (PPID 101) “I definitely have been into Indigenous spaces in some of the communities around here, and their health units are just, I don’t know. The colours are warmer, and there’s not the greatest kind of carpet but industrial carpet instead of such cold features, more of a circular sort of structure instead of sort of long, narrow spaces. Yeah, everything is very medical, like lots of files out and that kind of thing. It’s not that sort of warm, inviting space with personal sort of touches.” (PPID 125) “I think one of the biggest things around the environment is moving away from that clinical, cold, white walls, institutional doctor’s office to something that’s a little bit more culturally knowledgeable and then shows the fluidity of Indigenous nations within it because knowing one Indigenous person who’s accessing these supports doesn’t speak for what’s safe for every Indigenous person.” (PPID 111) One participant highlighted their experience asking for an alternative option to meet their care provider in a different room to receive their consultation. “I don’t like the clinical setting. Yes, I know they need a clinical office, but when I’m sitting with a doctor, I don’t want to be sitting there. I always tell my doctor, ‘Do you have another room? Do we have to be in here with this medical bed and all this medical stuff? I’m just here to talk to you. I’m not here for you to examine me. Do we have to be in examination room? Can we be just in a room?’ … [M]eeting them in a clinical office compared to meeting 64 them in the examination room can make all the difference with somebody’s comfort level.” (PPID 123) Following their experience, they discussed their desire to have options in nature as this would be something they wanted rather than be confined in an examination room. “I guess not everybody wants to meet somebody out underneath the tree. I get that, but you have that option. If you don’t want to, you can go to the clinical setting, but there’s no option to go anywhere else. We need to have the option.” (PPID 123) Some participants mentioned the smell of the healthcare space as an important highlight, where having the “hospital smell” brought on unwanted feelings including feeling less comfortable in the space because of it. “I think the access to Elders or knowledge keepers, I think, is super important even within a hospital setting. To be honest with you, I think that’s actually a great place to have it. I think there needs to be more spaces that aren’t so sterile-feeling and were a bit cozier, because I mean, I don’t know. Abortion and even birth control, even an IUD can be super intimidating, and it’s like you’re super vulnerable. If you’re just laid on a stretcher with starch-white walls and floors that—I don’t know—and just that hospital smell to it is just kind of anxiety for me even thinking about. I think just having spaces where if you don’t need to have a space that you need to hose down, maybe put a rug in there and make it a little bit more comfortable so that it brings people’s anxieties down and, yeah, like I said, having an elder that will be able to be on call or even people knowing that there’s Indigenous advocates in a hospital” (PPID 119) “Well, probably the first person you talk to when you walk in, like the receptionist, usually, that gives you an idea of what you’re signing up for. That and, yeah, I guess I’m just imagining the facility I went to at my university or the medical centre. I liked it. Like, it felt clean. It felt colourful whereas sometimes hospitals specifically smell a certain way. It didn’t smell like that, and I liked that.” (PPID 113) “For me, it would need to be, I think it needs to have, be able to smell smudge. It has to be able to, you have to be able to smell cedar. You have to be able to smell sort of moose hide. You have to have those, you have to waken to those blood memory, that blood memory that makes you feel Indigenous and comfortable to be in that space.” (PPID 123) 65 2.4.7: Conclusion In this qualitative investigation I explored two questions: What are Métis clients’ experiences of accessing contraception and abortion services? Have Métis clients encountered racism and stereotypes in accessing these services and what did those experiences involve? I conducted qualitative interviews with sixteen Métis participants aged 20 to 69 years who lived in various areas of British Columbia. My use of a Two-Eyed Seeing approach and storytelling methodology provided me a deep understanding of Métis clients experiences in accessing family planning care. My findings add new knowledge of how Métis clients’ experiences impact their overall access to the services. Throughout the interviews, the participants discussed Métis-specific features of care that would result in an increase in accessibility. Synthesis of Qualitative Results Participants’ experiences of access to family planning care as Métis individuals illustrate their processes of ‘reflection’ to ‘action’ where participants’ reflections of the care they received catapulted their recommendations of characteristics required to create good models of family planning care for Métis people in British Columbia. To describe the relationship pattern of emerging themes from the data, I illustrated how the four experience-based themes: “Searching for a consistent healthcare provider: “I’ve never gone to the same doctor twice””, “Feeling isolated in family planning care due to legacies of trauma”, “Prioritizing care despite the costs”, and “Jumping through hoops to find information” led to an overarching theme described in 66 “Needing Métis-specific family planning services”. As pictured in Figure 2.1, the impact of not having a consistent healthcare provider led to participants having to find pathways to access care on their own where participants struggled to find programming and care services within their area relying on the internet which may have had outdated information or misinformation. This led to participants suffering from mistreatment, and neglect while accessing services as a result of their need to sacrifice monetary, mental, and physical costs to access contraception and abortion services from ‘unsafe’ providers as their options were limited due to factors such as locality. Feelings of shame due to the presence of Christian teachings forced on Indigenous communities by colonizers influenced participants access to contraception and abortion services so, by prioritizing the care they needed and experiencing mistreatment in the system, stronger feelings of shame arose. This feeling of shame isolated participants from accessing support from community as well as looking toward our health system for support and care. I observed that participants would use their experiences accessing family planning care to define “good characteristics” of care which were described through Métis-specific services. Throughout their experiences, most participants described needing supportive and relational care throughout their entire family planning journey where they wanted ‘a person’ to be able to connect with as support system and advocate. This encompasses idea of relationality being vital for clients to access adequate family planning care. This can be seen through participants’ examples: 67 “I wish I would have had a healthy-minded individual around that could help me actually check in with, “Hey, let’s find something that’s not the pill that we can do for you to help you not get pregnant.”” (PPID 117) “I think, in the ideal world, it would be something, it would be somebody that, well, went through that process with you, whether that’s just supporting or guiding you through what options there were and then providing that follow-up.” (PPID125) Figure 2.1 Illustration of Key themes In this next chapter, I further investigate the features of care that would increase access to family planning services, guided by the question, What are the characteristics of good access to contraception and abortion care for Métis clients? 68 Chapter 3: Coming Together at the Kitchen Table: Métis Perspectives on Developing Better Access to Family Planning Care in British Columbia: A Community Conversation 3.1. Purpose In this chapter, I introduce the results of a conversation with Métis community members to better understand models of culturally safe family planning care for Métis clients in British Columbia. This project was inspired by my previous qualitative investigation (Chapter 2), where attributes and experiences of “good access” were a minor theme resulting from my analysis. To define this concept and answer my third objective, I identified the need to further investigate: 3) What are the characteristics of good access to contraception and abortion care for Métis clients? To do this, I developed a project using integrated knowledge translation (iKT) and Kitchen Table methodology. The project consisted of one online community conversation with Métis clients of care followed by collaboration with a graphic facilitator to create an infographic. 3.2 Methods 3.2.1 Development of the Kitchen Table Talk 69 In Chapter 2, I employed a study design and an interview guide that were co-developed by the Story Project research team using a framework exploring access to care developed by Davy et al. (2016) – “Access to primary health care services for Indigenous peoples: A framework synthesis.” In my interview study, using this guide, I sought to identify gaps in services and identify features that optimize access to family planning services for Indigenous clients in British Columbia (31). Throughout the interviews, one concept participants repeated was the need for Métis-specific family planning services. To investigate this concept further, and answer my third research question, I then developed a second topic guide adapted from Davy et al (2016) and the evidence I generated from the qualitative investigation. Through this revised topic guide (attached as Appendix I), I sought both to add to existing theory as well as test and extend my empirical results through new data collection. I structured the new data collection activity with a trauma-informed research approach (attached as Appendix J) created by Story Project co-lead Danette Jubinville and used Kitchen Table methodology to guide my data collection and analysis, as defined and described in my Introduction (Chapter 1). Specifically, co-Principal Investigator, Danette Jubinville created a “Trauma-Informed Care in Research” procedural document for the Story Project which guided my development of the Kitchen Table Talk. Using this procedure allowed me to continually reflect on strategies that aimed to support participants to feel in control and have a safe space throughout the experience. Focus groups are defined as qualitative research tools used in order to lead a group interview where discussion is formed based on the interactions between the participants rather than between a participants and a researcher (48,49). In this instance, researchers take on the role of 70 facilitator, guiding from one topic to another and insuring respectful conversation within the participants interactions to create a safe space for everyone to share their perspectives (48,49). The Kitchen Table Talk used some of this method, but I approached it with culturally tailored methodology and rather than presenting myself as a researcher, I was a community member involved in the activity (30,38,41). Dr. Munro and I decided on this activity based on the fact that Métis community members would be able to share more in-depth and collaborative knowledge to reinforce and develop what features are required in family planning care to make it accessible to Métis clients (30). Before engaging in any activities, I began by researching Métis-specific methodologies that I could use to create a culturally relevant experience in order take an “anti-oppressive approach” which reduces re-traumatizing participants while elevating resilience (7,8,9). I decided on “Kitchen Table Methodology” as it is defined as “a safe space to gather for dialogue, knowledge sharing, eating, drinking tea, and learning from a Métis worldview.”(38). This methodology allows for the creation of reciprocal relationality, knowledge development in a community-engaged space (30,38,41). Although this methodology has been recorded being conducted in-person, due to the diverse locality of the participants, I wanted to adjust this methodology in order to accommodate a virtual activity. This also allows for participants to engage from their safe space and reduce the power-imbalance between researchers and participants (50,51,53,54). In combination of the methodology and the virtual nature of the activity, participants were able to keep their cameras off and take a break or leave the conversation if necessary. This allowed participants to remove themselves from conversations and prevent possible re-traumatization (7,8,10,11). 71 In this chapter, although the related documents refer to this activity as a “focus group,” I will be defining and referring to this activity as a “Kitchen Table Talk” or “community conversation.” In the process of seeking ethical approval from UBC, the Behavioural Research Ethics Board (BREB) only offered the term “focus group” as an option to describe my proposed activity. Based on the requirements of the BREB, it was required terminology in order to receive ethical approval. This is an imperfect classification due to the fact that Indigenous methodologies have applicability in the real world context where as Euro-Western research practices are considered “separated and a value-added investment in non-Indigenous knowledge systems” (55). Euro-Western methodologies rarely address the power imbalances and systemic barriers that tie culturally appropriate knowledge that is useful from the research (55). 3.2.2 Participant Invitations All individuals invited were previous participants of the qualitative investigation (Chapter 2), who were interested in further study activities and consented to being contacted. I drafted an email template (attached as Appendix K) to invite twelve participants to attend the Kitchen Table Talk. Two participants were not available, two participants were unresponsive, and eight participants confirmed their availability and attendance. Kitchen Table methodology is fluid and flexible like Métis culture and identity which varies across Turtle Island (30). Métis scholars welcome adjustments to this methodology based on the environment and community you are interacting with (30,41). Based on this I am using qualitative focus group literature to define the number of participants for the community conversation. Based on the current literature, qualitative focus groups should have no more than five to twelve participants in order to 72 adequately discuss the topic in depth (48,49). I designed the Kitchen Table Talk and the invite list with this in mind. Best practices by Morgan 2 and O.Nyumba et al 3 suggested to minimize the group size as it allows everyone a chance to share (48,49). Participants were emailed the consent form one week prior to the activity and invited to ask questions prior to signing. The evening before the activity, participants were reminded that being a part of the conversation was optional and had agency to take pauses whenever needed and that cameras were not required in order to participate (53). For privacy reasons, participants were welcomed to use an alias, if needed. This ensured participants had options through out the entire activity process from start to finish (53,56). 3.2.3 The Kitchen Table Talk Activity The activity consisted of a community conversation followed by the collaboration with a graphic facilitator from Fuselight Creative to develop an infographic to describe the key themes of the discussion. The conversation was hosted virtually via video conferencing platform, Zoom. This allowed participants from all across British Columbia to access the activity and include perspectives of rural and remote individuals on developing improved access to family planning services outside of metro Vancouver. This option also reduced barriers of power imbalances and privacy as participants were able to participate without cameras and in their own space, which aimed to support participants to feel comfortable and open about their perspectives and experiences (34,50). Prior to the interview, I sent out an email with instructions to join Zoom, and an agenda to all participants (attached as Appendix L). 73 At the beginning of the activity, I began with a land acknowledgement and intention setting. I did a brief introduction to the purpose of the activity and followed with conversation guidelines on privacy and respectful dialogue to keep the space safe. Participants were offered the opportunity to introduce themselves which led us into a “way of visiting” (30). We opened the discussion into discussing traditional knowledge sharing amongst Métis families, and I began by sharing specifics of my own. I finally invited participants to the virtual “kitchen table” in order to enter a culturally safe space where Métis community could come together and connect (30). I opened the activity with the following structured questions to guide the discussion, leaving time for responses and follow ups after I posed each question: 1) When thinking about acceptance of family planning services from your support network and community, what do you need that to look and feel like in order to access said services? 2) What do we need communication to look like in terms of communicating information about family planning services? 3) What are the costs that arise in accessing family planning care? What can help mitigate this as a barrier to accessing family planning care in British Columbia? 4) How do culturally safe services play a role in accessing family planning care? How do culturally safe services increase access? I facilitated the conversation for 2.5 hours which included nutrition breaks. 3.2.4 Interpretation and Graphic Facilitation Process The activity was audio recorded via the Zoom video conferencing application. I wrote down memos in order to record key themes and ideas discussed through out the activity. I listened back 74 to the recording to summarize and reflect on my initial notes to develop a brief summary for the graphic facilitator, Jessie Mead from Fuselight Creative. Rather than transcribing the recording, I wanted the graphic to be reflective of the conversation including the tones of excitement, pauses, and hesitancies for the graphic facilitator and myself. By conducting my processes of analysis this way, I was able to group themes after the conversation with notes taken down throughout. Whereas through a transcription the themes and ideas are in the order of conversation and I may not have been able to recall the conversational tones and the energy at certain points. In addition, I wanted to demonstrate the key themes based on what is seen on the graphic rather than tie in primary quotes as it gives a deeper understanding of the graphic facilitator and my process. I decided on this so that I could build context around the imagery with descriptions of the participants and important details that took place during the conversation. In the process of working with Mead to prepare for the activity, we discussed imagery and terminology that may be used which is culturally tailored to the Métis community, as well as the overarching purpose of the activity. Although the graphic facilitator was unable to attend the activity, the absence of a third party enabled the community to engage in a Métis-only space, which may have enhanced a sense of privacy and relationality among participants. I provided Mead with a brief summary that included the topic guide and short notes to guide them while they listened to the recording. These raw data plus my initial analysis supported Mead to create the first draft. This process means that the knowledge presented in the graphic recording resulted through multiple perspectives – those of the participants who engaged in the conversation, my perspective as facilitator and analysis, and those of Mead who prioritized specific parts of the conversation through their graphic representation. These multiple perspectives speak to the 75 subjectivity of qualitative research and build on the Two-Eyed Seeing approach that guides the Story Project. After Mead had prepared the graphic recording draft, I compared the audio recording and my notes to the draft to establish trustworthiness of the ideas that were expressed in the activity. I also reviewed and discussed the data sources and my analysis with Dr. Munro as an additional check, after which we requested a few minor edits from Mead to provide better clarity of terms. Mead provided the final draft one week later, and the end result was an eye-catching design that encapsulated the key themes, and quotes from participants. 3.2.5 Rigor and Trustworthiness I circulated the infographic to the Kitchen Table Talk participants. I invited participants via email to provide optional feedback on whether the infographic was an accurate depiction of the knowledge we exchanged and our key discussion points. In addition, as described above, I compared the key themes and ideas represented in the infographic with my notes taken through out the activity. I also compared the infographic with my codebook developed in my interview investigation (Chapter 2), to help contextualize, compare, contrast, and synthesize my results, which will be presented in my Discussion (Chapter 4). I took on an additional approach by reflecting on my personal experiences as Métis women accessing contraception and abortion care, and as a business analyst at Vancouver Coastal Health that allowed me to further understand the barriers within the British Columbian health system. This allowed me to understand the conversation in a deeper context as it helped me address and lay bare my biases and assumptions towards things I believe would have been considered “good characteristics” of access to family planning care. 76 3.2.6 Protection of Human Participants The activity was approved under the STORY project’s ethics approval from University of British Columbia’s Behavioural Research Ethics Board in order to conduct this study (Ethics #H21-01171). All participants had previously consented to be contacted after the initial interview for future Story Project related activities and member checking. All digital files with identifiable information were kept on Dr. Munro’s SharePoint Drive which is maintained by the University of British Columbia server. All files were password protected when possible. All participants were given a numeric identifier (PPID #) which was stored in a password protected excel spreadsheet with personal information. All participants were notified that this would be an activity that involved other community members and were welcomed to keep their cameras off and use an alias if needed. After completing the activity, all participants who attended were provided with a $100 electronic transfer to their email address to compensate them for their time. All honoraria was sent by the research manager (AW). 3.3 Results 3.3.1 Participants Eight participants took part in the Kitchen Table Talk activity. Based on the demographic data collected in their previous interview with the Story Project, all participants self-identified as Métis and held Métis Nation British Columbia (MNBC) citizenship (n=8). Three participants 77 were within the Northern Health Authority catchment area, three participants were within the Interior Health Authority catchment area, one participant was within the Fraser Health Authority catchment area, and one participant was within the Vancouver Island Health Authority catchment area. The session lasted for 2.5 hours, punctuated by two breaks, and took place using the Zoom video conferencing application. 3.3.2 Final Graphic Facilitation As illustrated below in Figure 3.1, the final draft of the graphic highlights details of care that participants need in order to receive good access to family planning care. Some participants detailed their experiences to describe the barriers and facilitators of access to family planning services and through this community conversation, three themes emerged based on the participants discussions. 1) Acceptance from our Elders and health care professionals 2) Communication: ‘There is a huge disconnect’” 3) Cultural Safety: Could the answer be Métis-Specific Services? The first theme is described by participants experiences of mistreatment or lack of treatment based on their identity. This led to participants feeling shame and stigma after receiving treatment. Participants used these discussion points to explain the need for relationality in their care through supportive programs and services. 78 The second theme describes the need for information and communication pathways through community in order to receive contraception and abortion care service information. This led participants to highlight cultural nights as a possible pathway for family planning information. The third theme discusses the importance for culturally safe services which participants highlighted through the need for Métis-specific spaces and services. This theme highlights good characteristics of models of care. 79 Figure 3.1 Kitchen Table Talk Infographic 3.3.3 Acceptance from our Elders and health care professionals At the beginning of the conversation, we started it off discussing the term “acceptance” in relation to accessing family planning services. Participants described current challenges that themselves and their community are facing in terms of accessing family planning services. Participants discussed the mistreatment of Métis clients who identified in the LGBTQIA2S+ community and the lack of providers who understood the culture, histories and current social context of the clients who identify in this community (31). This led to participants having the feelings of shame and stigma after receiving family planning care, which deterred them from accessing services in other instances. Participants also shared examples of feeling left behind when trying to access abortion services, as providers’ biases continue to impact the care, they 80 provide. Many participants shared experiences of interacting with providers in our health system who declined care due to their religion (e.g. conscientious objection). Another participant suggested an elder program or “supportive grandma 4 rent” program, would allow for clients accessing care to have a supportive figure and advocate through out an appointment with a healthcare provider. This could supply in-real time education to the provider if required as well as ensure that the client feels a sense of agency over their appointment. Discussion of the potential role of Elders in family planning care led to a further in-depth conversation about the impacts of colonization on our community. Unfortunately, the assimilation into Christianity and Catholicism in particular has created barriers between elders and younger generations. Based on our conversations, some elders provide no support “when it comes to 2-Spirit and LGBTQ” as their beliefs on gender, sexuality, and reproductive choice have been impacted by these belief systems. This allowed all of us to reflect on the bigger picture of the healthcare system itself, and how the overall system has to be “decolonized” prior to our conversation of efforts to decolonize community. It also led us to consider how it is critical to work with Elders in a non-judgmental manner. As one participant described, “be gentle and consider their history.” 3.3.4 Communication: ‘There is a huge disconnect’ As participants were located in different parts of British Columbia, we also started off discussing access to family planning service information in their communities. It was highlighted that in the metro Vancouver area, information was “more easily” accessed compared to in the Northern Health Authority area. The diversity of location for where participants were situated allowed for 81 an extensive conversation of lack of information on services in different areas of British Columbia. Although participants came to an overall consensus that there is a lack of a communication infrastructure to streamline information so that ‘services are being provided in a timely manner for that person’ , it was highlighted how powerful information is, especially through community. One participant shared an example of a program where they provided beading nights for community members to attend, as shown in the centre of Figure 3.1. Through out these events, sexual health services were offered in a different room as well as physical resources and tools such as pamphlets, condoms, and lube were available at a table out of view. Many participants were excited about this idea, and echoed how important accessing information through community as well as the distances they would go to access this. One participant called attention to the fact that health matters can be particularly triggering whereas cultural practices such as beading are forms of medicine meant to heal us, so their personal preference was to keep the two separate (“maybe we should separate cultural practices from health matters”). This led to a discussion of safeguards that could be put in place to prevent triggers from happening such as using the beading nights as a place to connect to community and a place of where information can be accessed if wanted rather than having health providers there. This was reflected as more of a realistic scenario for many of the participants’ communities as scheduling healthcare providers to attend regular cultural nights is more complicated than having culturally relevant information available. 82 3.3.5 Cultural Safety: Could the answer be Métis-Specific Services The final piece of our conversation revolved around the importance of cultural safety in accessing contraception and abortion care. Although cultural safety was hinted through out the entire experience through participants experiences and suggestions, this part of the conversation led to the discussion of Métis-specific spaces and services. Drawing attention to the middle of the graphic to the bottom right corner, you can see the evolvement from “Sharing information through community” depicted on the Métis sash in Figure 3.1 to discussing Métis-specific services that elevated the need for “culturally sensitive help” where healthcare providers “understand generational trauma” as described by Figure 3.1 with specific quotes from participants in the conversation. In the context of this activity, we discussed space as both physical and virtual environments. This encompasses buildings where people access services as well as conceptual health networks and online services. Participants discussed their need for Métis-specific services and referred back to First Nation Health Authority as an example of distinctions-based services. Many participants echoed they would like Métis Nation BC to create a similar infrastructure to expand their health programming so that clients could access services through them rather than their current health authority. Physical support systems were also mentioned, participants highlighted the benefits of spaces like this increasing access to support through out their contraception and/or abortion care journeys. Participants highlighted required features such as “culturally sensitive help” where generational trauma was not only understood but trauma-informed approaches were used by workers in these spaces. It was noted that there is a lack of peer-based support and wanted to see more Indigenous folks in liaison positions. This is highlighted in Figure 3.1 where the participants further define Indigenous liaisons as making “peer recommendations”. Participants spoke strongly on this as they would trust an Indigenous 83 liaison to connect them with a health provider or services that was culturally safe. Confidentiality was described as a barrier to access, participants highlighted this through envisioning it in our conversation of what good characteristics were needed to create access to family planning care. Mental wellbeing was touched on in two sections of Figure 3.1 (bottom left and top right of the graphic). A few discussed the mental cost of accessing contraception and abortion care, in which they wished mental supports were available in an occasion like this. The participants represented this idea through “online and wraparound care” which is spotted on another Métis sash that borders “supporting clients through their choices”. This calls attention to a theme that was highlighted above, where participants wanted relationality in their care through a supportive service like text message check-ins or “supportive grandma 4 rent” program. 3.3.6 Framing the Conversation within ‘Access to Care’ The results of this Kitchen Table Talk conversation also align with several components of the Accessibility Framework for Indigenous peoples accessing Indigenous primary health care services developed by Davy et al (2016). In that framework, the authors posit that health services self-managed and delivered by and for community enhance care for Indigenous communities as there is sense of ‘ownership’. In this model of care, they argue, clients are more likely to receive culturally safe care which addresses both the supply (acceptability) and demand (ability to seek) side of the Accessibility Framework for Indigenous peoples accessing Indigenous primary health care services (31,32). In Davy et al’s (2016) work, clients were able to seek the services if providers had a good understanding of the population they were serving, as they felt safer to attend. Similarly, this emphasis on self-managed and -delivered family planning services was a core concept in the Kitchen Table Talk. Participants discussed their willingness to access 84 available services based on the health care provider’s willingness to provide culturally appropriate care, which is a concept generated by Davy et al (2016) (31). Participants also expressed a need for a Métis-specific space and services as they wanted these services to be organized and owned by Métis Nation BC and community. They discussed the lengths they would travel to access these services. This ties into the Davy et al (2016) concept of “community ownership” that encourages community to access services. The authors also highlighted in their framework that when information about services is inaccessible through community, fewer people are aware about accessible services (31). This was mentioned throughout our activity – accessing information through community would make it easier to know about what services are available in their area, and which are acceptable to Métis clients. Finally, although cost was prompted in one instance of the Kitchen Table Talk, it was a minimal contribution compared to other impactful suggestions regarding good access to care. In the initial discussion with Mead, I shared the list of prompts and questions with her prior to the Kitchen Table Talk which discussed the impact of cost of access to family planning care. Participants discussed the financial impacts of needing to travel, taking time off of work, cost of invitro fertilization treatments and the cost mental health supports. This portion of the graphic, although important was not elevated by the participants in the same manner as the other themes. The Davy et al (2016) synthesis mentions cost as a major component in Indigenous people being able to access services, but this was not a comparative component in this instance. 85 3.4 Conclusion My Kitchen Table Talk activity and analysis provides an in-depth perspective of what “good characteristics” of access to contraception and abortion care should include based on the perspectives of Métis clients and healthcare professionals. Although there is currently a lack of Métis-specific health services in BC, this conversation highlighted the importance of distinction-based care and communicated a range of suggestions, such as a check-in program via text messaging for clients who accessed abortion care, and requiring Métis-specific physical spaces where community can access safe, peer-based, and culturally-safe wellness practices separate from formal healthcare. As the conversation continued, participants did not feel adequately up to date on how to access information regarding culturally safe contraception and abortion care. In addition, they had no knowledge of how to identify Métis health providers or allies in our current system, resulting in the need for peer-to-peer recommendations. In this chapter, the participants and I investigated the concept of access to family planning services in British Columbia. The activity resulted in an infographic that I co-produced with a graphic facilitator that illustrates that key themes and community connections that occurred through out the experience (Figure 3.1). Next, in Chapter 4, I compile the evidence from Chapter 2 and 3 in order to synthesize my results, describe where my two projects lies in the current research, identify strengths and limitations of my approach, and suggest potential next steps for research and practice. 86 Chapter 4: Discussion and Conclusion 4.1 Discussion 4.1.1 Summary of Findings My thesis builds on our current understanding of Métis clients’ experiences of accessing abortion and contraception care in British Columbia. In this final chapter, I will synthesize my key findings from Chapter 2 and Chapter 3, consider how the results fit in existing literature, discuss the strength and limitations of my thesis., and propose recommendations for how the results may impact future directions. My thesis began with a qualitative investigation to explore the experiences of Métis clients accessing contraception and abortion care in British Columbia (Chapter 2). After analyzing interviews with 16 Métis participants, I identified one overarching theme "Feeling lost in a system that does not value relational care” which is described by this participants dream of what family planning care would look like. “I think, in the ideal world, it would be something, it would be somebody that, well, went through that process with you, whether that’s just supporting or guiding you through what options there were and then providing that follow-up.” (PPID 125) Participants highlighted the lack of relationality in the care they received through out of all of the concepts mentioned in Chapter 2. Underpinning this concept were five key themes describing Métis clients’ experiences relating to family planning service access and envisioning “good characteristics” of family planning care from the perspectives of Métis people: “Searching for a consistent healthcare provider: “I’ve never gone to the same doctor twice””, “Prioritizing care 87 despite costs”, “Jumping through hoops to find information”, “Feeling shame in family planning care due to legacies of trauma”, and “Needing Métis-specific family planning services”. Participants described the lack of having a consistent healthcare provider (“Searching for a consistent healthcare provider: ‘I’ve never gone to the same doctor twice’”) impacted their access to care as many had to search for care through walk-in clinics and hospitals. Without the option to have a consistent provider due to shortages, many participants experienced unwanted experiences and missteps in their care. Furthermore, participants discussed they would have preferred to discuss their family planning needs with someone whom they have a relationship with, as relationality is important to build trust and understand one’s histories. This is consistent with Taanishi Kiiya: Métis Public Health Surveillance report, a provincewide report that discusses the overall health of Métis individuals in British Columbia where one participant mentioned “Asking Métis individuals to engage a doctor to get personal health information, like blood pressure, glucose testing, etcetera is not [a] reasonable strategy considering many Métis individuals do not have a family doctor.” (2). Although this is describing overall access to safe primary care services, this supports the struggles mentioned by participants in my investigation who were rarely able to engage with health care providers due to a lack thereof. Another key theme that I identified through the interviews was the costs participants endured in order to access contraception and abortion care (“Prioritizing care despite costs”). Participants shared that they experienced financial, mental, and physical tolls that continue to impact them. Participants described experiences of borrowing money in order to buy birth control as well as choosing methods of contraception based on price rather than preference. Furthermore, 88 participants described depending on others for rides to clinics in order to receive an abortion or insert an IUD. Many participants described these experiences with tears in their eyes due to the stress experienced throughout accessing family planning care. Some of these experiences illustrate the disappointment and frustration being denied access to a prescription due to capacity of clinics, whereas others describe the burden of keeping their abortion from their families and communities due to the religious undertones that have been pushed for decades into our communities by colonizers. This theme is supported by Monchalin et al (2023) conducted a qualitative investigation with 15 Indigenous participants across Canada using conversational interview methods to explore and elevate knowledge around experiences and access to abortion services. This study identified key themes that coincide with themes that I generated. Monchalin et al (2023) describes barriers that hinder access to abortion services for Indigenous people across Canada. In this study, participants illustrate the struggles of trying to access services due to financial hardship from out of pocket travel costs and distance to the abortion service (23). In Monchalin’ s study, one participant shared, “I called and I made the appointment, and it was a couple weeks later … I didn’t have a car, so I didn’t know how I was getting there. I didn’t have money to get there. It’s about a seven- or eight-hour drive from where I was living, and that’s the only place that anyone in Newfoundland can go (006).” Travel burdens were common experiences that participants shared in my investigation (23). In addition, participants further explored their feelings of isolation when accessing contraception and abortion care due to intergenerational trauma (“Feeling shame in family planning care due to legacies of trauma”). Participants recounted internalized stigma through terms such as “shame”, “humiliation”, “weird”, and “uncomfortable.” Furthermore, many participants relayed these terms when describing their community’s comfort with contraception and abortion care. 89 Participants shared an underlying expectation from community to have “big Métis families” and to want to be a lifegiver. Although throughout this theme I discuss the challenges participants experienced while interacting with the Western health system, I also highlighted that the stigma felt by the participants and community are the antecedent of colonialism and the patriarchy. This coincides with Monchalin et al’s (2023) emerging theme of “Impacts of colonialism on attitudes towards abortion”. The connectivity “between religion, colonialism, and the fracturing of intergenerational reproductive health knowledge” heavily influences the expectations of Indigenous women and their reproductive choices (23). Moreover, my analysis yielded data on participants’ lack of knowledge of where to access information about contraception and abortion care. Many participants answered with a simple “no” or “I don’t know” when asked about where to access Indigenous specific services or who would they reach out to for safe and knowledgeable family planning information. This was a very reflective point in the interview for many, only then realizing they would not know what to do if they needed the information. It was noted similarly by Monchalin et al (2023) that information on abortion access was inconsistent across Canada and that finding an abortion provider proved challenging and participants had to call service providers in order to confirm availability (23). Finally, all participants expressed a need for family planning services that were specifically designed for Métis clients (“Needing Métis-specific services”). Participants discussed examples of present services offered by First Nations Health Authority they would like to see in a Métis specific context, and highlighted how pan-Indigenizing services were ineffective as they did not 90 feel accessible. Beyond programs, participants described the importance of “seeing themselves” in the healthcare setting, such as through identity concordance with an abortion provider, as this makes them feel safer when accessing services. In addition, many participants re-imagined healthcare spaces to include details such as coloured walls, plants, and different styles of seating to bring “warmth” into spaces. Monchalin et al (2022) conducted a qualitative investigation focused on 24 Métis clients’ accessing health and social services in Victoria, British Columbia. This study identified several key themes similar to those I created in my analysis. Similarly, recommendations of “warm and inviting spaces” where they further described the need of physical features such as plants, windows, local Indigenous artwork, and comfortable seating (57). Beyond physical features, this study highlighted the importance of Indigenous healthcare providers and Indigenous people in the waiting room as seeing representation of themselves would feel more comfortable when accessing care (57). Further investigation was needed to deepen my understanding of what “good characteristics” of family planning care for Métis individuals looked like in the British Columbia context. In my Kitchen Table Talk (Chapter 3), I explored Métis-specific models of care through one community conversation activity. I designed and facilitated the activity using trauma-informed research practices and Kitchen Table methodology. These approaches allowed me to generate three themes: “Acceptance from our Elders and doctors”, “Communication: ‘There is a huge disconnect’” and “Cultural Safety: Could the answer be Métis-Specific Services?” At the beginning of the conversation, the participants (n=8) and I discussed the meaning of “acceptance” in terms of accessing family planning services (“Acceptance from our Elders and 91 doctors”). Participants engaged in passionate discussion of the need for acceptance from health care providers, to prevent mistreatment due to lack of knowledge of our histories and culture. This led to participants describing a service where Métis clients accessing family planning care had a supportive in-person figure throughout their journey to ensure they have someone to advocate for them if needed. Participants discussed Elders as a vital piece in our healthcare settings but again mentioned that Elders continue to be impacted by colonialism and that for some it bleeds into the support they provide. This is supported further by Monchalin et al. (2022) who discusses the need for “non-judgmental service providers” as participants experienced mistreatment due to providers’ beliefs. As mentioned previously, colonialism has impacted Métis communities through enforcement of religion and patriarchal ideologies (23). This has resulted in community members, including some Elders, being less accepting of diverse identities (e.g. LGBTQIA2S+) and reproductive choices, which is further described in the Kitchen Table talk. In addition, the nation-wide study conducted by Monchalin et al. (2023) also highlighted the need for additional follow-up care. They discuss a recommendation that encompasses support throughout an entire abortion experience from start to finish, one participant mentioned the idea of an abortion doula “to help with navigating appointments, travel, post-abortion, and as often shared, ‘to have somebody to hold your hand’” (23). To further solidify this, LaRoche and Foster (2017) Another key theme was needing information communicated through their communities (“Communication: ‘There is a huge disconnect’”). Participants discussed how accessing information in different regions of British Columbia varied but, specifically, information is “more easily” attainable in the metro Vancouver area. Participants suggested incorporating sexual health information into cultural nights as this could be an attainable action for chartered 92 communities anywhere. Western knowledge sharing and translation practices have been challenged by Indigenous scholars to create strategies that are culturally tailored and community oriented. This observation is described in Smylie, Olding & Ziegler (2014) where they explored important considerations of culture and history to create easier pathways to health information for Indigenous communities (58). They highlighted “Indigenous KT strategies and protocols are commonly dynamic, participatory, integrated into family and community activities, repeated or cyclical, and intergenerational,” which aligns with our conversation on incorporating family planning information into cultural nights such as beading nights (58). Lastly, all participants echoed a need for Métis-specific services as participants felt that this was key in order to receive culturally safe care. Participants referred to First Nations Health Authority programs as examples to strive for as citizens of Métis Nation BC. This was illustrated through visions of physical spaces tailored to Métis clients and receiving care from Métis people as participants mentioned feeling invalidated by healthcare providers due to blood quantification questions to determine “how Métis someone is”. Participants discussed the need for online and wraparound care options such as check-in programs for support especially in the event of traumatic experiences. In addition, participants elevated the importance of not just Métis individuals but in general Indigenous people in liaison positions as they trust them to be connected to providers that are culturally safe. This is reflected specifically in a recent Métis study based in Victoria, British Columbia that refers to participants needing a space that does not challenge their identity as well as a Métis-specific clinic within their area that provides care which focuses on the needs of Métis people (57). 93 Throughout my analysis, I took a constructivist grounded theory (CGT) approach, where I sought to build relationships with and hear from 16 individuals (Chapter 2) whose stories reflect their experiences and reality, interpreted through the lens of my analysis (42). I demonstrated this CGT approach throughout my research experience with flexibility as it is a method that allows for the researcher and participants to co-construct the meaning of these realities (42). My role within this research process was to be curious and seek to comprehend the social complexities for Métis clients accessing contraception and abortion care in British Columbia. Although I have been able to weave their stories together and discuss commonalities amongst the individuals, I prioritized each individual’s definition of their experiences as I felt this was a more trauma-informed approach than to focus on patterns of experiences across the sample as a whole, which deviates slightly from a CGT approach. When considering how to answer my research question, “Have Métis clients encountered racism and stereotypes in accessing these services and what did those experiences involve?” I also constantly battled with a philosophical response, “Who am I to define what their story means?” Though many of their stories hinted at the nuances of structural racism and white supremacy, participants rarely used these terms. As a researcher and community member who participants entrusted with their words, I felt the need to adhere as closely as possible to their own language when interpreting the interview data. When reflecting back on the themes I have presented in Chapter 2, I believe there is an opportunity to extend my analysis further and to be more explicit regarding my interpretation of how structural racism and white supremacy operate within their experiences. Throughout participants’ stories, their experiences aligned with the In Plain Sight Report’s (2021) address of maltreatment due to stereotypes. For instance, participants in my 94 study described the absence of communication from their healthcare providers, inappropriate interactions with healthcare providers, and lack of cultural competency where healthcare providers and systems excluded family and community from clients’ healthcare experiences (3). When asking the participants if they felt comfortable identifying as Métis or Indigenous with their healthcare provider, many actively chose to conceal their identity as they feared being stereotyped and being mistreated. These fears demonstrate the insidiousness of white supremacy. In addition, for the few who discussed their identity with healthcare providers, they were also the individuals (PPID 117 and PPID 119) who shared their experiences with reproductive coercion and discriminatory interactions with healthcare providers and described the impact of those experiences on their well-being and willingness to interact with our healthcare system to this day. Although my thesis has run its course, the Story project will continue as a whole, and I will be challenging and extending my analyses to further call out racism and white supremacy. 4.1.2 Strengths and Limitations In the qualitative investigation (Chapter 2), I was able to conduct my research imbedded in a large province-wide study which allowed me access to resources that furthered my reach to participants from different regions of British Columbia. Through this larger project, I had an experienced team of qualitative researchers, research coordinators and community partners that guided my work which further strengthened my study. By allowing remote data collection methods such as Zoom and phone, this allowed interviews to be conducted in locations that were 95 inaccessible for in-person interviews due to transportation, time, and cost, as well as allow individuals to participate from an environment that was comfortable. The recruitment posters required eligible participants to be at least eighteen years of age for the interview. Thus the results of this study may not be adaptable to youth, who may encounter different barriers in accessing family planning services due to their age. Participants in this study may have had a higher degree of comfort discussing contraception and abortion care (selection bias), which suggests that results may not be relevant for Métis clients who are less comfortable with or knowledgeable on the topic. Recall bias may also have limited what participants shared during the interviews as they may not accurately remember previous details or experiences. In the community conversation (Chapter 3), I created a trauma-informed and culturally relevant approach that allowed for individuals to feel safe to participate. Designing the conversation this way allowed for participants to be recognized for their knowledge and expertise through their experiences, in turn decolonizing the practice of focus group research. By taking a decolonial approach, I prioritized culture and a sense of community, allowing for exciting collaboration and fostering distinctions-based suggestions for models of family planning care. The Kitchen Table talk was held over Zoom to reduce barriers related to travel, cost, time, and comfortability. This allowed for participants to engage in an environment of their choosing and keep their cameras off if wanted which allowed participants to share more freely. 96 It should be noted, however, that participants invited had participated in a previous interview within the qualitative investigation (Chapter 2) mentioned above. Based on previous eligibility, we did not collect data from individuals below the age of 18, which means we may not have captured recommendations to improve models of family planning care that fit Métis youth. In addition, after the Kitchen Table talk was completed, participants were invited one month later to review the final infographic. I received feedback from one out of the eight participants that took part in the Kitchen Table talk. Feedback on the final graphic was an optional step for participants. A potential limitation related to this step was inviting participants to give written feedback which requires additional time and resources. Reflecting back on this step, I would likely suggest different methods that requires less time and resources, and that allow for anonymity. For instance, a short survey through Google forms may be more likely to elicit feedback. The limited feedback received reduced capacity to determine if the infographic properly captured the key themes and ideas of the participants resulting in details that may have been omitted during the initial interpretation by the graphic facilitator. The overall strengths of my thesis involved using trauma-informed research practices that were reflected through a distinctions-based and Two-Eyed seeing approach with the goal of decolonizing the research and the interactions between the researcher (myself) and participants (community members). At every stage of my study and the Kitchen Table talk, I grounded myself in community and took time building relationships and trust to ensure that community members understood where the work was coming from. This allowed for Métis individuals of 97 varying identities and backgrounds to participate as all of the research practices and materials were shared transparently. 4.1.3 Future Directions In the qualitative investigation, I considered Davy et al.’s (2016) Indigenous adaptation of Levesque’s Patient-Centered Access to Health Care framework through a distinctions-based and Two-Eyed seeing approach, to explore the experiences of Métis clients accessing family planning services (31). This allowed me to understand the barriers and facilitators of access in this specific instance. Throughout the interviews (Chapter 2) and the community conversation (Chapter 3) I noted that, in order for Métis individuals to access contraception and abortion care, one aspect of the framework required a stronger consideration compared to the others. Specifically, participants discussed the need for acceptability from the place of care (supply side) in order to have the ability to seek family planning care (demand side) (31). This theme arose from participants’ experiences of stigma, shame, and anti-Indigenous racism while receiving family planning services from a provider. Participants discussed their need for Métis-specific services through Métis Nation BC and their respective health authorities in order to receive comprehensive care that is culturally relevant. Although in Chapter 3 I was able to capture aspects required to create Métis-specific services, future work may conduct a deeper exploration into this topic. In future research, qualitative investigation with healthcare providers, health system leaders and Métis Nation BC could generate additional evidence and aide in understanding how to develop optimal models of family planning care for Métis people across British Columbia. 98 In addition, the stories shared by participants inspired strong messages on the need for relationality, specifically, for a supportive companion throughout one’s experience of accessing family planning care. The participants recounted this idea in many shapes and forms, through terms such as “Rent a grandma” and through the feel they anticipate they would have after receiving optimal care. They also spoke about relationality for after-care, such as receiving a text from a designated person post-abortion. Each of these examples was related to opportunities for connectedness and came from the participants’ desires to not feel so alone. In order to explore this idea more, I believe that further investigation is required into wraparound care and what it could look like in the context of family planning services in British Columbia. As previously mentioned above, while looking in Métis-specific models of care, an additional sub-study looking into this specific program development could allow for a more guided investigation into supportive, person-oriented care. An example of this could involve a combination of interviews with providers, Métis clients and Métis Nation BC health leaders in order to create an evidence base for comprehensive services available for Métis citizens. Services could be delivered either via a phone or in-person at Métis-specific spaces that have multi-use across British Columbia. As my thesis findings have touched on these themes, my research demonstrates that there are possible implications in health systems change and program development. For example, my results include evidence on experiences in accessing family planning services for Métis clients and evidence for recommendations for adapting family planning models of care to be more accepting and culturally safe. This data can support health authorities, Indigenous organizations, and the British Columbia Ministry of Health to design programs and create policies that increase 99 access to family planning services in a way that is acceptable and accessible through the eyes of Métis communities. Throughout this process of reflection and analysis, the overarching message that I would like to be taken away from my thesis is that people require a real person contact through their family planning experiences. Participants continuously painted pictures of this message through terms such as “rent a grandma,” “ a person,” “peer-based support,” and “text-message check-ins” during and after receiving family planning services. All of these ideas have a common goal of creating supportive pathways of care, to minimize the feeling of loneliness that all participants described in their own stories. A vital piece of my thesis work used a distinctions-based approach, and I believe using this approach elevated the strength of Métis people’s voices and allowed participants to have a “Métis space” to share their experiences and recommendations for which there are few opportunities. As I previously noted in chapter 2, my journey of interviewing Métis clients was an uplifting and celebratory experience for the participants and was also a space where I connected more to my culture as well as a family member who I have never met. This experience opened up my process when interviewing and conducting analysis. I found myself being more intentional with my introduction with participants and sharing pieces about my family. Many participants and I shared laughs about the similarities in kitchen staple brands we grew up on such as China Lily soy sauce. As I continued this practice, it altered my perspective on how family, and culture were so much more connected to how participants shared their stories with 100 me, and I recognized the depth I was reading into the transcripts. I think this spark of familial connection allowed me to look at the transcripts with more intimacy. Many participants shared their excitement and comfort in talking to a Métis interviewer (myself) and excitement to be a part of Métis-specific knowledge generation. It allowed individuals, including myself, to feel empowered and grounded in culture. I was able to weave Kitchen Table theory into my thesis, which centres the importance of the kitchen table for our cultures. This in turn gave a feeling of familiarity to both me and to participants. In addition, by using an arts-based approach (graphic facilitation), participants could see their words and cultural representations such as the sash. This approach highlights the importance of creative ways to connect with our Métis identity and culture. I believe using a distinctions-based approach is important when working with community, recruiting participants, and conducting data collection. However, I believe the recommendations and themes that emerged are not necessarily unique to the Indigenous experiences collected so far in the Story Project. Many of the themes and recommendations discussed in this thesis are echoed with participants who identify as First Nation. This does not minimize the voices of people who participated but suggests there may be more impactful work to be done in broader Indigenous health programs that address cultural safety and humility and, in particular, the UNDRIP implementation plan in BC . Many participants discussed their use of FNHA’s “Doctor of the Day” program. These observations lead me to consider, are the principles that other Indigenous programs are using translate to features that Métis people need in their care experience? Could broader Indigenous programs be adapted to be more culturally safe and welcoming for Métis clients? This idea of 101 working across programs and communities in unison circles back to the development of the Story Project’s values in research co-developed by the MACK (attached as Appendix M). The core principle, “Chen Chen Stway,” is a Squamish law meaning working together. Although Métis-specific spaces and programs would be transformative in implement across British Columbia, based on locality and capacity this may not be realistic. In some spaces it is important to look at the incremental steps that our health care system leaders can take to enhance these spaces to be truly inclusive of all Inuit, Métis, and First Nation clients of care. These questions are too complex and multi-layered to be answered through my thesis, but my work contributes to this conversation and will enrich the future literature that investigates these complexities in Indigenous healthcare. 4.2 Conclusion My thesis contributes to the current literature available and deepens our understanding of the experiences of Métis clients accessing family planning services in British Columbia, as well as Métis perspectives on good characteristics of family planning services. My results highlight a need for Métis-specific services and person-centered support programs that allow clients to feel cared for throughout their whole family planning care experience. My methodological approaches allowed me to build meaningful relationships with communities and participants, allowing me to test and extend theoretical frameworks to explain the experience of Métis clients accessing care. Exploring the roles of shame, stigma, and anti-Indigenous racism, I learned the deep impact they play in participants’ access of contraception and abortion care, as fear and distrust of the system hinders their ability to seek care. 102 Furthermore, through a community conversation, I learned the priorities of Métis community members when describing safe models of family planning care. Here they described characteristics of acceptability needed from healthcare staff, and community when accessing services, accessing information through community, as well as a strong need for support programs that are available throughout one’s family planning experience. “Well, if you haven’t heard by now, my heart is in the game. I’m thinking about the generations that are going to come after me and the suffering and stuff that I had to endure as an Indigenous person and still do. I would like to see our children or the children that come after me or walk in my footsteps later don’t have to feel that they don’t have a space of their own to go to and/or don’t have the ability to create family in the way that they so choose to, and it shouldn’t always be from a clinical perspective. I think we need to integrate our Indigenous ways of knowing and/or teaching into the systems of the colonial context and actually be able to massage them in and allow our youth to have the option. We are both, so what is your choice? Do you want this one or would you like this one or would you like a combination? I think until we do that, as Métis people, we’re going to continue to struggle in this world of mental health and wellness.” (PPID 123) 103 References 1. Métis Nation British Columbia. 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Altern Int J Indig Peoples. 2022 Sep;18(3):327–34. 58. Smylie J, Olding M, Ziegler C. Sharing What We Know about Living a Good Life: Indigenous Approaches to Knowledge Translation. J Can Health Libr Assoc. 2014;35:16–23. 108 Appendices Appendix A Recruitment Poster 109 Appendix B Social Media Square 110 Appendix C Community Facing Interview Guide 111 Appendix D Preliminary Codebook for qualitative investigation (Chapter 2) Theme Sub-theme Description 1 [Access to consistent healthcare provider] [Relationship building] PPID 113: “I think we need consistency, and we need relationality. We need people that, we need doctors who, we need to be connected with doctors who understand us.” PPID 124:“she knows my body not just right now but what’s happened in the past..” This theme explores the widespread concern among participants regarding the absence of a dedicated family physician. Consequently, participants found themselves consulting various healthcare professionals when in need of care, making it challenging to establish meaningful relationships with their providers. [Lack of access to family doctors] PPID 113: “I’ve never gone to the same doctor twice” PPID 126 :“Well, if I had a family doctor, I feel like I would feel safer talking about that, those kind of issues, so someone with a relationship, I guess.” 2 Needing alternative healthcare providers to access family planning services [Relying on pharmacists to get contraception] This theme explores the importance of receiving consistent comprehensive care from pharmacists. Many participants discuss the relief that they feel now that 112 they can access contraception through a pharmacist rather than a practitioner as many do not have someone they can see consistently. PPID 126: “I have experienced that losing my family doctor, but yeah, I’m thankful that kind of thing is available easily at the pharmacy now.” PPID 126: “Well, I think it’s available at the pharmacy now, isn’t it? I know doctors and clinics are really difficult to get into. I have experienced that losing my family doctor, but yeah, I’m thankful that kind of thing is available easily at the pharmacy now.” PPID 125: “Give me a feeling of safety and trust? Um, I don’t feel unsafe with my family doctor, and I don’t necessarily trust him in the way that I would trust my pharmacist.” 113 [Feeling supported by practitioners who offer holistic care] This theme explores the importance of receiving comprehensive care from various healthcare providers, such as midwives, counselors, doulas, and patient navigators. PPID 126: “Um, I always felt really supported by midwives, so I mean, I would say them” – “They just spent a lot of time with me. They even came to my house for different things easily, so they just had more time for the patients. I wasn’t really clear on why that’s so different from, say, a family doctor, but it was very apparent. They seem to be more willing to have time caring for you.” 3 [Depending on community for support and information] PPID 124: “Through their aunts and their sisters and their friends, it’s still through that women connection like you said, in our family, because I didn’t know about some of these options” [Community] PPID 125: “Then from there, I was connected with a community-based agency that provided supports to, yeah, either young moms or moms that needed that extra support.” This theme describes the involvement of friends, family, and communities when participants access contraception and abortion care. 114 PPID 126: “I find them [chartered community] really useful for events in my area, so I’m really grateful to get those.” [Family and friends] PPID 124: “Yeah, so I wish I had known about these when I was younger. Back then, we were told only about condoms and birth control. If you had one bad auntie that had the Depo shot, you weren’t allowed to get that. Now there’s more education or more, like, I don’t know if it’s, I don’t know if they’ve always been out here or if it’s we’re learning about them now, but now there’s newer things to us, so we have access to IUDs, and we just go through the doctor. You actually have to go to the hospital to get them put in, but it’s a way better option for women, in my opinion.” PPID 109: “I also remember not being informed about any other method at the time. It was sort of everyone, all of my friends were going there for pills, so I went there as well and started on the birth control pill.” 115 4 [Accessing care from a safe environment] PPID 119: “I think COVID really showed us that we can do a lot of things from a distance, so things don’t need to be right at your doorstep to be helpful.” [Different options of follow-up care e.g. home visits] PPID 125:” I think, in the ideal world, it would be something, it would be somebody that, well, went through that process with you, whether that’s just supporting or guiding you through what options there were and then providing that follow-up. For me, I am not a fan of talking on the phone, so I would enjoy, like, it would be meaningful for me to get a text message. I really want to thank you for prefacing this whole interview with saying like, “If things feel uncomfortable or you don’t want to continue, then we can stop. If at any time you want to retract anything, you can do that.” It’s like setting up all those safety pieces to ensure that somebody is there for you, but there’s no This theme describes participants seeking alternative ways of receiving care different from the traditional clinic visits. This could be due to convenience of not having to travel to the clinic or to be in a safer environment while receiving care. 116 pressure for you to take that support either. They’re there if you need them, and they’ll continue to reach out until you don’t want it or just having that communication, so for me, yeah, that would probably be by a text message or an e-mail, maybe not necessarily a person, face to face.” [Virtual Care Options] PPID 126: “Um, well, I don’t know. I guess if it was something like a Zoom call or something where you feel kind of in your own environment, you feel a little bit safer, I guess, to know about the person’s background a little bit. I think those things would help.” 5 Trying out different birth control options to find something that fits [The frustration experienced while trying to find a contraception that works] Participants described having to try different contraception before finding a good fit. The need to try different ones stemmed from the side effects they experienced. PPID 125:“It was a frustrating experience, I think, trialing many different types of birth control.” 117 PPID 119: “Birth control, I’ve gone through quite a few different ones. I tried the pill when I was younger. I have ADHD and was undiagnosed then, so that did not work well for me at all. Just trying to remember. Then I was on the Depo shot for a while, and even then having to do it every three months, I forgot. Now I currently have an IUD.” 6 [No money for birth control but made it a priority] Several participants echoed how expensive birth control was. For LARCs, it was difficult to cover the large upfront cost that was required. Cost was also a reason why participants will opt for less ideal contraception methods. PPID 119:“The IUD cost $300. I asked my brother for the money because, at the time, I wasn’t working, and there’s no way that I would have been able 118 to afford it otherwise.” PPID 125: “Yeah, so definitely the cost piece. Even after I had my daughter, so I had graduated from high school and then got pregnant. My doctor never, nobody ever told me about PharmaCare, so I was paying for all of my prescriptions—birth control being one of them—out of pocket at full expense. It wasn’t that I didn’t, I’ve made it a priority because it was a priority to me, but we had no money. It is definitely a big expense, and it wasn’t one that I should have had to pay if somebody would have told me that there’s PharmaCare to help cover some of these costs. That was a frustrating experience after I had found out that there was help that I could have had to pay for it, and I didn’t have to struggle in other aspects of my life, because I was paying for a medication that should have been covered otherwise.” 119 PPID 105: “Yeah, so it was really difficult to afford birth control because I wasn’t able to handle birth control pills. I had severe side effects with it, so the only option for us were IUD.” 7 [Medical System Failures] Experiencing the shortcomings of the BC Medical system [Needing flexible appointments] PPID 113: “it’s really hard to get somewhere from Monday to Friday, so I honestly wish that clinics were open on Saturdays and Sundays because that would be more helpful” This theme describes experiences in accessing contraception and abortion care that were present due to failure of the medical system. This range included the lack of availability in practitioner services, experiences of poor treatment from healthcare providers, and the lack of time for appointments. [Medical system not considerate of people’s lives] PPID 125: “You feel more like a number than a human being.” PPID 117: “I went for the abortion. It was, the guy who got me pregnant came, brought me to the hospital, and he was sitting in the waiting room. The nurse that was attending went and said, “Are you here with anybody?” I said, “Yes,” and she said, “Is it the father?” I said, “Yes,” 120 and it was like, “Why are you asking me?” She left the room, got him, forced him to come in. I didn’t want him there. I did not know him well enough. He was my best friend’s cousin, so he wasn’t, I didn’t want him in there. I was in this vulnerable position. He didn’t want to be in there. That nurse made him, and she said, “You’re gonna watch this.” I was screaming because it hurt, and it was incredibly, um, it felt shameful and embarrassing and terrifying that this choice that I had made to not bring another life into this horrible, wretched world was now the cause for giving me trauma for trying to make a smart decision about a child’s life.” PPID 115: “Professionals, in my experience, it seems like they tend to try to keep patients moving, move us along, I guess, if that makes sense, so I guess it would just depend on who the person is, who the physician or the professional is that you’re seeing, but it just seems like a hit-and-miss for having someone 121 that’s supportive and someone that you can trust.” PPID 123: “As a young person, as an Indigenous person, I found it very hard, I found it very hard to get as a young person. Then when I met my partner, I noticed that she could get it quite a bit easier than I could. Like, it was, and not that I wanted it as a contraceptive, but it just seemed like if I went and asked my doctor, they went and asked their doctor, it just seemed to be a very different, very different exchange for whatever reason.” 8 [Reworking the space where we receive care] PPID 116: “Things from lighting to seating to smells to even just art and representation.” This theme describes the ideal care environment desired by participants, encompassing both the physical outlook and interactions with healthcare providers. PPID 113: “Um, it will, I would say, I don’t know. Whenever I walk into a place that I visually see Indigenous peoples, not necessarily the people themselves but art and regalia, not regalia, but do you know what I mean? If I see a drum or if I see 122 a Métis sash or if I see different Indigenous art, right away, I’m like, “Okay. Somebody here knows, is woke, and knows what’s happening,” right? Then I also think being able to use your ID and it taken as a valid ID is really important.” PPID 116: “I think if you had physical places that had those people that work in those things, even an elder, you know, tea, like a nice invited, I think, too, we’re just so used to our sterile western world, but we could actually, you know, if you go to a nice spa or you go get Botox somewhere nice, it’s gonna look inviting. It’s not gonna look like just chairs and old magazines, right? People can take some pride in their business to kind of make it roomy and comfortable. When I think about some Indigenous spaces or some of the ones that are becoming popular, they have a welcoming feel to them.” 123 PPID 123: “Well, first of all, yes, absolutely, it would be underneath a tree. No, just kidding. For me, it would need to be, I think it needs to have, be able to smell smudge. It has to be able to, you have to be able to smell cedar. You have to be able to smell sort of moose hide. You have to have those, you have to waken to those blood memory, that blood memory that makes you feel Indigenous and comfortable to be in that space, so I think that’s one thing..” PPID 116: “It would be nice to, like, if you saw smudging or somebody with a teaching or, like, I know too I’m still learning about culture. I know that water is very cleansing. I don’t know, I usually prefer outdoor water spaces to do that, but if you were maybe in a physical thing where you were trying to do something, just the people to kind of guide you or help you 124 or offer those prayers or teachings or things that could help you with the spiritual side get through the physical thing, especially at a clinic that’s dealing with pregnancy or loss or abortion or family planning.” PPID 117: “A big botanical garden honestly. Plants are healing things for me, and I think garden spaces because plants give you healing. They’re a healing thing. When you’re healing, you need tactile things.” 9 Experiencing reproductive coercion This theme describes any form of pressure to use or not use contraception and/or receive abortion care. PPID 104: “I was a foster kid, and it [birth control] was kind of forced upon me by my doctor.” PPID 117:“My experience more comes from my life experience where it was I couldn’t get birth control because my mother was a Fundamental Christian.” 125 10 [Informational gaps, people do not know where to look] PPID 115: “it just seems like you have to jump through a bit of hoops to find the answers that you need.” Participants shared that they did not have adequate information about contraception and abortion care. This includes lack of information about options, where to access care and the failure of health care practitioners to inform participants of the side effects of the selected methods. PPID 104: “I didn’t have anybody that would freely, openly talk to me about sex and then contraception or anything like that.” PPID 113: “I was so naive that I didn’t even know, like, when you get a prescription, it’s renewable, right, so you get it for three months. Then every three months, you can go in and get another pack. I didn’t even know that. The doctor never even explained it to me, and this was my first time going to the doctor by myself as an adult without my parents knowing kind of thing, right?” 11 [Barriers in accessing LARC contraception] Participant described the process of getting LARCs as a multistep 126 Wanting streamlined services when accessing LARC process (getting the prescription, placing the order with the pharmacy, picking it up, and going to an HCP for insertion) which they found cumbersome and discouraging. They voiced a need to have a more streamlined process. PPID 109: “I do remember that the time it took from that referral to actually having it done was probably close to at least four to six months after putting the referral in, so there was quite a long wait” 12 Questioning culturally safe care Missing cultural safety PPID 117: “I know those are still there, so I know it’s still not a safe space, but I wish it was, genuinely. I wish that I could genuinely be able to point somebody to those services and say, “It is with my whole heart and my whole belief, my whole everything that I can say this is a culturally-safe space or just a safe space,” period. People can say it, but with the things I hear, not true, not true.” Participants described what culturally safe care means to them and their relevant experiences. 127 Seeing yourself/allyship in the healthcare system PPID 119: “so having Métis workers in a specific space that is Métis, so then there’s your cultural things around you and you can feel super comfortable, but even if you’re in a hospital and you could see a nurse or a doctor with the little sash on them, that would make me feel just absolutely amazing.” PPID 116: “I was gonna say I think they’re trying. Then I saw a nurse that had one of those “Every Child Mattered” lanyards, and a few others were wearing them. Then some other people were wearing whatever else lanyard, so then you kind of see, “Oh, I might have some allies or some people who understand.” PPID 123: “ I think you need to be able to see yourself, but also to have Indigenous doctors or people that are Indigenous-competent that have passed or have been vetted by Indigenous people. I’m not saying that all have to be Indigenous but 128 been vetted by Indigenous people that these people are culturally safe enough to be in this space, and they are re-vetted every year.’ PPID 123: “. To me, what makes it so warm and welcoming, first of all, is the staff that work there. Most of the people who work there are Indigenous, and/or when you walk in the door, you see yourself right away.” Wanting more knowledge about culturally relevant options PPID 105: “Mm-hmm. I think having Indigenous staff or having questions asked, like, even asking, for example, not what pills you take but, “Do you take any medicines, like cultural medicines?” You know what I mean? Questions like that that are more inclusive, I feel, would change the comfort level of the person going in because they’re considering who you are and you’re not just walking through.” PPID 123: “Again, I think teaching our Indigenous people about their moon 129 cycles, what that relevance is, and the strength in that will only allow, again, as we look bringing families into the world, if we strengthen our women from that (strength-based) perspective of the power that they hold within their moon cycle, the power that they hold, the reason why we’re here, I think that gives Indigenous children and youth and people who are creating families, especially women life-givers, that they have a certain role to play in community and it’s not just about bringing a baby into the world. “ 13 [Distinction-based services] [Needing Métis specific health services] PPID 113: “I wish there was a Métis clinic or an Indigenous clinic I could go to for women. I wish that it was just more obvious where to start with that.” PPID 119: “No, so there’s First Nations Health Authority, but I mean, again, it’s in the name. They only deal with First Nations health, so when it comes to Métis, we don’t get to access those resources. Participants shared a need and desire to have contraception and abortion services that are Métis specific. Many participants now talk about different types of services available, but they are not necessarily eligible or comfortable accessing said services. 130 In Kamloops, we do have our, we have a delegated agency. They’re super awesome in the sense that they’ll do a lot of other wraparound support, so I’m sure that they would help, but at the same time, I think it’s really intimidating for somebody who’s facing pregnancy or Planned Parenthood or anything like that to walk into a child protection agency and be like, “Hey, can you help me?” That almost feels like you’re setting yourself for really bad things down the road. Yeah, in the way of Métis specifically, no, there’s really not.” Looking towards Indigenous services (FNHA) for infrastructure examples PPID 116: “Yeah, the First Nations Health Authority has the Doctor of the Day, and I started using the Doctor of the Day when it was advertised on TV. I think it was right around pre-COVID or around COVID times, but now, I just phoned recently because I was having some trouble with my asthma. They’re so busy, they 131 were booking in my local area in December, so I ended up at the ER to get some asthma medication.” PPID 116:” I think that would be good, and I think if you had a Doctor of the Day that was, like, if Métis Nation had regional doctors or tele-doctors or telehealth, I think that would be hugely beneficial.” PPID 119: “I love the idea of the First Nations Health Authority. Again, with the way that the medical system pan-Indigenizes everyone as if we all had the same culture is probably one of my biggest bitches about everything. I hate it so much, so I think just having offices that are actually Métis specific with Métis workers in it.” 14 Transportation and distance to access care [Accessing care isn’t convenient] PPID 105: “The women’s clinic is very, very far away from me. I think it would be three busses away, so that’s not very accessible.” This theme describes situations where participants had to take time and travel to access care. Many participants also discuss the barrier of distance between them and services. Some were able to get transportation in order to access appointments but [Accessing care in remote communities] 132 PPID 117: “I wasn’t thinking about those things, but yeah, there was travel, and again, if I didn’t have to have that ride, that experience would have never happened. That guy came in with me and made the situation worse, because I could have had a cab or something, but unfortunately, I didn’t have the financial resources to do that.” others were deterred and looked for alternatives. 15 [Privacy and confidentiality] This describes participants concerns about privacy and confidentiality when they access contraception and abortion care PPID 126: “Are they gonna talk about me at the dinner table?” PPID 124: “No one knows why you’re here.” 16 [Feeling uncomfortable with receiving care from a male doctor] Several participants shared a preference for receiving contraception and abortion care from female providers. PPID113: “Yeah, I would say that I feel way more comfortable with women in those 133 situations. I don’t know exactly what it is. Obviously, I’m thinking of Pap tests and pregnancy things, and I feel like I just do not feel comfortable about men because it’s such an intimate thing.” 17 Experiencing emotions when accessing contraception and abortion care This theme describes the range of emotions (shame, internalized stigma) participants feel when accessing contraception and abortion services. PPID 117: “I mean, I’m still crying about it this many years later, which is 30 years later. It’s still raw for me. I still feel that shame and that humiliation. Just it gave me a lot of negative feelings about myself and just about interactions with people and added to the trauma that I’d already gone through, and it’s just there’s so much there that it’s, like, if your cup is full and you’ve got more stuffing dumped in, it’s like you can’t deal with all of those things, so it’s just one more 134 unnecessary thing to have to deal with in this big glass of trauma, right?” PPID 116: “And I wasn’t sexually active till I was 17 anyway, so even going on birth control at a younger age for period issues but still feeling shameful, I wasn’t using it for other purposes.” 18 [Identifying as Métis in the healthcare system] This theme describes the willingness to identify as Métis in healthcare settings. PPID 114: “I’ve had to educate them [HCPs] as to what Métis are, and I always go in with a pamphlet and leave it with them so they can read it and understand what Métis is, but they have no knowledge of what’s culturally relevant for a Métis person for their health and well-being and their cultural relevance, whatever.” PPID 124: “Like, it was you’re either First Nations or you weren’t, so I was that kid that would make a box and write “Métis” 135 when I’d go sign up at school or go to get some of these things, or they’d ask I was Indigenous or First Nations. I would say, “No, I’m Indigenous,” or back then, we would say, “Aboriginal.” PPID 119: “I would, yes, but that’s because I’m a pretty loud advocate as it is. But I definitely know a lot of people don’t feel comfortable disclosing that they’re Indigenous if they don’t have to.” 19 [Community strongly pushing against abortion] PPID 124: “Yeah, birth control good to go, abortions “No don’t do it.” This theme highlights the acceptance of contraception within certain communities, while abortion remains a sensitive or taboo topic. PPID 124: “Yeah, birth control, good to go. Abortions, “No, don’t do it.” Yeah, it’s pretty cut and dry like that. You are, like, everyone is well aware. People are, obviously, at every age, you know, they’re active, but you do not get an abortion. No, you do not. I don’t know if it is just, I don’t think it 136 is just our Indigenous side because, obviously, a lot of us are Catholic, and that’s a big, “No, you don’t do that.” Yeah.” PPID 117: “I can say, within the community, it is looked down on, abortion. Contraception is still kind of iffy. Abortion, certainly because of religious. I’m not trying to be insulting towards religious people. I get that they have beliefs. I am not because of the trauma that I went through and the trauma that my father went through, but it is definitely shameful, horrible, “you don’t do it” thing, and it is definitely because of religion.” 20 Envisioning a perfect health system “a one-stop shop” This theme discusses what participants would like to see in a ‘perfect’ health system. PPID 115: “I feel like it would be nice to have a few professionals that, not like a one-stop shop because that kind of sounds cheap, but to have at 137 least a few professionals that have their strengths in different areas so that, say, you go to, um—I don’t know—a gynaecologist, but then she doesn’t have the best information on how to deliver a baby or something. I don’t know. I feel like it would be nice to have more than one professional there that has strengths in separate areas so that if this person can’t answer your question, then there will be somebody that can and that can support your decisions.” PID 105: " It would be great to have a clinic that is specialized in family planning and these services.” 21 [Post-abortion care] PPID 105: “There was absolutely no follow-up" Participants shared that there was a lack of follow up care after getting abortions PPID 105: “There was absolutely no follow-up care, except for blood tests that they did afterward. There was no kind of psychological support. There was not even any support in terms 138 of family planning afterwards or anything. I had to research myself that losing one fallopian tube doesn’t necessarily decrease your chances of getting pregnant by too much, but I had to find that out for myself through Google. There was no follow-up. I was very traumatized laying on the floor, thinking I was going to die, and then having the surgery happen and really like, “You’re on your own” sort of thing. I would have really appreciated some follow-up. In fact, I still would appreciate follow-up. The second time where it was such a traumatic experience physically, emotionally, yeah, I would have really appreciated some good follow-up even by any healthcare professional would have been really appreciated.” PPID 109: “Yeah. No. Yeah, so there wasn’t. It was more so like, “If you have any concerns, contact us,” 139 22 Being “White-passing” This theme explores the discomfort experienced by participants who do not 'look Indigenous’. This led to some individuals hesitating to identify as Indigenous. It also covers instances where individuals received preferential treatment due to their appearance. PPID 124: “I can imagine that it’s gonna put words to how I’ve always felt, so” PPID 115: “I think that there’s some stigma around identifying as a Métis woman. I also got, because, I also, it feels like I kind of received some backlash sometimes because I have Métis ancestry, but I’m White, so it makes me uncomfortable to bring it forward because I don’t want to seem like I’m playing the system or taking it to my advantage, so it never really gets brought up when I talk about my healthcare options.” PPID 113:“but they assume that Indigenous people look a certain way, so when I walk into the room and I say I’m Indigenous or a Métis or they look at this ID card that they’ve never seen before, it doesn’t line up in the stereotype in their head of what Indigenous people look like.” . 23 [Preferring a contraception method that does not contain hormone] This describes participant’s preference for non-hormonal forms of contraception. PPID 105 - “I had severe side effects with it, so the only option for us were IUD. At first, we start, we use copper IUD, but because my 140 periods were so heavy, it was I ended up extremely anaemic, so I had to have that removed.” PPID 113: “Like I said, all the side effects I had, I wish I had known that those side effects were because of the pill I was taking and that all the crap I went through was because of that.” 24 [acquiring knowledge about contraception] [From HCPs] PPID 109: “I had gone to speak with my family doctor at the time about other methods because I was curious to know what else was available and just maybe other options that wouldn’t affect my mental health or mood so drastically, so I went to speak with him, and he was very informative.” This describes participants acquiring new information about contraception and abortion from HCPs and the internet. [From the internet] PPID 115: “but I do rely on Google quite a bit, and as far as the internet goes, you don’t, nothing that you read is ever 100 percent. Like, you always have to use your critical thinking to ensure that it’s a reliable source, so no, I feel like it’s, unless you’re doing 141 the research and then go through seminars or meetings, it’s just hard to access the information.” 25 [Free contraception for all] This theme covers the wide range of free contraception conversations including: -Participants shared the need for contraception to be free of cost. -Participant shared that they received contraception for free. -Participants discussing the new BC policy offering free contraception to all. PPID 116: “I think it’s great. I think, hopefully, if people, especially young people that are not sure if they’re wanting to have children or people with financial barriers, hopefully, they’re using and accessing the system, but then, hopefully, they’re getting an education about the system because it’s 142 medication, so there’s side effects, or people need to know what they’re doing to their bodies as well, right?” PPID 117: “I think it’s starting to show a small amount of movement towards an end goal that looks like genuine safety for people accessing personal decisions and having those personal decisions respected.” PPID 124: “Um, I cannot believe it’s been in for—April, May—I don’t know how many months, and I didn’t know that. I think it’s an amazing policy. Yeah, I’d love to see the stats from five years ago for the next five years. Man, that’s crazy. I do have a question, though.” 143 Appendix E Final Codebook for the qualitative investigation (Chapter 2) Theme Sub-theme Description 1 Searching for a consistent healthcare provider: “I’ve never gone to the same doctor twice” This theme explores the widespread concern among participants regarding the absence of a dedicated family physician. Consequently, participants found themselves consulting various healthcare professionals when in need of care, making it challenging to establish meaningful relationships with their providers. Relationality with a consistent provider builds better connections. This sub-theme is described by participants desire for a consistent relationship with a healthcare provider and how the participants feel this phenomenon would improve their accessibility to family planning services PPID 113: “I think we need consistency, and we need relationality. We need people that, we need doctors who, we need to be connected with doctors who understand us.” PPID 124:“she knows my body not just right now but what’s happened in the past..” This sub-theme is described by the participants’ experiences in their struggles trying to There is limited availability of family practitioners. 144 find a consistent healthcare provider and as a result it has impacted their accessibility to family planning services. PPID 113: “I’ve never gone to the same doctor twice” PPID 126 :“Well, if I had a family doctor, I feel like I would feel safer talking about that, those kind of issues, so someone with a relationship, I guess.” Pharmacists have become a consistent healthcare provider PPID 125: “Give me a feeling of safety and trust? Um, I don’t feel unsafe with my family doctor, and I don’t necessarily trust him in the way that I would trust my pharmacist.” PPID 126: “Well, I think it’s available at the pharmacy now, isn’t it? I know doctors and clinics are really difficult to get into. I have experienced that losing my family doctor, but yeah, I’m thankful that kind of thing is available easily at the pharmacy now.” This theme explores the importance of receiving consistent comprehensive care from pharmacists. Many participants discuss the relief that they feel now that they can access contraception through a pharmacist rather than a practitioner as many do not have someone they can see consistently. 145 “There was absolutely no follow-up" “Actually, I had to do it at the Kamloops hospital. I was sexually assaulted. I mean, you’d go up there, and it was just like, ‘Go home. Take the two pills,’ but I don’t know. I just felt like there was no checkup afterwards. I get that it was just like taking the two pills, and it should just be easy, but I mean, it was just everything surrounding that was pretty traumatic in and of itself, and then just not having, yeah, not having anybody kind of checkup to see how you’re doing afterwards is really hard.” (PPID 119) This sub-theme describes instances of follow-up after an abortion, as well as experiences of lack thereof. Feeling “more like a number than a human being” This sub-theme describes participants’ experiences in the British Columbia healthcare system where participants felt forgotten, mistreated, and judged Experiencing reproductive coercion This sub-theme describes participants’ experiences accessing contraception and abortion care. Reproductive coercion is the interference of an individual’s right to choose how, when and if they want to be pregnant. 146 2 Feeling shame in family planning care due to legacies of trauma This theme describes the internal and external stigma and shame experienced by participants when accessing family planning services. “Well, there’s still, there’s a giant stigma, and I live in a small community, still. That’s, it’s just not, it’s still not, and I know, ugh, it’s still not what we do. You’re not supposed to have an abortion.” (PPID 124) Worrying about confidentiality This is further deepened through the sub-theme, where participants shared stories that emphasized their concern of privacy and confidentiality when accessing family planning services. “My goodness. I don’t know. Unfortunately and, oh, I hate to say this, but if there was a private service, because I would hate to go through the public right now.” (PPID 124) 3 Prioritizing care despite the costs This theme is described through participants prioritized family planning services despite not being able to afford birth control, or in other instances there was emotional and physical costs to accessing family planning services. 147 “The IUD cost $300. I asked my brother for the money because, at the time, I wasn’t working, and there’s no way that I would have been able to afford it otherwise.” (PPID 119) 4 Jumping through hoops to find information This theme is described through participants’ struggle to access information on contraception and abortion services. “Yeah, I think it’s just the lack of information. Like, we don’t know where to go. We don’t know what’s out there. Then sort of the worry that you’re going to be treated poorly or kind of brushed off, I feel like a little bit that’s a female concern because, oftentimes, pain for females is not taken seriously, in my experience and in my family’s, and then also being Indigenous as well, so there’s a lot of concern with that. I’ve never ever known of a healthcare system that is actually inclusive of Indigenous people.” (PPID 105) 5 Needing Métis-specific family planning services This theme is described by participants’ vision for Métis-specific services after being asked how 148 they would change the healthcare system for family planning services. Wanting more culturally relevant options This sub-theme is described by participants wanting more culturally relevant options, entails distinction-based services – services that are culturally tailored to Métis clients. “if I knew that there was a Métis-specific, directed opportunity to see somebody, I’d probably take the drive. I think we need to focus, again, and look at First Nations-, Métis-, Inuit-specific-centered care, and where in Abbotsford or whatever city, how do we get an arm of that so that’s Indigenous-specific to First Nations, Métis, and Inuit.” (PPID 123) Looking towards Indigenous services (FNHA) for infrastructure examples This sub-theme is described by participants’ suggestions from real life examples. This concept is described by participants’ perspectives on the First Nation Health Authority’s programs and infrastructure. 149 “I do know that status folks can access support through FNHA, and then there was also the doula grant for if you kept a pregnancy, but there’s no Métis-specific reproductive care.” (PPID 111) Dreaming of safe and welcoming healthcare spaces This sub-theme is described by the ideal care environment desired by participants, encompassing both the physical outlook and interactions with healthcare providers: “Things from lighting to seating to smells to even just art and representation.” (PPID 116) 150 Appendix F Full Interview Guide Interview Guide for Indigenous Community Members Introduction to participant Thank you so much for agreeing to participate in the STORY Project. Our conversation today is part of this 4-year grant-funded study. Our goal is to understand Indigenous peoples' experiences of accessing contraception and abortion care, otherwise known as family planning. As a participant, you hold knowledge about what it means to have safe, culturally appropriate, and accessible care. Through this project our aim is to listen to stories and make recommendations for models of family planning care that are culturally appropriate, empowering, and accessible. Our intention with this project is to improve the healthcare system and not influence Indigenous peoples’ cultural knowledge or teachings related to family planning. Before we review your consent form, do you have any questions for me? *Instructions for interviewers* • Provide a summary of the consent form. • Confirm that participants have had a chance to review the interview guide. • Interviewers may begin by identifying themselves: who they are, where they are from, and who their ancestors are. • The recording will begin after introductions. Start recording. Verbal Consent Option Thank you for reviewing the consent form. Do you have any questions? 1. Do you consent to participate in this study? 2. Do you give your permission for me to email you a copy of your transcript so that you can check that your story is accurate? 3. Do you give your permission for me to email you with information about the results of the study? 4. [If conducted remotely] Where should we send your honorarium? You can share your email for an electronic fund transfer or address to mail a cheque. 5. [If conducted remotely and receiving honorarium by e-transfer] We have prepared a small gift for you. Are you comfortable sharing an address for us to mail it to? 0. Before we start our conversation, I have a few demographic questions. If you don’t want to answer a particular question, we can skip it. 1. What is your age? 2. What are your pronouns? 3. Do you self-identify as an Indigenous person, that is First Nations, Métis, or Inuk? 4. What is your nation or ancestry? 5. Do you have Indian status? (If needed, clarify “Registered or Treaty Indian as defined by the Indian Act of Canada”) 6. What is your gender? 7. What is your sexual orientation? 8. What are the first three digits of your postal code? 151 1. In this study we are interested in understanding Indigenous peoples’ experiences of accessing abortion and birth control in BC. I would love to hear about your experiences. • Can you please tell me about any experiences accessing birth control? • Can you please tell me about any experiences of accessing abortion care? o I’d like to learn more about [the experience the participant described]. o Can you tell me step by step what that looked? Paint me a picture, if you can. Repeat the questions to learn about other experiences, if relevant. 2. How do people usually get birth control in your community? What about if people need an abortion, how do they access one? • Do people have to leave the community to access care? If so, where do they go and how do they get there? • In your community, what Indigenous-specific health services are available to you for contraception care? What about birth control? 3. If you or a relative needed information about options for preventing or ending a pregnancy, is there a safe, knowledgeable person or place in your community to go to? Who or where would this be? • Do you feel as knowledgeable as you’d like to be about options for abortion and birth control? Can you share a little about why you feel that way? • What are some strategies that you think would work well for increasing awareness about options for abortion and birth control in Indigenous communities? 4. Are you aware of any supports that exist for follow-up care after receiving an abortion in your community? • What supports would you like to see? • How about for switching or ending birth control methods? 5. Thinking about the abortion and birth control experiences you have mentioned so far, what are the costs that you have experienced? • Was there ever a time where you needed to access birth control or abortion care and couldn’t get it? For instance, because of the cost, your health benefits, needing to travel, or finding a provider? • What out of pocket costs have you experienced when accessing birth control or an abortion, such as for travel, childcare, or after care? Can you give an example? • Are you aware of any Indigenous health benefits available to you related to birth control or abortion care? Probe for costs that were covered by a benefits plan, out of pocket for prescriptions, out of pocket for travel, and any indirect financial impact on loss of work, childcare expenses, etc 6. What would make it easier for you to get birth control when you need it? What about abortion care? 7. In this study we are exploring what “cultural safety” means in family planning care. What are the things that give you a feeling of safety and trust with your health care provider when talking about birth control and abortion? 152 • Have you ever experienced or imagined receiving culturally safe abortion or contraception care? What did it look like? • Have you ever avoided getting family planning care because you felt it wouldn’t be culturally safe? Please tell me more about that experience. • We talked earlier about local services for birth control and abortion. How welcoming are those spaces to Indigenous people? • What are some of the things that make the spaces more or less welcoming? 8. If bringing culture into your family planning experience is important to you, what would that look like? • What would you need from the health care system to be able to do it safely and accessibly? 9. We are curious to know about any resistance to abortion and birth control in the community, for religious or cultural reasons. How do people around you feel about family planning services? 10. We are curious to know about consent for contraception care. Ideally, people should be able to make their own, free choices about when, where, and how to have children with no pressure or control from others. However, we know that that’s not always the case. • Was there ever a time when you felt pressured to use birth control or have an abortion? What was that experience like? Where did the pressure come from? • Are there any other stories about pressure to use birth control or have an abortion that you would like to tell us about? 11. Was there ever a time where you felt fully supported to make your own choice about preventing or ending a pregnancy? Where did that support come from? • In these conversations, did you feel safe to bring up your Indigenous identity [or sexual orientation or gender]? Why or why not? • Tell us how family members are involved when you’re making choices about birth control or abortion? • How are your partner/s involved in those choices? 12. Have your thoughts and feelings about birth control and abortion changed over time? 13. If you could wave a magic wand and change the system, what would the patient journey look like for Indigenous people accessing birth control? What about for abortion care? • What existing clinic feels like the place you would be most comfortable to access contraception or abortion care? Why? • Who or which health care provider would be the most comfortable person for you to access contraception or abortion care? Probe also for midwives, allied health professionals, community health workers, patient navigators, doulas 14. On April 1st, you might have heard, the government made prescription contraception free for all in BC. I’m going to share how it works and then ask your thoughts about this new program. First, a person gets a prescription for free birth control in BC – they can get the pill, shot, implant, copper IUD, or hormonal IUD. The morning after pill is also free and does not need a prescription. Second, they take the prescription from a pharmacy and get their birth control for free. Third, some methods need 153 a health care professional to place it, like an IUD or an implant. They would go back to a clinic to get it inserted. • What are your thoughts about this new policy? Have you taken advantage of it? What was your experience like? • What challenges or concerns might come with this policy? • What benefits might come from this policy? 15. After having your experiences, what advice would you give to another Indigenous person who is accessing birth control for the first time? What about if they were seeking an abortion for the first time? 16. Is there anything else you think I should know to better understand how services could be improved? • Are there any other unmet needs related to family planning care for Indigenous people in your community that we haven’t discussed? • Is there anything that you might not have thought about before that occurred to you during this interview? • Is there anything you would like to ask me? • Finally, what motivated you to participate in the study? 154 Appendix G Email Script for Member Checking Taanishi! My name is Piper Scott-Fiddler, and I am a Métis graduate student working on the Story Project. I hope this email finds you well. During your interview process, you consented to review a copy of your transcript, a hand-written copy of our interview. Please review the transcript document, reflect on the story you shared, and consider these questions: 1. How accurately does the transcript capture your thoughts and experiences? 2. Is there anything else that could be added to the transcript to capture your experiences better? 3. If there is anything you would like removed, what would that be and why? You can reply by email with as much or as little feedback as you like. If you would prefer to share your feedback by phone, we can set up a 10-minute call at your convenience. To ensure your input is included, I kindly request that you complete this review by the end of the day on April 15th. Your transcript is attached here for your review. You can make edits using tracked changes or add comments directly to the document. Your transcript is password protected for security purposes, and I will provide the password in a second email following this one. Please do not hesitate to reach out to me if you have any questions. Thank you for your cooperation and participation in the project. 155 Appendix H Resource Guide 156 Appendix I Revised Topic Guide for Kitchen Table Talk Coming together at the kitchen table: Métis perspectives on developing better access to family planning care in BC Focus Group Script Introduction to the task: Thank you for agreeing to participate in this focus group. We are interested in finding out peoples’ thoughts Métis client’s access to family planning care. Your feedback will help us to understand what good access to family planning care for Métis clients looks like in the context of the British Columbia health system. You can talk as much or as little about your personal experiences. We understand that family planning care can be sensitive subjects for many people. You may have different attitudes and experiences from other people in the room. Everyone here has a valid opinion. There are no right or wrong answers. You have the right not to answer any questions and you can leave or take a break from the focus group at any time without giving a reason. This can include leaving the Zoom all together and re-joining, or muting and turning off your camera until you feel ready to re-join. The facilitator can check in with you via private chat or email. To help us have a safe and respectful discussion, let’s go over some guidelines: • Everyone treats others with respect • Our discussion will stay on topic • Everyone needs to listen, even when disagreeing • People will speak one at a time • We can take a break if needed • People can leave if they feel uncomfortable or emotional After the focus group is done, I will be here to answer your questions about any aspect of the research or topics we discussed. We ask that everyone here keep the discussion private and confidential. Introductions • Facilitator introduces themself and invites each participant to give their name and, if they wish, why they chose to join the focus group Questions for Moderated Discussion 157 1. When thinking about acceptance of family planning services from your support network and community, what do you need that to look and feel like in order to access said services? Probe for the following, in no particular order: • Communication with support network • Examples of what “good support” is • The definition of acceptance • Cultural aspects that improve access • The power of influence that community plays in access • Recommendations to mitigate influence of access • Confidentiality (Keeping the abortion a secret) • How can this support/acceptance be built • The identity of the person who recommended the clinic Ask probing questions about factors, including the above list, as needed: • [Participant] mentioned ____. Why is ___ important to you? • How would ____ impact your choice? • Does anyone else feel that _____ is important? If no, why would that be less important in your decision making? • No one has mentioned ____. I am curious to know why you think it hasn’t come up in our discussion. • A few people have strong feelings about ____. Can you share more about why this is important to you? • For the folks who have been listening, what would be important for your decision making? [Call on specific people who have been shy/quiet] 2. What do we need communication to look like in terms of communicating information about family planning services? Probe for the following, in no particular order: • Plain language information • Access to educational documents (online, pamphlets, ect) • Healthcare providers and their access to information from governing bodies • Communities access to information (where do you access information) • Recommendations to mitigate influence of access Ask probing questions about factors, including the above list, as needed: • [Participant] mentioned ____. Why is ___ important to you? • How would ____ impact your choice? • Does anyone else feel that _____ is important? If no, why would that be less important in your decision making? 158 • No one has mentioned ____. I am curious to know why you think it hasn’t come up in our discussion. • A few people have strong feelings about ____. Can you share more about why this is important to you? • For the folks who have been listening, what would be important for your decision making? [Call on specific people who have been shy/quiet] 3. What are the costs that arise in accessing family planning care? What can help mitigate this as a barrier to accessing family planning care in British Columbia. Probe for the following, in no particular order: • Different types of cost (monetary, mental and physical) • Length of travel time • Out-of-pocket travel costs • The number of appointments needed • Cost of supplies or services needed while recovering from an abortion • The effect on your life outside of the family planning care needed • Recommendations to mitigate these as a barrier in access Ask probing questions about factors, including the above list, as needed: • [Participant] mentioned ____. Why is ___ important to you? • How would ____ impact your choice? • Does anyone else feel that _____ is important? If no, why would that be less important in your decision making? • No one has mentioned ____. I am curious to know why you think it hasn’t come up in our discussion. • A few people have strong feelings about ____. Can you share more about why this is important to you? • For the folks who have been listening, what would be important for your decision making? [Call on specific people who have been shy/quiet] 4. How do culturally safe services play a role in accessing family planning care? How do culturally safe services increase access? Probe for the following, in no particular order: • Examples of access • What does it look and feel like • What is needed to build this • How do you want to access these services • Confidentiality • Peer recommendations • Recommendations to mitigate this as a barrier in access 159 Ask probing questions about factors, including the above list, as needed: • [Participant] mentioned ____. Why is ___ important to you? • How would ____ impact your choice? • Does anyone else feel that _____ is important? If no, why would that be less important in your decision making? • No one has mentioned ____. I am curious to know why you think it hasn’t come up in our discussion. • A few people have strong feelings about ____. Can you share more about why this is important to you? • For the folks who have been listening, what would be important for your decision making? [Call on specific people who have been shy/quiet] 5. What motivated all of you to participate in the study? 6. Do you have any questions for the research team? Thank You and Conclusion • Thank the participants for their involvement. Let them know when they will receive their payment by email. • Provide an opportunity for participants to ask questions by email or direct messaging via Zoom with the research team. • Identify participants seeking more information and provide a list of free, confidential resources for support. Identify participants needing emotional support and provide them with contact information of counseling services affiliated with their region. 160 Appendix J Trauma-Informed Research Approach Trauma-informed care (TIC) in research: From the group discussion where Dr. Sarah Munro’s CHÉOS Lab members shared information about what trauma-informed care in research looks like from various assigned sources, some key themes emerged centered on safety and agency. Safety in research means not doing harm physically, emotionally, psychologically, and spiritually 1-2. It also means understanding that trauma is a blanket term that can be used to describe a single incident to genocide 3 so taking into account interpersonal and structural harms, and pro-actively preventing them4. Some strategies to uphold safety in research include creating a safe space for participants so they feel comfortable4-5, abolishing power-dynamics 7,2, and ensuring the research being done is necessary and considering who will benefit from the research and results1Safety in research also means providing participants and research staff with culturally-relevant information, resources, and opportunities to debrief and ask questions1. Additionally, it means not needing to know the specifics about the trauma yet still aiming to avoid re-traumatization of both persons served and staff8, promoting resilience2,5, and respecting their pronouns and intersections in identity 2 . Agency in research means ensuring participants have control during the research process so they are able to make informed choices based on transparent information7. Some examples of how agency is incorporated into research include asking participants for consent before and throughout the research process4,7,10-11 and utilizing their input in the creation of consent forms or interview guides3-4,11. It also means ensuring participants are able to pause or take breaks during the interview4, and providing them options throughout the process, such as choosing how or where to conduct the interview1. Implementing TIC strategies in research is especially important for equity-deserving communities including Indigenous communities since they continually face burdens at the individual and societal levels due to colonial policies and practices. Thus, they are even more susceptible to re-traumatization during the research process. Some further strategies to implement TIC in research when working with equity-deserving communities includes building trust with those communities4, ensuring the research is worthwhile and not causing harm to those communities by asking people who are part of those communities11. Researchers should work towards providing comforting and culturally relevant objects and practices like STS9 during the interview process and ensuring the research team is familiar with protocols like OCAP (Ownership, Control, Access, and Possession), cultural humility and cultural responsiveness4. Researchers must understand their individual positionality in their role, and identify their own social identity and biases7. Below is a list of dos and don’ts that highlight what to do to uphold TIC in research and what to avoid. Do’s Don’ts Consider positionality & be reflexive4,7 Pry about the type of trauma participants have experienced Be aware of Indigenous rights to research data and the relational process of research4 Take a one-size fits all approach4 Contextualize trauma within broader structures3,8, such as colonization and violence Advise, praise, agree or attempt to relate Consider the power dynamics between researcher and researched2,7 Ignore the vast array of experiences of trauma (from a single event to genocide) and not acknowledge that trauma is a blanket term3 161 Embed consent into all stages of the research for participants, and make this explicitly known4,9-11 Consciously center safety and evaluate the how that looks within your study7 Be aware of how comfortable participants feel5-6 and respect how participants conceptualize safety2 Co-design the study with participants3-4, 11 Post-data collection ensure you leave the participant feeling heard and validated8,11 Communicate to participants that the data collected will be used meaningfully and not cause harm 11 Consider incorporating Indigenous ways of being into research (ex. carrying medicines, STS practice)9 Provide culturally-relevant and diverse resources to participants when appropriate8 Consider ethical obligations you have around disclosure and make this clear to participants prior to starting the study 4 Empowerment of participants7 Do provide honoraria (ex. For time/expertise in completing the study, transportation and childcare costs) 4 Think about how researchers can practice self-care2 Build a mechanism to accept participant feedback4 To summarize, TIC in research promotes the safety and agency of participants and researchers to avoid re-traumatization and promote resilience2,5 . A TIC research approach is especially important when working with equity-deserving communities, like Indigenous Peoples. We hope researchers will adopt a TIC approach into their projects to create meaningful research that will avoid unintentionally harming participants and researchers, while also centering community voices. 162 Reference List 1. Isobel S. Trauma-informed qualitative research: Some methodological and practical considerations. Int J Ment Health Nurs. 2021;30(S1):1456–69. 2. Washington, P.S. Trauma Informed Peer Support webinar [Internet]. Ontario, Canada; 2016 [cited 2022 Nov 3]. Available from: https://www.youtube.com/watch?v=x2ahPGR5sEM 3. Clark N. Shock and Awe: Trauma as the New Colonial Frontier. Humanities. 2016 Mar;5(1):14. 4. Nonumura R, Giesbrecht C, Jivraj T, Lapp A, Bax K, Jenney A, et al. Toward A Trauma- And Violence-Informed Research Ethics Module: Considerations And Recommendations. Centre for Research & Education on Violence Against Women & Children, Western University. 2020;60. 5. Cahill E.P., Doyle A. Trauma-informed abortion care. Current Opinion in Obstetrics and Gynecology. 2021 Dec;33(6):453–7. 6. Phillips, K. Trauma Informed Storytelling webinar [Internet]. Ontario, Canada; 2016 [cited 2022 Nov 3]. Available from: https://www.youtube.com/watch?v=3b6rBbMGOCI 7. Voith L.A, Hamler T, Francis MW, Lee H, Korsch-Williams A. Using a Trauma-Informed, Socially Just Research Framework with Marginalized Populations: Practices and Barriers to Implementation. Social Work Research. 2020 Dec 14;44(3):169–81. 8. University of Buffalo School of Social Work. A Trauma-Informed Framework for Working with Abortion Seekers. :1. Available from: https://socialwork.buffalo.edu/content/dam/socialwork/home/infographics/Trauma-informed-abortion-seekers-diagram.pdf 9. First Nations Health Authority and Research Ethics BC. Trauma-informed practices for researchers during COVID-19 [Internet]. British Columbia: British Columbia Academic Health Science Network; 2021 [cited 2022 Oct]. Available from: https://www.bcahsn.ca/sites/default/files/2021-06/Culturally%20Safe%20and%20Trauma-Informed%20Practices%20for%20Researchers%20during%20COVID-19.pdf 10. Ipas. Trauma-informed care for abortion providers treating sexual violence survivors in humanitarian settings. 2022;46. 11. Patrick L, Thomas W, Slater J. Approaching Community-Engaged Research Through a Trauma Informed Lens [Internet]. SFU Community-Engaged Research Initiative. 2021 [cited 2022 Nov 3]. Available from: https://www.sfu.ca/ceri/archive/videos/$classNewsController.getPageURL() 163 Appendix K Invitation Email Template for Kitchen Table Talk Coming together at the kitchen table: Métis perspectives on developing better access to family planning care in BC Orientation email – Focus group We appreciate your interest to participate! This study aims to understand what experiences and perspectives Métis clients in BC have when accessing family planning care. The goal is to develop an access to care framework specifically for Métis clients of care in BC. This project is funded by a 4-year grant from the Canadian Institutes of Health Research. Participating in the study involves participating a focus group. In the focus group, a member of our research team will ask questions about abortion and contraception access. They will ask about things such as acceptance of family planning care in community, the cost of accessing family planning care (how does distance and finances impact your decisions), and how can we develop culturally safe services, and what do they currently look like. You can speak about your actual experiences or describe what would matter to you if you faced this decision in future. The focus group will last 2.5 hours and take place on Zoom. It is scheduled for Saturday February 24th, 2024 from 9:30am to 12pm Pacific Time. It will be in English, and the audio will be recorded. All identifiable information will be confidential. If you complete a focus group, you will receive a $100 e-transfer by email as a thank you. Your time and input to our study is valuable. First, we ask that you review and sign the attached consent form. It includes information about the study, explains how your data will be used and stored, and some of the potential benefits and risks of participating. If you have any questions, please contact me, Piper Scott-Fiddler. You can also reach Dr. Sarah Munro, the Principal Investigator, by email at (redacted), or by phone at (redacted). Thank you again for your interest in the Story project. Piper Scott-Fiddler, BA Graduate Student Faculty of Medicine, UBC On behalf of, Dr. Sarah Munro, PhD (Study Principal Investigator) Assistant Professor, Department of Health Systems and Population Health, School of Public Health University of Washington 164 Appendix L Email Template with Zoom Link and Agenda Good evening, I am looking forward to connecting with you and other folks tomorrow morning. I just wanted to note that our group will be about 10 Métis individuals and that you are more than welcome to have your camera off if needed. Although we won't be discussing our personal stories rather making recommendations based on experiences and knowledge. I am letting everyone know in advance that taking a breather or needing a break at any point is completely welcomed. This could look like turning your camera off and messaging me privately over zoom that you are taking a break, or leaving the Zoom and coming back in when ready. Please see below the rough schedule, there will be at least a 10-15 minute break in the middle of the workshop and we will be ending by noon. If you could please sign the consent form in order for the workshop to be graphically facilitated, it would be greatly appreciated. This could look like an e-signature on the form, a photo of the form printed and signed, ect. Please let me know if you are having any difficulties and we can figure something out 😊 9:30am: Opening words, intention setting 9:45am – 10:15am: Social and cultural determinants of access 10:15am – 10:45am: Communication Infrastructure 10:45am-10:55am: Break 10:55am – 11:15am: Cost 11:15am-11:50am: Culturally Safe Services 11:50am – 12pm: Closing remarks Take care, Piper 165 Appendix M Matriarch and Knowledge Keepers Values in Research Graphic Facilitation
Thesis/Dissertation
eng
Women+ and Children’s Health Sciences
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Hanley, Gillian E.
Munro, Sarah
Bridging stories : exploring métis experiences in accessing family planning services
Text