Exploring Métis health, spirituality and well-being: a patient-oriented community-based qualitative study with the Métis Nation of Alberta – Region 3
=========================================================================================================================================================

* Carla S. Ginn
* Craig W.C. Ginn
* Lawrence Gervais
* Judy Gentes
* Doreen Dumont Vaness Bergum
* Noelle Rees
* Travis Ronald
* Tom Doupé
* Ashley Camponi

## Abstract

**Background:** There is a lack of Métis-guided participatory research on factors that contribute to individual, family and community well-being, such as developing social support and engaging in cultural, social and historical processes for healing and health. The purpose of this study was to explore links among health, spirituality and well-being within the Métis Nation of Alberta (MNA) – Region 3.

**Methods:** In the largest of 12 MNA – Region 3 communities, together with a working group of 9 community members, informal and elected leaders, and an Elder, we codeveloped a qualitative structured survey exploring health, spirituality and well-being. Following face-to-face distribution of the paper survey to community members (February to March 2019), we engaged with 7 working group members in coding and theme development. Results were shared with the community.

**Results:** Thirty-one community members requested surveys, with 29 participants aged 28–80 years (mean 54.77 yr, standard deviation 15.31 yr) completing the surveys (94% completion rate). Six participants were in the working group that codeveloped the survey. An overarching theme of connection and 4 corresponding subthemes were identified; central to well-being was maintaining connection and balance in mental, emotional, spiritual and physical aspects of health. Connection to Métis ancestry required understanding identity; connection to community involved feeling at home; connection to land included belonging; and connection to tradition encompassed blending of cultures.

**Interpretation:** Connection among ancestry, land, community and tradition contributed to well-being in our sample. Under the direction of each MNA region, exploration of health, spirituality and well-being with the use of our survey could be considered in community-specific Métis-guided ways across the remaining 5 MNA regions; the survey may also be of use to other provincial bodies in the Métis Nation.

### **Plain language summary:**

There is much information about colonization, loss and marginalization among Métis people in Canada; however, more community-based research is needed about building community, developing social support, and engaging in cultural, social and historical practices for healing and health. In this study, we explored links between health, spirituality and well-being within the Métis Nation of Alberta (MNA) – Region 3. We met with elected MNA – Region 3 leaders to discuss potential study topics and discussed ways to go about the study. With a working group of community members, informal and elected leaders, and an Elder from MNA – Region 3, we codeveloped a survey and distributed it face to face in the largest of the 12 MNA – Region 3 communities (Calgary). We analyzed the survey results together and identified a main theme of connection: connection to Métis ancestry, to community, to land and to tradition. We plan to collaborate with our working group to codistribute, coanalyze and codisseminate the survey in community-specific ways throughout the other MNA – Region 3 communities to increase understanding about health, spirituality and well-being.

There are 3 groups of Indigenous peoples in Canada: First Nations, Métis and Inuit. “Métis” means a person who self-identifies as Métis, is distinct from other Indigenous peoples, is of historic Métis Nation ancestry and is accepted by the Métis Nation.1 In 1870, Métis leader Louis Riel negotiated Manitoba’s entrance into Canadian confederation and was subsequently exiled. Later, Métis people in Saskatchewan asked Riel to assist in obtaining titles for their land, and, when peaceful negotiations failed, Riel and Gabriel Dumont (a peacemaker who assisted First Nations people and who spoke Cree, Ojibwa, Sioux and Blackfoot fluently) waged a resistance against the Canadian government.2 Peaking at Batoche, Saskatchewan, in 1885, this struggle resulted in a battle in which 5000 Canadian soldiers fought 400 Métis and Cree. Métis families were scattered and forced into hiding.2,3 Riel gave himself up, received an unfair trial and was executed; many Métis leaders were jailed.2

In the late 19th and 20th centuries, further intergenerational trauma resulted from the forced transfer of Indigenous children (9% of whom were Métis) into residential schools, as well as the “Sixties Scoop,” in which thousands of Indigenous children were taken into foster care and adopted, in most cases by non-Indigenous families.3–6 Today, Indigenous children in foster care are among the most vulnerable children in Canada.7 Currently, 7% of children in Canada are Indigenous, yet Indigenous children account for 52% of children less than age 14 in care.8 In addition, 10% of children overall in Canada live in low-income families; this proportion increases to 50% for Indigenous children.9,10 Métis people continue to experience questioning of Indigenous identity, changes to traditional ways of life and a lack of legal rights.11

The Truth and Reconciliation Commission of Canada Calls to Action indicate that research arising from within First Nations, Métis and Inuit communities can promote equity and justice.12 Much research regarding detrimental effects of colonialism exists, but there is a lack of Métis-guided participatory research on factors that contribute to individual, family and community well-being, such as developing social support and engaging in cultural, social and historical processes for healing and health.13,14 In addition, there is an urgent need for research contributing to policy development to increase health equity for Indigenous people.15

The objective of this study was to explore links among health, spirituality and well-being within the Métis Nation of Alberta (MNA) – Region 3. Our research question was: “What are the ways that health, spirituality and well-being are connected?”

## Methods

### Setting

Alberta has the highest number of Métis people in Canada. More than 114 375 self-identified and 42 000 registered Métis people live within 6 MNA regions.16 This patient-oriented community-based study took place in Calgary, the largest of the 12 MNA – Region 3 communities.

### Design

The purpose of this patient-oriented community-based qualitative study was to develop and administer a structured survey exploring links among health, well-being and spirituality in MNA – Region 3. Following Tri-Council Policy Statement-2 guidelines,17 we engaged respectfully with community members, informal and elected leaders, and an Elder of the region for the study.

Three theoretical frameworks grounded our research. First, we incorporated Indigenous ways of knowing, a belief in the connectedness of all things with transmission from generation to generation.18,19

Second, we used the principles of participatory action research, influenced by Lewin,20 who questioned the permanence of social change without community involvement, emphasizing the harmful effects of colonialism. The concept of participatory-action research was developed by Freire21 (placing those being researched at the centre of knowledge translation) and Fals-Borda22 (assisting grassroots groups to incorporate local knowledge into change).

Finally, we framed the study using the International Association for Public Participation Spectrum of Public Participation ([https://iap2canada.ca/](https://iap2canada.ca/)) (Figure 1). We collaborated with MNA – Region 3 community members, informal and elected leaders, and an Elder to engage in meaningful Métis-led research in which they eventually became the decision-makers regarding survey development, distribution, analysis and dissemination (Figure 1).

![Figure 1:](http://www.cmajopen.ca/https://www.cmajopen.ca/content/cmajo/9/2/E451/F1.medium.gif)

[Figure 1:](http://www.cmajopen.ca/content/9/2/E451/F1)

Figure 1: 
International Association for Public Participation (IAP2) Spectrum of Public Participation. © International Association for Public Participation ([www.iap2.org](http://www.iap2.org)). Reproduced with permission.

### Participants

Our target population was the 14 000 registered MNA members 18 years of age or more residing in MNA – Region 3, specifically those living in Calgary and surrounding area (6300 members). We excluded those who self-identified as Métis but were not registered by the MNA.

### Data sources and collection

The structured qualitative survey that was developed included all ideas and areas of interest brought forward by 9 working group members (community members, informal and elected leaders, and an Elder of MNA – Region 3) from November 2018 to January 2019, in conjunction with 2 authors (C.S.G. and C.W.C.G.). More details on community and patient involvement in the development of the survey are provided in the patient engagement section.

The survey was approved by the elected leaders of MNA – Region 3 for distribution in early February 2019. The survey was paper-based; it contained checkboxes for areas of interest on the first page and 5 open-ended questions spread over 5 pages, with space for writing ideas and answers (Appendix 1, available at [www.cmajopen.ca/content/9/2/E451/suppl/DC1](http://www.cmajopen.ca/content/9/2/E451/suppl/DC1)).

As recommended by elected community leaders, data collection occurred face to face at 2 MNA – Region 3 community “mixers” (monthly social events), in February and March 2019. Two authors (C.S.G. and C.W.C.G.) introduced the study, described the process of survey development, reviewed informed consent procedures and invited interested people aged 19 or more to participate. Questions were discussed, written consent was acquired, and surveys were completed individually or in groups, as per participant preference, at tables scattered throughout the room.

### Patient engagement

Our research was guided by the National Aboriginal Health Organization principles of ethical Métis research, including building reciprocal relationships, respecting practices and protocols, recognizing diversity, researching with outcomes of relevance, and understanding relevant Métis history including straddled worldviews.23 Crucial to our research was the involvement of author C.W.C.G., a member of MNA – Region 3 who had explored interest in engagement in research over the previous few years with community leaders.

We formally met with the elected leaders of MNA – Region 3 in April 2018 to inquire about the possibility of a study, potential topics and how to conduct the research. They suggested exploring issues surrounding health, spirituality and well-being, and recruiting volunteers through community mixers, to which all MNA – Region 3 members are invited.

At an October 2018 mixer, all MNA – Region 3 members over the age of 18 were invited to participate in survey development through working groups. During the first working group meeting, in November 2018, 7 participants discussed meaningful survey ideas and questions to explore links among health, spirituality and well-being. Six participants attended a second working group in January 2019, at which the draft survey was completed (3 participants from the first working group were absent, and 2 new participants attended). At both working group meetings, a community member (A.C.) and research team member (C.S.G.) took notes while attendees discussed areas of importance for survey inclusion regarding health, spirituality and well-being.

Working group members also participated in data analysis; those who participated in data analysis are coauthors (L.G., J.G., D.D.V.B., N.R., T.R., T.D. and A.C.). As well, working group members participated in dissemination and affirmation of the initial findings and final study results at a May 2019 mixer and an October 2019 mixer, respectively.

After data collection, the survey was revised by a survey design expert (a research associate in the Nursing Research Office, Faculty of Nursing, University of Calgary) and was subsequently approved by MNA – Region 3 elected leaders for codistribution in community-specific ways throughout the remaining MNA – Region 3 communities.

### Data analysis

We de-identified, scanned and transcribed the surveys. Working group members who had codeveloped the survey were invited to participate in data analysis, and 7 volunteered.

In April 2019, we engaged with this working group of community members, informal and elected leaders, and an Elder in participatory coding and theme development.24,25 All survey data were laid out on a large table on separately printed pieces of paper. Participants picked up written statements that held the most meaning to them, discussed why and placed them in piles, developing themes. An overarching theme and subthemes were identified by working group members.

Throughout the process of data analysis, stories were shared as written statements brought up memories and additional ideas for themes. No limit was placed on the amount of statements that could be chosen, and no limit was placed on the number of themes. Differences of opinion as to the most salient content and themes were resolved through group discussion.

Two authors (C.S.G. and C.W.C.G.) drafted an initial manuscript, which was disseminated to the working group for further insight, questions and validation. This data analysis process and initial results were discussed and affirmed at an MNA – Region 3 mixer in May 2019. At an October 2019 mixer, working group members codisseminated the study results, which were discussed and affirmed within the larger community.

### Ethics approval

We obtained ethics approval from the University of Calgary Conjoint Health Research Ethics Board (REB18-0433).

## Results

Thirty-one community members requested surveys, and 29 participants completed surveys (completion rate 94%). Of the 29 surveys completed, 6 were from participants who had been in the working group that codeveloped the survey. Participants ranged in age from 28 to 80 years (mean 54.77 yr, standard deviation 15.31 yr).

An overarching theme of connection and 4 corresponding subthemes were identified: connection to Métis ancestry, connection to community, connection to land and connection to tradition (Table 1).

View this table:
[Table 1:](http://www.cmajopen.ca/content/9/2/E451/T1)

Table 1: 
Quotes supporting primary theme and subthemes

### Connection

Maintaining connection and balance in mental, emotional, spiritual and physical aspects of health was central to well-being for participants. Practices maintaining connection and balance included prayer, exercise, smudging, teaching of the Elders, sharing circles, cultural field trips, Lac Ste. Anne pilgrimages, learning about history, nutrition, having patience, quitting drinking, open-mindedness, self-control and self-assessment. Addiction and spirituality were described as powerful opposites with deep effects.

#### Connection to Métis ancestry

Some participants had always been aware of their Métis identity, whereas discovery of Métis ancestry happened later for others. Because of the residential schools and the Sixties Scoop, many families hid their Métis identity. Historical and ongoing tension surrounding personal disclosure of Métis identity existed for many participants. In relation to Métis ancestry, experiences of racism had occurred in conjunction with experiences of belonging.

#### Connection to community

Health, spirituality and well-being were all connected to Métis identity and community. Participants identified intergenerational effects of trauma on individual and community healing and wholeness, with much emphasis on breaking cycles of addiction and violence. Participants wrote about hopelessness being replaced with healing and wholeness through connection with culture, language, spirituality, religion and self-governance at the individual and community level.

#### Connection to land

Connection to land and community contributed to health and well-being but had been interrupted. Fostering connection to land included passing on historical knowledge and traditions through music, art, games, jigging (a traditional dance usually accompanied by the fiddle), smudging and being connected to heart in the context of community.

#### Connection to tradition

Connection to Indigenous and Roman Catholic traditions of wellness and healing included actions, practices and rituals. Participants wrote about respecting all spiritual practices, describing how spirituality and identity were deeply connected with Métis cultural traditions.

## **I**nterpretation

In this community-based participatory qualitative study in which we engaged with members, informal and elected leaders, and an Elder in the largest MNA – Region 3 community to codevelop, coanalyze and codisseminate a survey exploring health, spirituality, and well-being, our participants described the importance of telling their stories, sharing who they are, and pursuing well-being for themselves and their community. An overarching theme of connection emerged, to Métis ancestry, to community, to land and to tradition.

Our findings of connection coincide with the National Aboriginal Health Organization’s historical, current and future determinants of Métis health.26 Historical determinants were colonialism, racism, marginalization, lack of Métis rights and lack of Métis land, and determinants moving forward are loss of culture, and Métis knowledge, language and spirituality. Other current and future determinants include self-determination, resiliency, healing, resurgency and education.27

Some participants in our study had always known they were Métis, whereas others discovered it later in life; tension between hiding and revealing identity was common. Passing as “White” had been used as a survival tactic and could contribute to decreased connection with spirituality.28 Participants noted that hiding or “passing” was not conducive to well-being. Findings from a 2018 federal government emergency meeting regarding the high number of Indigenous children in care identified ignorance among child welfare authorities about who the Métis people are as a key factor.8 Métis children are overrepresented and unrecognized in Canada’s child welfare systems, and Métis people are more likely than non-Indigenous Canadians to experience health and social challenges, with resulting social work involvement.29

Health, spirituality and well-being occur in community, and, although our participants described individual and community wholeness and healing, they also described effects of trauma and the need to break intergenerational cycles of addiction and abuse. Impacts of residential school on former attendees and subsequent generations include poorer physical health, increased rates of chronic and infectious disease, mental distress, depression, addiction, substance misuse, increased stress and suicidal behaviour; past collective trauma affects current health.26,30 Managing intergenerational trauma, resultant health disparities and ongoing structural violence requires protective buffers including decolonizing strategies such as self-determination and self-governance, identity formation such as cultural engagement and culturally adapted interventions that address historical trauma.31

On June 27, 2019, the MNA signed the first agreement between a Métis Nation and the Government of Canada, with a clearly defined process to implement Métis jurisdiction in core areas of self-government.32 Participants in our study described wanting to reconnect with land and how they were seeking reparation for wrongs done in their families and communities. The Canadian government has moved slowly regarding Métis land claims.33 Each generation of Métis people has experienced challenges, with resultant resilience, determination, independence and a strong, adaptable work ethic; current challenges include reconnecting with Métis identity, culture and tradition.34

Participants attributed well-being to connection with spirituality, including Indigenous and Roman Catholic traditions of wellness and healing. Some practised Roman Catholic traditions, viewing God as Creator, others blended Indigenous traditions with Roman Catholic beliefs, and some included more than 1 religious tradition in their actions, practices and rituals. This hybridity was evident in the life of Louis Riel, a devout Roman Catholic who also embraced Indigenous spirituality.28 Participants emphasized honouring and respecting different cultures and spiritual practices, including praying, smudging, sweats and picking sacred plants used as medicines.

Maintaining connection to Métis ancestry, to community, to land and to tradition presents a potential for increased health and well-being, and healing intergenerational trauma. Engaging in community pilgrimages to sacred sites and cultural tours to historical sites may contribute to individual, family and community health, spirituality and well-being. In addition, communities may benefit from meeting together regularly to participate in meaningful activities, focused on balancing mental, emotional, spiritual and physical health.

This survey was approved by the elected leaders of MNA – Region 3 for face-to-face codistribution in community-specific ways throughout the 12 communities of MNA – Region 3. Under the direction of each MNA region, further exploration of health, spirituality and well-being by means of Métis-guided community-based research specific to each community could be considered across the 5 other MNA regions; other provincial bodies in the Métis Nation may also find the survey of use.

### Limitations

Limitations of our study include a small sample in 1 geographic area; therefore, our findings may not be generalizable to the entire MNA – Region 3 or beyond. We collected only date of birth from participants, which limited our ability to describe their demographic characteristics. We did not pretest individual questions within the survey or the survey as a whole. Completing the survey by hand was labour intensive and may have limited responses. In addition, response bias may have occurred through distribution at community mixers. Some people may have preferred the anonymity and convenience of electronic distribution, which may have affected their decision to participate or the quality of their responses. Distribution only to those who attended the mixers may have resulted in the engagement of a different group than those who did not attend (e.g., older community members), which also may have resulted in response bias. Finally, we were unable to calculate a response rate, as the number of members attending each mixer was not recorded; this may have resulted in response bias.

### Lessons learned from patient engagement

Engaging the MNA – Region 3 community in this patient-oriented community-based qualitative study in codeveloping, coanalyzing and codisseminating results of the survey presented an opportunity for increased individual and community knowledge regarding Métis identity and ancestry, health, spirituality and well-being; increased research capacity within MNA – Region 3; increased collaboration in community-led identification of priorities for community-initiated funding and policy development; and contributed to increased understanding regarding individual, family and community well-being within MNA – Region 3. Participants described the importance of telling their stories, sharing who they are and persisting in pursuing well-being for themselves and their communities.

### Conclusion

In the largest of the 12 MNA – Region 3 communities, connection emerged as the overarching theme of a qualitative structured survey exploring health, spirituality and well-being. Connection to Métis ancestry, connection to community, connection to land and connection to tradition contributed to healing and well-being. This research will contribute to opportunities for further research with the survey in collaboration with other MNA regions, in Métis-guided, patient-oriented, community-specific ways. The findings have the potential for improving patient outcomes by increasing health care providers’ knowledge of who Métis people are.

## Acknowledgements

The authors honour the memory of Marlene Lanz, who was the Regional President of MNA – Region 3 when they began this project and encouraged them to keep moving forward. The authors thank the Elders, leaders and community members who participated in survey development and data collection and analysis.

## Footnotes

*   **Competing interests:** None declared.

*   This article has been peer reviewed.

*   **Contributors:** Carla Ginn and Craig Ginn conceived of and designed the study and drafted the manuscript. All of the authors contributed to survey development, analyzed the data, revised the manuscript critically for important intellectual content, approved the final version to be published and agreed to be accountable for all aspects of the work.

*   **Funding:** This study was supported by a research stipend (project 10016275) from the Faculty of Nursing, University of Calgary.

*   **Data sharing:** Survey data are available from the corresponding author on request.

*   **Supplemental information:** For reviewer comments and the original submission of this manuscript, please see [www.cmajopen.ca/content/9/2/E451/suppl/DC1](http://www.cmajopen.ca/content/9/2/E451/suppl/DC1).

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

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