Culturally safe health and social service access for urban Métis women: a scoping review

Métis people, one of Canada’s three constitutionally recognized Indigenous groups, experience detrimental impacts on their health, identity, and access to culturally safe services as a result of colonial systems and policies. There is also a critical gap in research surrounding the health of urban Métis women. This scoping review aims to explore the experiences of Métis women seeking to access culturally safe health and social services in urban settings across Canada. To conduct this knowledge synthesis, the authors applied a decolonizing methodological approach to Arksey and O’Malley’s framework for conducting a scoping search. A thematical analysis of relevant literature identified three interwoven themes: (a) racism, discrimination, and marginalization; (b) jurisdictional barriers to health and social services; and (c) lack of culturally safe care. The article concludes with opportunities and recommendations for further development to support culturally safe health and social service access for urban Métis communities.


Introduction
Métis people are one of three constitutionally recognized groups of Indigenous peoples in Canada.Nested within fur trade relationships, Métis people have developed distinct cultures, languages, identities, and ways of life (Auger et al., 2022;Macdougall, 2017).While majority of Métis people in Canada today live in urban contexts, there is a critical gap in health data and literature surrounding the experiences and availability of culturally safe health and social services for Métis people living in urban homelands (Smylie et al., 2011;Urban Aboriginal Knowledge Network, 2013).This is worrisome, as available data highlight that while Métis people comprise 35% of the Indigenous population (Statistics Canada, 2021), they experience major disparities in health determinants and outcomes compared to non-Indigenous Canadians (Monchalin, Smylie, & Nowgesic, 2020).Métis people's current health determinants, outcomes, and the lack of availability of culturally safe services are largely the result of historical and ongoing colonial practices and policies.These practices and policies have dispossessed and dislocated Métis communities from their kinship networks, languages, lands, and culture and are perpetuated in part due to an ongoing lack of recognition of Métis people's unique experiences and contemporary presence in urban homelands across Canada (Macdougall, 2017;Monchalin, Smylie, & Nowgesic, 2020;Urban Aboriginal Knowledge Network, 2013).Colonial practices also obscure the reality that many Canadian cities reside on traditional lands of the Métis and other Indigenous groups (Newhouse & Peters, 2003).For example, the city of Winnipeg is home to the largest Métis population of any Canadian city.Winnipeg has been a traditional gathering place for Indigenous peoples for thousands of years and originates on the basis of Nations conducting trade and participating in ceremony (Burley, 2014).Although many urban Metis people across Canada are in fact living within their ancestral homelands, there is a significant gap in health and social services that are culturally safe for Métis (Macdougall, 2017).
While Métis people as a whole are subject to health inequities relative to the non-Indigenous population, disparities in health outcomes within Métis communities have been argued to be more prominent among Métis women.The literature suggests that health and well-being of Métis women have been shaped by gender discrimination and the intergenerational and ongoing impacts of colonialism, resulting in Metis women being distinctly and disproportionately subject to harm when accessing health care (Desmarais, 2017;Jones et al., 2020;Monchalin, Smylie, & Dupre, 2020;Turpel-Lafond & Johnson, 2021).For example, Desmarais (2017) draws attention to the experiences of Métis Women Elders in relation to their male counterparts.She notes how Métis women have fewer social, political, and economic resources and less power, resulting in negative impacts on the health of Métis Women Elders and their ability to access necessary health care.Research in Toronto, Ontario found that the influence of patriarchy as it related to Métis identity, health, and wellness contributed to unique gender-based barriers to health service access for Métis women (Monchalin, Smylie, & Dupre, 2020).Gender-based health disparities were further identified within a recent report titled, In Plain Sight: Addressing Indigenous-specific racism and Discrimination Within the B.C. Health Care, which found that Métis women are disproportionately affected by poor health compared to their male counterparts.In the reports' analysis of acute and chronic disease data, half of Métis women in British Columbia.were found to experience five or more health conditions by the time they reached early adulthood, which is over twice the rate seen within both Métis males and non-Indigenous females (Turpel-Lafond & Johnson, 2021).
This scoping review aims to explore health and social services for Métis women in urban homelands across Canada by identifying research gaps and opportunities for further development.Through applying a decolonizing methodological approach to Arksey and O'Malley's (2005) scoping review framework, the authors present the study methods, including data sources, search strategy, and eligibility criteria, and search terms utilized for this study.The authors then share and discuss the overarching themes identified within the literature: (a) racism, discrimination, and marginalization; (b) jurisdictional barriers to health and social services; and (c) lack of culturally safe care.The scoping review concludes with opportunities and recommendations for further development to support culturally safe health and social service access for urban Métis communities.Chambers et al. (2018) argue that when a scoping review on Indigenous health is conducted from a Western paradigm alone, researchers are at risk of propagating the dominance of Western ways of knowing at the expense of Indigenous epistemologies.In contrast to Western approaches, Smith (2021) identifies four primary purposes of an Indigenous research agenda: to decolonize, transform, mobilize, and heal Indigenous communities from the effects of colonial oppression.Accordingly, the research team sought to engage in a methodological process that valued Métis ways of knowing and contributed to a collective vision for healthy futures within urban Métis homelands.Conversations for this work began around our kitchen tables and living rooms during the project entitled Our Health Counts Toronto (OHC), a longitudinal cohort study co-led by the Well Living House (WLH) and Seventh Generation Midwives Toronto (SGMT) in 2015 and 2016 (WLH, 2015).Upon learning from OHC that Métis people in Toronto needed health care services but did not receive them, the second author (R.M.) conducted an in-depth, follow-up study in 2018-2019 for their doctoral research project under supervision of the third author (J.S.) and in partnership with WLH and SGMT (Monchalin et al., 2019;Monchalin, Smylie, & Dupre, 2020;Monchalin, Smylie, & Nowgesic, 2020).This research involved conversations with 11 self-identifying Métis women living in and or accessing health and social services in Toronto.Results highlighted the lack of access to culturally safe services due to racism and discrimination, lateral violence between First Nations and Métis people, and the influence of patriarchy as it relates to Métis identity, health, and wellness.

Decolonizing the scoping review process
Based on this information, the research team applied to and received a Canadian Institutes of Health Research planning grant titled, Ka niisho atooshkayhk (working together): Improving access to culturally safe Health and Social Services for urban Métis people.The goal of this grant was to further explore the relevance and appropriateness of health and social services for Métis women living, working, and accessing health and social services in urban homelands through conducting a scoping review and hosting community gathering.Due to COVID-19, the authors hosted a virtual community gathering in November 2020 titled Métis Women, Two-Spirit People & COVID-19: A Kitchen Table Conversation.This panel invited three Métis community members who work on the front lines of health and social services to exchange knowledge, stories, and experiences with respect to service access during COVID-19.The panel audience consisted of Métis community members, health and social service providers, and academics.One audience member shared, "It was the first time I've seen representation of Two-Spirit Métis anywhere.I am so grateful" (Community member).This virtual gathering refined scoping review priorities, as many community member attendees expressed an urgent need for culturally safe health and social services for urban Métis women, Two-Spirit, and gender diverse people.
Building on engagement with the Métis community, this scoping review is also informed by the authors' personal, family, and communities' experiences as Métis people accessing health and social services in our various communities, and a collective vision for healthy futures within urban Métis homelands.This research is an effort by and for Métis women seeking to do what needs to be done to remove barriers for community well-being.The authors' hope is that the impact of this research will extend beyond academia to directly benefit our communities.

Methods
This scoping review applied a decolonizing methodological approach to Arksey and O'Malley's framework for conducting a scoping search.Arskey and O'Malley (2005) outline five steps within their scoping framework: (a) identifying the research question; (b) identifying relevant studies; (c) study selection; (d) charting the data; and (e) collating, summarizing, and reporting the results.The research team identified a scoping review as the most practical approach because our purpose was to determine gaps in research and opportunities for development, while raising awareness of the dearth in Métis-specific health service research.This approach to literature synthesis is also considered ideal for topical areas where evidence is emerging or complex, or the depth of evidence is relatively unknown (Chambers et al., 2018).Our team came to consensus on inclusion and exclusion criteria.The first two authors collaborated to screen all articles, meeting regularly during the screening progress to dialogue and reach consensus surrounding any concerns with the data, which for the most part related to a lack of clarity surrounding a report's breakdown of findings.We extracted and charted the data using a standardized data extraction form (Supplementary Material 1) and used a thematic analysis to identify themes within the literature.

Data sources and search strategy
The research question that guided this scoping review was: What are the experiences of Métis women (inclusive of all those who self-identify as women, including Two-Spirit, trans, and queer identifying Métis community members) seeking to access culturally safe health and social services in urban settings?To identify relevant literature, a comprehensive search strategy was developed through conversations among the research team and with assistance from a librarian at the first and second authors' university.The strategy was conducted in August and September 2020.It was broad in scope and included several electronic databases, an extensive gray literature search, and citation snowballing.Electronic databases that covered a wide range of disciplines were searched for literature, including MEDLINE, PsycINFO, JSTOR, EBMR, Journals@Ovid, and CINAHL.Additional searching within databases that center Indigenous sources such as Indigenous Studies Portal and Native Health Database was conducted by hand.To minimize the risk of exclusion of relevant literature, we also carried out advanced searches in Google, reviewed the content on relevant community websites, and searched other sources recommended by our relational network.Any relevant sources, including gray and unindexed literature, were included in the search.
All citations, along with abstracts, were imported or manually entered into the reference manager Mendeley.Duplicates were removed manually after assembling citations.Associated full-text articles were then added.Studies identified by the database search, hand-searches, or citation snowballing were screened for relevance.Citations within articles were searched if they appeared relevant to the scoping review.This snowball technique was adopted to ensure a comprehensive and thorough search.

Eligibility criteria, procedure, search terms
Our search terms and eligibility criteria were developed through dialogue and consensus among the research team.Terms included "Métis OR Michif OR Halfbreed" AND "Health OR Health Access OR Social Service Access OR Health Programming OR Public Health" OR, AND "Identity OR Racism OR Discrimination" AND "Cultural Safety OR Culturally Safe OR Culturally Relevant" AND "Women OR Two-Spirit OR Trans OR Gender Diverse OR Queer" AND "COVID-19 OR Coronavirus OR Pandemic." The scoping selection was subject to three inclusion criteria: (a) available in English or French, (b) includes a specific focus on urban Métis people, and (c) has a focus on health or social service access.We did not include year of publication minimum given the limited research that is available.Research was excluded if it did not include an urban Métis-specific breakdown of findings, had only male-identified participants, or was reported in a language other than English or French.

Results
The initial search of electronic databases yielded 1,304 articles, where 66 duplicates were removed.Title and abstract screening identified 235 articles for full-text review.Full-text screening yielded nine articles for systematic analysis.The references cited within the literature included in the systematic review were manually examined, which produced a further two records to be included.Manual review of relevant community websites identified one additional article, for a total of 12 records eligible to be included for synthesis.The included reports were synthesized using thematic synthesis-where data were organized into common themes according to our review questions regarding the experiences of Métis women seeking to access culturally safe health and social services in urban settings across Canada.
The final 12 records included findings from research conducted in cities within Ontario, British Columbia, Alberta, Saskatchewan, and Manitoba.Of the various study designs, qualitative methodologies, including grounded theory and an Indigenous narrative approach, were most commonly featured (n = 11).Among these 12 articles, five (n = 5) reports incorporated a mixed-methods approach.For example, Infinity Consulting (2010) included a literature review on Métis maternal and child health as well as qualitative analysis of transcripts from interviews and gatherings held for a Métis community-based DVD project, while Wesche (2013) drew from semi-structured interviews with Métis women in addition to focus groups with service providers.Studies reported drawing from analytical frameworks including the Metis Life Promotion Framework, Social Determinant of Health Framework, Indigenous Feminist Theory, Critical Theories Paradigm, and Genderbased Analysis Plus.Below, we report on the scoping review themes based on our research question: What are the experiences of Métis women seeking access to culturally safe health and social services in urban settings?

Experiences and availability of culturally safe health and social services for Métis women in urban homelands
The thematical analysis identified three interwoven themes that highlighted the experiences of urban Métis women seeking to access culturally safe health and social services: (a) racism, discrimination, and marginalization; (b) jurisdictional barriers to health and social services; and (c) lack of culturally safe care.It is important to note that these themes are not mutually exclusive.Rather, the experiences of Métis women accessing health and social services are multi-faceted and intersect in complex ways.

Racism, discrimination, and marginalization
A prominent theme within the reviewed literature was urban Métis women's experiences of racism, discrimination, and marginalization when accessing both mainstream and Indigenous-specific health and social services.This included fearing, witnessing, and experiencing racism and discrimination, experiencing judgment from health service providers, and having identity questioned.For example, Monchalin, Smylie, and Nowgesic (2020) found that Métis women attempting to access mainstream health and social services described not receiving the services they needed due fear of, or experiences with, racism and discrimination.Participants described witnessing and facing racism from health providers, denial of access to needed pain medication and services, discrimination from health care providers toward ceremonial practices, sexism, judgment, and even assault.Infinity Consulting (2010) further found that pregnant Métis women face discrimination and judgment from health care providers due to the widespread stereotype that Indigenous women have too many children or are unable to care for their children.A similar finding was shared by Monchalin, Smylie, and Nowgesic (2020) whose research reported that Métis women in Toronto would sometimes refrain from disclosing their Métis identity to avoid risk of child apprehension due to anti-Indigenous stereotyping.Métis women would also try to pass, meaning to shift their racial reference group, including to other groups of color, to avoid discrimination from service providers for their Métis identity (Fiola, 2012).
While Métis women within the literature reported negative experiences accessing urban mainstream services, many also described experiences of marginalization and discrimination when accessing Indigenous-specific services.Some Métis women in the study by Monchalin, Smylie, and Dupre (2020) shared their uncomfortable experiences with male employees in Indigenous health and social service centers.Métis women also reported discomfort accessing Indigenous services due to perceptions they were not Native enough, while others experienced having their identity questioned by reception staff (Kumar et al., 2012;Monchalin, Smylie, & Nowgesic, 2020).In total, eight (n = 8) studies in this scoping review found that Métis women would experience discrimination when accessing Indigenous-specific services, while six (n = 6) reported that Indigenous-specific services were focused on the priorities of First Nations People or would overlook the diversity within urban Indigenous populations, including Métis-specific needs.Similar to non-Indigenous health providers, participants in research conducted by Wesche (2013) noted that even Indigenous health providers can have a limited awareness of Métis identity.Ghosh and Spitzer (2014) found that many health providers were either unaware of the cultural diversities within and between Indigenous populations or found it too complex to consider in their scope of practice.A key informant within a report by Les Femmes Michif Otipemisiwak-Women of the Métis Nation (2019) suggested that many service providers do not even recognize Métis women as belonging to an Indigenous group at all.

Jurisdictional barriers to health and social services
An overarching theme within the identified literature was the lasting impact of jurisdictional barriers on the health and well-being of Métis women living in cities.This included Métis women being denied access to health services meant for First Nations people and confusion on eligibility of services by both Métis women and service providers.The literature demonstrates at the systemic level, health and social service provision in Canadian cities perpetuate inequitable and exclusionary policies and practices that contribute to barriers to service access for Métis women.A commonly identified barrier was the exclusion of Métis from federally administered Indigenous health initiatives, which results in limited funding opportunities for Métis-specific service provision and contributes to gaps in culturally safe service options (Barron-Mcnabb, 2009; Les Femmes Michif Otipemisiwak-Women of the Métis Nation, 2019; Wesche, 2013).For example, Ghosh and Spitzer (2014) found that urban Métis women in Ontario are denied equitable access to diabetes prevention and support services, whereas each woman interviewed by Barron-Mcnabb (2009) stated that they either experienced or witnessed problems related to accessing health services and programs as a result of jurisdictional issues.Barron-McNabb further described how arbitrarily imposed entitlements have contributed to confusion among both Métis women and their health providers, creating a widespread lack of awareness regarding what health services are available to them.These inequities were also found to further exacerbate Métis women's experiences of the earlier theme of racism and discrimination.As not only were Métis women impacted by exclusion from federal Indigenous health initiatives, but also experience discrimination when accessing mainstream health services and programs (Barron-Mcnabb, 2009).
Across the literature, Métis women's lack of entitlement to the Non-Insured Health Benefits (NIHB) Program, which provides health benefits such as prescription drugs, vision, and dental coverage for eligible First Nations and Inuit people residing in Canada, was widely identified as a barrier to urban health access.The literature suggests that a lack of coverage through NIHB imposes a unique hardship on Métis women, who experience higher rates of unemployment, underemployment, and poverty compared to non-Indigenous Canadians and Métis men (Desmarais, 2017;Haworth-Brockman et al., 2009).Desmarais (2017) notes that Métis Women Elders typically have fewer resources than their male counterparts and are less likely to benefit from a pension or employment-related supplementary health insurance.Similarly, Les Femmes Michif Otipemisiwak-Women of the Métis Nation (2019) shared that many Métis women cannot afford counseling and do not have benefits or funds to pay for services, "so they are suffering in silence" (p.68).Ghosh and Spitzer (2014) echoed that a lack of access to NIHB creates considerable challenges in either preventing diabetes or slowing its progress and discussed the unmet need for monetary supports to cover medications, supplies, and healthy foods.In a study by Iwasaki et al. (2005), Métis women also reported rationing both food and medications due to marginal economic conditions and high costs associated with living with diabetes.Overall, six (n = 6) studies identified limited income as a barrier for urban Métis women to access necessary health and social services or supplies.

Lack of culturally safe care
The literature reviewed in this search outlined significant gaps in the availability of culturally safe health and social services for Métis women living in cities across Canada.The paucity of culturally safe options was described by one Métis woman as not a gap in services but "a giant hole" (Les Femmes Michif Otipemisiwak-Women of the Métis Nation, 2019, p. 68).There are very few Métisspecific services; and even less that are specific to women (Barron-Mcnabb, 2009;Dyck, 2008;Les Femmes Michif Otipemisiwak-Women of the Métis Nation, 2019;Wesche, 2013).Examples of gaps in culturally safe health and social services include a lack of health services offering holistic approaches, a lack of health care providers who speak their language of choice, and an overall lack of Indigenous health care providers (Barron-Mcnabb, 2009;Infinity Consulting, 2010;Wesche, 2013).Urban Métis women report little to no availability of Métis-specific programs or services, and limited opportunities for Métis women to connect with traditional Métis knowledge and health practices.The literature further suggests gaps in culturally safe services persist across multiple service sectors including mental health, victim services, reproductive and maternal health, legal services, diabetes supports, supports for Elders, and services addressing urban food insecurity.Urban Métis women report having to self-advocate for basic service needs while also having to educate service providers on what is culturally safe (Ghosh & Spitzer, 2014;Les Femmes Michif Otipemisiwak-Women of the Métis Nation, 2019;Monchalin, Smylie, & Dupre, 2020).At the same time, Métis women also report that they are often not listened to or taken seriously by medical professionals (Les Femmes Michif Otipemisiwak-Women of the Métis Nation, 2019; Monchalin, Smylie, & Nowgesic, 2020).
The literature demonstrated that many urban Métis women shared the perception that of the few culturally safe services that do exist, they are not safe or accessible to all Métis women.For example, urban Métis women who participated in research by Monchalin, Smylie, and Dupre (2020) spoke of Indigenous men at Indigenousspecific services being harmful and shared experiences of male organizational leaders being disrespectful and dominating discourse and policies regarding Métis identity and wellness.Similarly, participants in Desmarais (2017) identified political turmoil within Métis organizations, a barrier to community connection and health access for Métis Women Elders.Key informants in British Columbia and Manitoba pointed out that while there are Métis-specific supports for families, Métis women without children are unable to access these services, and there are often no other targeted services for Métis women in their respective communities (Les Femmes Michif Otipemisiwak-Women of the Métis Nation, 2019).The same report noted that many service providers working with urban Métis women face capacity issues and are often overworked and under-resourced.As a result, Métis women experience long wait times or are turned away because providers may not accept new clients.Desmarais (2013Desmarais ( , 2017) ) found that poverty and the high cost of transportation were barriers for women Elders to access both Métis community supports and necessary health services, while participants in Ghosh and Spitzer (2014) shared how services tend to be concentrated in the downtown core and were difficult or impossible to access for Métis people living in other areas of the city.

Discussion
Métis women living within urban homelands face a multitude of barriers to accessing health and social services.Across the available literature, barriers include experiencing, witnessing, and fearing racism and discrimination, jurisdictional inequities, including being denied services, or experiencing confusion on service eligibility, and an overall lack of culturally safe services for Métis women.Cultural safety was defined as having access to holistic health services, Indigenous service providers, being able to speak in their language of choice, Métis-specific programming, and opportunities to connection with traditional Métis health knowledge and practices for example.
For the theme of racism and discrimination, Monchalin, Smylie, and Nowgesic (2020) note that Métis people are often left out of discourses surrounding racism and health and social service access.Allan and Smylie (2015) highlight how racism serves as a major barrier in access to health care, leading to delayed, lack of, and avoidance of treatment.Allan and Smylie breakdown racism into four different types as defined by Paradies et al. (2008): (a) systemic racism, also known as structural or institutional racism; (b) interpersonal racism, also known as racism occurring between people; (c) epistemic racism, which includes judgment of which knowledge is considered valuable; and (d) internalized racism, which is the internalization of negative, stereotypical beliefs of one's racial group.This scoping review demonstrates that urban Métis women would experience racism and discrimination in mainstream services through each of these four categories.
As demonstrated in this scoping review, Métis women experience systemic racism as health and social services in Canadian cities perpetuate inequitable and exclusionary policies and practices that contribute to access barriers for Métis women.For example, given that Métis are excluded from federally administered Indigenous health initiatives, they are frequently left accessing mainstream services that do not often meet their needs (Richardson, 2016).As a result, urban Métis women will strategically refrain from disclosing their identity to avoid racism and discrimination from service providers (Monchalin, Smylie, & Dupre, 2020;Monchalin, Smylie, & Nowgesic, 2020;Wesche, 2013).This leads into interpersonal racism, which was demonstrated to occur when Métis women experienced poor treatment and anti-Indigenous stereotyping by serviceproviders.These findings are consistent with and expand upon existing literature regarding how Métis people continue to be negatively affected by the colonial and racial divide inflicted upon them by the Canadian government when it comes to health and social services offered in urban settings (Smylie et al., 2009).Interpersonal racism is sometimes referred to as lateral violence, such as in reported experiences of discrimination from Indigenous service providers (Ghosh & Spitzer, 2014;Iwasaki et al., 2004;Monchalin, Smylie, & Nowgesic, 2020;Wesche, 2013).Lateral violence is defined as occurring within "oppressed societies and include[s] bullying, gossiping, feuding, shaming, and blaming other members of one's own social group as well as having a lack of trust toward other group members" (Bombay et al., 2014, p. 2).Reflecting on the decades of oppression experienced by Indigenous Peoples in Canada, Bombay et al. (2014)

state,
As oppressed people it is not surprising that we oppress our own people out of anger and frustration . . .I recall the words of a leader when he reflected, "We-our people-have become our own worst enemies."He was right.(p. xi) This scoping review demonstrates that interpersonal racism and lateral violence become internalized among urban Métis women.For example, by having their identity questioned by reception staff, or service-providers not recognizing that Métis are Indigenous, Métis women reported to not feel Native enough to access Indigenousspecific services.Finally, epistemic racism was demonstrated as Métis women would face discrimination from health care providers toward traditional practices to support their well-being.Métis women further reported their experiences and knowledges being disregarded, disbelieved, or minimized by health care providers.
To support the development of culturally safe health and social services where Métis people feel safe, respected, and are able to be themselves, the authors provide two recommendations stemming from the scoping review findings.First, to remove barriers to health and social service access in urban settings, more research by and for urban Métis communities needs to be supported.The lack of Métis-specific data limits the potential development of culturally specific, appropriate, and effective health programs and services for Métis people (Evans et al., 2012;Brant Castellano, 2004;Vizina, 2005).This is notably visible surrounding experiences of Métis Two-Spirit and gender diverse community members.In speaking to research on Two-Spirit health and well-being, the Métis Nation of Ontario (2022) states that "the experiences of Two-Spirit have been historically overlooked by researchers for a variety of reasons.Prior to the turn of the 21st century many researchers lacked an awareness of Two-Spirit people and the uniqueness of their identity" (p. 7).Hunt (2016) further states that "people working to shape both Aboriginal and non-Aboriginal health policies, programs and frameworks have a responsibility to educate themselves about the cultural, gender and sexual identities of Two-Spirit People in order to provide appropriate, accessible, nonjudgmental and safe services" (p.22).This gap in the literature signals the need for Métis-specific health research and funding that is available specifically for Two-Spirit and gender diverse communities.
Research demonstrates that Métis women hold practical solutions to improving health and social service access (Monchalin et al., 2019).In response to the scoping review's theme of the need for culturally safe health services, urban Metis women in Toronto, Ontario and Victoria, British Columbia made the following recommendations (Monchalin et al., 2019(Monchalin et al., , 2022)).Toronto recommendations included (a) Métis presence, which included having staff who identified as Métis; (b) holistic interior design, which included incorporating Indigenous artwork and natural elements into the service space; (c) Métis-specific or informed service space, which meant having a space specifically for Métis people, or a space where Métis people were involved the development of; (d) welcoming reception or front desk, which included friendly and welcoming reception staff; finally, they recommended for (e) culturally informed service providers, which encompassed a provider with knowledge and understanding of Indigenous peoples' histories and Métis identity, a holistic approach to care, and awareness of issues surrounding power, privilege, and oppression (Monchalin et al., 2019).Similarly, Victoria recommendations included (a) warm and inviting service spaces, including the incorporation of relaxing music, warm and neutral wall colors, calm lighting, windows and natural lighting, plants, comfortable chairs, and accessible for those who are hearing impaired or physically disabled; (b) Métis-specific cultural safety training that can educate service providers about Métis people's unique experiences, rather than the pan-Indigenous approach to cultural safety training that is currently offered; (c) Indigenous or Métis-specific clinic, with Indigenous service providers so that they would not have to explain their identity; (d) wholistic or integrative service delivery that approached health and wellness not as separate elements, but rather as a whole, recognizing the connection of physical, emotional, spiritual, and mental; and (e) non-judgmental service providers that would not minimize experiences, who are transparent and reassuring, make eye contact, are trauma-informed and ask for consent (Monchalin et al., 2022).While Toronto and Victoria are unique urban settings, these recommendations can provide insight into health and social service delivery across Canada, while demonstrating that communities hold practical solutions for change.
At the same time, Evans et al. (2012) explain that carrying out research with Métis communities is not a straightforward process.Common barriers include [F]irst, a lack of health care infrastructure, such as a lack of Métis-specific health care centers; secondly, limited human resources, including community health directors similar to those found in First Nations reserve communities; thirdly, reliance upon volunteers; and fourthly, political instability.(Evans et al., 2012, p. 57) A result of the barriers to accessing funding is a lack of culturally safe and effective health services for Métis people (Evans et al., 2012).This brings us to the second recommendation, the need for Métis-specific health research funding.Métis-specific funding will better support Métis people across Canada to conduct research by and for their communities.Indigenous health resources and funding need to be made accessible for Métis communities by having funders acknowledge the limited resources rooted in an ongoing history of assimilation and take steps to remedy the lasting impacts of our systemic exclusion.The Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls (2019) echoes the need for Métis-specific funding in the Calls for Justice and states, 17.7-We call upon all governments to fund and to support culturally appropriate programs and services for Métis people living in urban centres, including those that respect the internal diversity of Métis communities with regards to spirituality, gender identity, and cultural identity.(p.211)

Strengths and limitations
While this scoping review is the first of its kind, it may not be representative of all urban Métis women's experiences with health and social service access across Canada.For example, this scoping review eliminated studies that fell outside of an urban context as they did not fall within our inclusion criteria.This resulted in a small number of eligible articles, given that the urban experience is often absent from many Métis-specific studies.Furthermore, the literature was also limited surrounding smaller urban centers that are home to significant Métis populations.This includes Prince Rupert, Prince Albert, and Thompson, where Métis people comprise large proportions of the overall population, and where the availability of culturally safe services may be quite distinct from those in larger cities (Place, 2012).
While eligibility criteria for this scoping review was inclusive of Two-Spirit, trans, gender diverse, and queer voices, results did not provide insight into service access, experiences, or availability that were specific to Métis lesbian,gay,bisexual,transgender,queer,questioning,intersex,and asexual (2SLGBTQQIA) communities.Those who identify as 2SLGBTQQIA are often left out of conversations around the health and wellbeing of Métis communities.The gap in the literature, in addition to the conversations that took place in our community gathering to inform the scoping review, signals the critical need for Métis-specific health research and funding that is available specifically for 2SLGBTQQIA communities.Despite these limitations, this scoping review is a contribution to the developing efforts taking place across Canada to better understand the experiences, knowledges, and priorities of urban Métis women and culturally safe health and social services access across Canada.

Conclusion
The goal of this scoping review was to advance research exploring the relevance and appropriateness of health and social services for Métis women accessing services in urban homelands across Canada.Although the quantity of research included within our review was limited due to the lack of studies that incorporate an urban Métis-specific breakdown of findings, the synthesis of available literature identified interwoven themes of racism, discrimination, and marginalization; jurisdictional barriers to health and social services; and a lack of culturally safe care.This scoping review calls on policy makers and service providers to work toward closing the culturally safe service gap for Métis people living across Canada and to support research that is both by-and-for Métis communities.