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Opiate substitution therapy (OST) is an interdisciplinary treatment method for individuals experiencing opiate addictions. Municipalities internationally are working through a process of responding to both the need for OST clinics and community concerns around these clinics. The purpose of this quantitative descriptive study was to better understand the geographic spread of those currently accessing OST in an urban area in Canada. This will serve to assist related policy-making. Postal codes of 796 individuals accessing OST were obtained from one clinic and one dispensing pharmacy. Representing 581 unique data points, these were mapped across the 26 residential neighbourhoods in the city of study. Individuals accessing OST were located within an 11 km radius of the clinic and pharmacy. Situated in every neighbourhood in this radius, individuals accessing OST were in 24 of the 26 possible residential neighbourhoods. Ultimately, data support the hypothesis that individuals accessing OST are located in all residential neighbourhoods in the urban area of study. This supports current literature indicating that addiction exists throughout all urban areas rather than being limited to only certain neighbourhoods. This has implications for zoning of OST clinics and pharmacies, as municipalities must balance neighbourhood concerns while not overly restricting access throughout the municipality.
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Drugs: Education, Prevention and Policy
ISSN: 0968-7637 (Print) 1465-3370 (Online) Journal homepage: http://www.tandfonline.com/loi/idep20
The geographic scope of opiate substitution
therapy in an urban area in Canada
Abram Oudshoorn & Ken Kirkwood
To cite this article: Abram Oudshoorn & Ken Kirkwood (2017) The geographic scope of opiate
substitution therapy in an urban area in Canada, Drugs: Education, Prevention and Policy, 24:5,
369-375, DOI: 10.1080/09687637.2016.1216947
To link to this article: https://doi.org/10.1080/09687637.2016.1216947
Published online: 16 Aug 2016.
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ISSN: 0968-7637 (print), 1465-3370 (electronic)
Drugs Educ Prev Pol, 2017; 24(5): 369–375
!2016 Informa UK Limited, trading as Taylor & Francis Group. DOI: 10.1080/09687637.2016.1216947
The geographic scope of opiate substitution therapy in an urban area
in Canada
Abram Oudshoorn and Ken Kirkwood
Faculty of Health Sciences, Western University, London, ON, Canada
Abstract
Opiate substitution therapy (OST) is an interdisciplinary treatment method for individuals
experiencing opiate addictions. Municipalities internationally are working through a process of
responding to both the need for OST clinics and community concerns around these clinics. The
purpose of this quantitative descriptive study was to better understand the geographic spread
of those currently accessing OST in an urban area in Canada. This will serve to assist related
policy-making. Postal codes of 796 individuals accessing OST were obtained from one clinic and
one dispensing pharmacy. Representing 581 unique data points, these were mapped across the
26 residential neighbourhoods in the city of study. Individuals accessing OST were located
within an 11 km radius of the clinic and pharmacy. Situated in every neighbourhood in this
radius, individuals accessing OST were in 24 of the 26 possible residential neighbourhoods.
Ultimately, data support the hypothesis that individuals accessing OST are located in all
residential neighbourhoods in the urban area of study. This supports current literature
indicating that addiction exists throughout all urban areas rather than being limited to only
certain neighbourhoods. This has implications for zoning of OST clinics and pharmacies, as
municipalities must balance neighbourhood concerns while not overly restricting access
throughout the municipality.
Keywords
Addiction, zoning, stigma, treatment, policy,
opiate substitution therapy
History
Received 13 January 2016
Revised 13 July 2016
Accepted 20 July 2016
Published online 12 August 2016
The purpose of this quantitative descriptive study is to better
understand the geographic spread of those currently accessing
OST within a medium-sized urban area in Canada. This has
implications for municipal policies designed to address
community concerns frequently expressed regarding sub-
stance treatment facilities.
Background
People who are dependent on opioids face serious health and
social problems caused by their dependence (Degenhardt
et al., 2013). Their risk of premature death as a result of
accidental overdose, drug-related accidents and violence is
high (Health Canada, 2008). Sharing of drug paraphernalia
places them at high risk of acquiring human immunodefi-
ciency virus (HIV), hepatitis C virus (HCV) and other blood-
borne pathogens (Health Canada, 2008). In addition to health
risks of those experiencing an addiction, opioid dependence is
an expensive social problem (Birnbaum et al., 2011), and
when left untreated results in costs that are associated with
medical care, drug treatment, lost productivity, criminal
activity and transmission of blood-borne pathogens (Health
Canada, 2008). In the Canadian context, addiction is costing
municipalities $243 million per year in social, medical and
law enforcement costs which includes losses in productivity
(City of London – Planning Division, 2012).
Globally, opiate substitution therapy (OST) remains the
most commonly used type of treatment for opioid dependency
(Degenhardt et al., 2014; Harris & McElrath, 2012). A
comprehensive approach to OST usually incorporates a
number of components, including medical care, treatment
for other substance use, counselling, mental health services,
health educations, linkage to other supports and outreach
support. OST is ‘‘effective in reducing the use of opioids, the
use of other substances, criminal activity, mortality, injection-
related risk behaviours, other risk behaviours for transmission
of HIV and STDs, and transmission of HIV (and potentially
the transmission of HCV and other blood-borne pathogens)’’
and also saves a community approximately $7 per every dollar
spent on treatment (Health Canada, 2008).
Characteristics correlated with opioid dependence include,
but are not limited to, physical health problems, mental health
problems (Ross et al., 2005), low or no income (Du et al., 2007;
Sigmon, 2006; Spiller, Lorenz, Bailey, & Dart, 2009; Yoast,
Williams, Deitchman, & Champion, 2001), low education
(Yoast et al., 2001), involvement in criminal activity (Ross
et al., 2005) and polydrug use (Du et al., 2007; Ross et al.,
2005). However, in recent years, prescription opioids have
grown in many communities to be the substance of choice
across diverse demographics. An American study by Sigmon
(2006) compared characteristics of prescription drug users to
Correspondence: Dr. Abram Oudshoorn, RN, PhD. E-mail:
aoudshoo@gmail.com
heroin users. This study found that prescription opioid users
appeared to be more stable than heroin users, had fewer family
and social problems and less illegal income. Such information
lends to the idea that more and more people who seek OST may
be coming from all walks of life.
Increased evidence regarding the impact of replacement
therapies has resulted in treatment centres proliferating in
most developed nations (Smith, 2010; Strike, Urbanoski,
Fischer, Marsh, & Millson, 2005). Despite this increased
access, it has been suggested that OST resources do not meet
current demands (Strike et al., 2005), and the number of
people who are able to access OST varies significantly
between and within nations (Mathers et al., 2010). In the next
section, it will be demonstrated how stigma, an exercise of
social power that labels deviance from norms and discrim-
inates against those who have been labelled (Link & Phelan,
2001), and municipal policy can interact to further limit
access to care.
Literature review
Stigma around substance addiction plays a primary role in
community opposition to drug treatment facilities, including
OST clinics and pharmacies. Illicit drug use is in and of itself
considered a ‘‘deviant’’ and publicly dangerous behaviour
(Joh, 2009), and although substitution therapy is a treatment
modality, OST frequent serves as a synonym for illicit drug
use in public discourse (Fraser, 2006). In studying popular
media presentations of substitution therapy in the form of
methadone treatment, Fraser (2006) notes that the very
conceptualisation of substitution or replacement highlights
the similarity to opiates, positions the patient as still an addict
and the substitution as not a solution. Hence, OST is
perceived within the realm of deviance and those accessing
OST as being unwelcomed neighbours. In an ethnographic
case study analysis done by Smith (2010) in Toronto, Ontario,
the author found that both residents and business owners
displayed socio-spatial stigmatisation in their opposition to an
OST clinic relocating to their community. Consistent with the
findings of Fraser (2006) that use and treatment are often
conflated, participants in Smith (2010) felt the clinic was a
site of infection, drawing in clients who were agents of
contagion that threatened to bring the ‘‘disorder of drugs’’
into the neighbourhood. Education regarding the benefits of
clinics was insufficient to overcome resistance. This stigma is
also institutionalised into the OST system, with patients being
treated as deviants in accessing their medication, facing strict
‘‘rules that reinforce addict and deviant identities’’ (Harris &
McElrath, 2012, p. 814).
Although different forms of harm reduction may elicit
differing community responses, stigma extends to other
modalities of reducing the harm of substance use, such as
needle exchange. The similarity in stigma comes from both
OST and needle exchange being about addiction, and
therefore perceived as being within a realm of deviance,
whereas differing perceptions of these modalities arise from
perceived curative versus supportive outcomes. Therefore, we
offer review of work on needle exchange to understand the
stigma around harm reduction responses with the acknow-
ledgement that needle exchange and OST may be received
differently. A qualitative study was done by Strike, Myers,
and Millson (2004) that focussed on stigma faced by the staff
of needle exchange programmes (NEPs). They found that no
matter how staff planned the implementation of a new NEP,
they were always faced with opposition and scepticism from
local residents. They found that the primary concern of these
residents appeared to be maintaining safety in their neigh-
bourhood, which explicitly meant excluding drug users.
Residents typically denied any existing drug problems in
their community, even when presented with evidence to the
contrary. At issue is not whether substitution therapies or
harm reduction programmes improve health outcomes, but
that the individuals who will be coming to these programmes
are considered unwanted elements by vocal residents.
However, research has shown that over time these perceptions
of harm reduction services can alter, with a study on the long-
term perceptions of a supervised injecting centre finding that
perceived benefits increase while perceived harms decrease
(Salmon, Thein, Kimber, Kaldor, & Maher, 2007). That said,
in their sample, at five-year follow-up, 14% of residents still
perceived the centre as attracting drug users to the
neighbourhood.
Research has been conducted regarding the false assump-
tions underlying this stigma. It should be noted that there are
significant nuances in measuring public perceptions around
addiction, as simply changing the wording of surveys can
skew the perceived measure of support or opposition for harm
reduction modalities (Hopwood, Brener, Frankland, &
Treloard, 2010). Boyd, Fang, Medoff, Dixon, and Gorelick
(2012) state that despite extensive research that has shown
OST decreases crime among treated patients, resistance by
communities to OST facilities still persists. To add to this
body of knowledge they collected reports of crimes in
Baltimore between 1999 and 2000. The authors found that
whereas crime counts do not necessarily change based on
distance of separation from OST clinics, they do change as
distance to a convenience store decreases (Boyd, Fang,
Medoff, Dixon, & Gorelick, 2012). In a literature review done
by Strike et al. (2004) regarding stigmatisation and the
challenges in finding a location for needle exchange pro-
grammes in Ontario, the authors found that over time
opponents to NEPs tended to be convinced by the scientific
evidence supporting the effectiveness of NEPs. Similarly,
Dear (1992) states that familiarity and understanding regard-
ing the client group and its problems tend to increase
tolerance and acceptance from the public. He recommends
using media sources to increase public awareness to facilitate
this process. Last, a qualitative study conducted by Polcin,
Henderson, Trocki, Evans, and Wittman (2012) focussed on
the community context of sober living houses in California.
They established that the more the local community under-
stood about the sober living houses and the people who used
them, the more they would support them. This would decrease
preconceived biases and notions regarding the clientele.
Therefore, providing education to address the false assump-
tions has some measurable impact. Lenton and Phillips (1997)
report on an intervention that included explaining the
rationale and effectiveness of a harm reduction programme,
in this case a NEP. In their sample, perceptions of the
importance of access to NEP increased from 75.5% to 86.9%.
370 A. Oudshoorn & K. Kirkwood Drugs Educ Prev Pol, 2017; 24(5): 369–375
For those who understand the therapeutic value of
addictions service yet still resist them being sited within
their community, it is possible that their concerns are rooted
in negative experiences with those who use substances. To
address this possibility, Gerdner and Borell (2003) looked at
stigma faced by a variety of different human service
establishments, including ones that provide service to
people with addictions. They discovered that 18% of the
facilities had experienced negative community reactions
regarding opening of the facility, which included fears
around increased drug use and crime and decreased property
value. They found that in 17 of the cases, protests began as
early as the planning process, 3 were when the services started
to operate, and only 1 came as a result of a critical incident
with the facility. They concluded that it is not fair to claim
that stigma occurs solely as a result of incidents because most
intensive reactions typically occurred before facilities opened.
They established that the most important factor associated
with a negative reaction is the size of the facility and whether
the area was otherwise primarily residential. This supports the
literature highlighting that although members of the public
are likely to see addictions services as useful (Treloar &
Fraser, 2007), and can be educated to understand their
therapeutic impact, the primary concern is the location of the
clinic and its fit with the neighbourhood.
Policy also plays a role in the existence of stigma around
substance treatment modalities, as evidenced by Tempalski,
Friedman, Keem, Cooper, and Friedman (2007) who
completed interviews with NEP directors in the United
States to examine socio-cultural and political processes that
shape community and institutional resistance towards estab-
lishing NEPs. In their research they extended the concept of
stigma from the local level to higher systemic levels of
government and national culture. They analysed the oppos-
ition to NEPs into the following themes: ‘‘(1) institutional
and/or political opposition based on (a) political and law
enforcement issues associated with state drug paraphernalia
laws and local syringe laws; (b) harassment of drug users and
resistance to services for drug users by local politicians and
police; and (c) state and local government (in)action or
opposition; and (2) stigmatization of drug users and NEP
resistance from neighbours and businesses’’ (p. 1256). It is
conceivable that these same themes of opposition might hold
true for OST clinics and pharmacies. The authors state that
substance use response strategies have faced explicit stigma
from community members who are part of widespread,
national networks with ties to political decision-making.
Gap in the literature
In summary of the literature, stigma regarding OST and other
addictions services is rooted in the perception of addicts as
deviants, and therefore clients are unwelcome in communities
regardless of whether they are accessing treatment. Some
resistance is based on a lack of understanding of the positive
impacts are various modalities, and this can be addressed
through education. However, even those who are informed
and supportive of OST ultimately are likely to resist
development of such services within their own neighbour-
hood. Arguments are made that such services are a poor land
use fit with the neighbourhood, or not required in particular
neighbourhoods where addiction is perceived to be absent. To
address this second argument, data on the geographic
distribution of treatment service users would be helpful.
However, to date few studies have been done to understand
the geographic distribution of OST users within urban areas.
Strike et al. (2005) looked at the Methadone Maintenance
Registry of Patients and the Registry of Methadone
Prescribing Physicians from Ontario, Canada to examine
changes in patient populations including distribution of
patients in Ontario between 1996 and 2001. Within their
results, they discovered that in 1996, the central and largest
municipality in the region (Toronto) had the highest number
of OST patients as well as the highest number of OST clinics
and services. As clinics and services were established in other
regions of the province during the five-year period, the
number of OST patients increased in these other regions and
actually decreased in the Toronto region. This finding
indicates that patients were actually distributed all over
Ontario, which was only evident as access increased through-
out the province.
Wong, Lee, and Lin (2010) used a geographic system to
determine the spatial distribution of OST clients in Hong
Kong. They discovered that 93.7% of respondents were living
in the district if Tai Po where all of the OST clinics were
located. They also discovered that the proximity of the
residents’ living locations and that of Tai Po’s residential
buildings infers that OST clients were integrated in the
resident population. They also argue that the large distribution
of OST clients close to the clinics could have been a result of
clients migrating to the area where OST was available over
the last 30 years since the clinics were established.
Policy context
This research project was envisioned in the context of a policy
change in a mid-sized urban area in Ontario, Canada. This
municipality had recently seen the community concerns
around substance use treatment in conflicts related to public
policy regarding OST facilities. This local situation began
when a clinic was proposed for a light industrial area adjacent
to a residential neighbourhood. At the time, there were no
zoning requirements unique to OST clinics and nearby
residents expressed concerns to the local newspaper and to
city council about neighbourhood safety impacts related to
such facilities. City council then requested a report from
planning staff on OST, with a focus on methadone mainten-
ance treatment, which subsequently included a list of
suggestions for policy direction regarding a new zoning and
licencing by-law specifically geared towards OST clinics and
pharmacies. Shortly thereafter, an interim control by-law was
passed that put establishment of any new OST clinics or
pharmacies on hold until the municipality could explore the
by-law options. Once the by-law studies were completed, in
March 2012 the municipality passed a new zoning by-law that
includes specific siting guidelines for clinics, such as set-
backs from other land uses, and site issues such as parking
and adequate waiting areas. Additionally, a licencing by-law
was implemented that includes a licencing fee related to the
number of clients served.
DOI: 10.1080/09687637.2016.1216947 Geographic scope of opiate substitution therapy 371
Part of the planning process included in this municipalities
new by-laws was a public participation meeting for any new
clinic zoning. The first two public participation meetings
subsequent to the by-law enactment generated significant
media and citizen engagement. A common question from
residents was the logic of siting new clinics in particular
urban areas, particularly those perceived as middle or upper
class regions of the municipality. Residents clearly expressed
their perception that ‘‘no one in our neighbourhood uses
OST’’. Similar to findings in the literature (Cruz, Patra,
Fiscer, Rehm, & Kalousek, 2007; Strike, Myers, & Millson,
2004), most residents came to agree with the therapy as a
useful treatment, but were fundamentally opposed to its
availability near their homes. The indication was that those
seeking treatment for an addiction only reside in certain
neighbourhoods in a municipality, and therefore any OST
clinics developed should only be located in ‘‘those’’
neighbourhoods.
Methodology
Building on the question of where people who access OST
live in urban areas, it was hypothesised that they would
occupy all residential neighbourhoods. To test this hypothesis,
postal code data were required from active users of OST.
Therefore, all five OST clinics in the municipality of study, as
well as one dispensing pharmacy, were approached for
participation in the study. Ultimately, postal codes of 796
individuals accessing OST clinics were obtained from one
clinic and one dispensing pharmacy. Access to clinics for
participation proved challenging due to caution within the
sector around stigma. Only two clinics met with the research
team to consider participation, with only one ultimately
providing data. Only one dispensing pharmacy was
approached, as the limited number of individuals served by
each pharmacy made for limited return on time invested to
secure participation. The 796 individuals in the data set
represented 581 unique data points (meaning that there were
215 redundant postal codes), and these were mapped across
the 26 residential neighbourhoods in the municipality of
study. Postal codes were provided from the clinic and
pharmacy databases, so may not represent the most current
address, although would be mostly congruent with the
individual’s health card. Only individuals considered
‘‘active’’, having received service within the last year, were
included.
Research Ethics Board approval was sought and obtained
from the University at which the lead author is situated.
Primary ethical considerations included displaying the data in
a manner that would not identify individual OST patients, and
that would not increase stigma against particular marginalised
communities. This led to utilising the neighbourhood as the
level of analysis versus individual postal codes.
Findings
Ultimately, data support the hypothesis that individuals
accessing OST are located in all residential neighbourhoods
in the city of study. Individuals accessing OST were located
within an 11 km radius of the clinic and pharmacy from which
data were obtained, both of which were located in the east end
of the municipality. Situated in every neighbourhood in this
radius, individuals accessing OST from our data set were in
24 of the 26 possible residential neighbourhoods (Figure 1). It
is predicted that inclusion of the three clinics in the west end
of the city would yield full coverage of all 26 residential
neighbourhoods. This supports current literature indicating
that people seeking OST reside throughout all urban areas
rather than being limited to only certain neighbourhoods
(Strike et al., 2005). This has clear implications for zoning of
OST clinics and pharmacies, as municipalities must balance
neighbourhood concerns and land use impacts while not
overly restricting access throughout the entire municipality.
Discussion
Despite the growing need for OST across the country,
significant resistance is met when new facilities are proposed.
As a population, people who use substances have been found
to have the highest degree of community opposition (Dear,
1992, Strike, Myers, & Millson, 2004) and stigma remains
prevalent with addiction treatment and human services
facilities (Gerdner & Borell, 2003; Strike et al., 2004, 2005;
Tempalski, Friedman, Keem, Cooper, & Friedman, 2007).
This stigma is expressed by resistance that has been
colloquially termed ‘‘NIMBYism’’. The term NIMBY,
which originated in the 1980s, is an acronym for the phrase,
‘‘not in my backyard’’ and can be defined as the opposition to
locating something that is considered undesirable in one’s
neighbourhood (Merriam-Webster, NIMBY, 2013). People
who participate in NIMBYism often resist initiatives in their
community which aim to establish facilities seen as undesir-
able (Mendes, 2001), a concept which is closely linked to
stigmatisation which occurs when a group of people possess a
status which makes that group less desirable to other people
(Lloyd, 2010). This is congruent with the literature regarding
addictions services, where community members often
acknowledge the value of these facilities but resist them
being located within their neighbourhood (Lenton & Phillips,
1997).
Communities may perceive the siting of addiction services
in their region as a threat to self and to the community (Strike
et al., 2004). Opposition to addiction treatment is distin-
guished by concern that such programmes will draw unwanted
people into the community (Smith, 2010; Strike et al., 2004),
therefore implying that people requiring addiction support are
not already present. Fear of increased criminal activity
(Gerdner & Borell, 2003; Smith, 2010), physical infection
(Smith, 2010), presence of illicit behaviours (Gerdner &
Borell, 2003; Strike et al., 2004), decreased property value
(Gerdner & Borell, 2003; Pol, Di Masso, Castrechini, Bonet,
& Vidal, 2005; Strike et al., 2004; Tempalski et al., 2007),
decreased personal and family security (Strike et al., 2004;
Tempalski et al., 2007), negative role models for children
(Gerdner & Borell, 2003), economic burden (Gerdner &
Borell, 2003), a less attractive community (Gerdner & Borell,
2003) and decreased quality of life/neighbourhood status (Pol
et al., 2005; Tempalski et al., 2007) are often described by
concerned residents in the proposed community. However,
findings in this study demonstrate that these concerns are not
necessarily evidence-based and individuals experiencing
372 A. Oudshoorn & K. Kirkwood Drugs Educ Prev Pol, 2017; 24(5): 369–375
addictions are already located through all neighbourhoods in
the municipality of study. Additionally, several studies to date
have established that OST actually reduces criminal activity,
health care costs, unemployment, transmission of infectious
diseases, homelessness, mental illness, use of social services,
drug and alcohol-related medical visits and negative preg-
nancy outcomes (Yoast et al., 2001). In regard to where
people experiencing addictions may be situated, Williams and
Ouellet (2010) completed a survey study in Chicago to
explore movement of individuals in and out of neighbour-
hoods and access to harm reduction services. They collected
data to determine reasons why clients of NEPs spent time in
the area where the NEP was located. Of their entire sample,
they found that only 3.8% reported spending time in the area
because they were there to exchange needles. Such results are
contradictory to the idea that NEPs draw users and drug
activity into the regions where they operate, and demonstrate
that users actually spent time in the area for a variety of other
Figure 1. Planning districts with methadone clients.
DOI: 10.1080/09687637.2016.1216947 Geographic scope of opiate substitution therapy 373
reasons. Although addiction is often perceived as only a
‘‘downtown’’ problem that is limited to the poor and
homeless population (London CAReS, 2009), our data
demonstrate a much more complete distribution. Even when
we looked only at data from a clinic and pharmacy situated in
one area of town, the geographic distribution was broad.
Alexander states that, ‘‘The reality is that if you look for
drugs in any community, you will find them – when the police
go looking for drugs in one community, they’re going to find
them in that community and not in others.... Because it’s
those communities that have been targeted’’ (as cited in Count
the Costs, 2013, p. 7).
Oakley (2002) warns that the stigma expressed by
community members can become perpetuated by policy-
makers when governments and neighbourhood organisations
together over-use zoning restrictions to fully exclude various
kinds of community facilities (Oakley, 2002). Drug treatment
facilities in particular have consistently run into zoning
problems because they are often excluded in zoning by-laws
that define allowable uses (Dear, 1992). Strategies that
demonstrate NIMBYism include petitions, and establishment
if interim zoning by-laws are common in NIMBY conflicts
(Dear, 1992; Smith, 2010). This NIMBYism can have
detrimental effects on human services such as withdrawal of
tax dollars or closure of a facility which impacts client well-
being negatively (Dear, 1992), and community practitioners
worldwide are faced with economic and social obstacles to
initiate these much needed services (Gerdner & Borell, 2003).
Ultimately, this study serves as a demonstration that those
who would access OST are located throughout a mid-sized
urban area. This means that zoning by-laws must take into
account the distributed nature of the potential clientele. By-
laws should always take into consideration land use impacts,
but if they overly restrict facilities to certain geographic areas
they may unintentionally restrict access to treatment. There is
potential for further study to replicate results across both
urban and rural areas in regions or nations with different
policy contexts. Additionally, questions still exist regarding
patient preferences of treatment sites as well as other issues
related to access such as mode of transportation. OST clinic
zoning serves as a fascinating example of the interaction
between stigma, health care, and public planning policy.
Declaration of interest
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article. Funding for this study was provided jointly by Sigma
Theta Tau – Iota Omicron Chapter, and the City of London
Planning Division.
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