**5. Conceptual Framework for Land Tenure Security and Health Nexus**

Drawing evidence from the preceding section, we propose that looking into concerns and variations of land tenure security has the potential to address, promote, make resilient, or render susceptible multiple dimensions of neighborhood and individual health through four pathways described in the conceptual framework as displayed in Figure 2. Traditional biomedical frameworks for addressing health and diseases assume that health outcomes are a result of deviations from measurable biological factors. Hence, they leave little room for the social, environmental, psychological, and behavioral dimensions of health [129]. In contrast, social epidemiological and biopsychosocial frameworks acknowledge that a basis for understanding the determinants of health and arriving at appropriate interventions for addressing health patterns is that the social context in which a person lives is taken into account [18,57,129]. Land tenure security represents both a social context and social position that influence health through multiple dimensions and outcomes. From a health promotion perspective, land tenure security can be viewed as a multidimensional, behaviorally based socio-environmental intervention that has the potential to modify factors that affect health outcomes.

**Figure 2.** Conceptual framework for land tenure security and health nexus.

Land tenure security has been shown to provide psycho-ontological security which reduces the stress and anxiety associated with tenure insecurity to deliver positive mental health outcomes [47,55,115,116,122]. Reduced residential mobility and sustained social ties associated with tenure security is shown to promote social cohesion, keep families together, reduce place blemishes and social stigmatization, and enable households to focus on longterm goals such as personal relationships, career development, child health, and human capital development which collectively impact social health [115]. Similarly, secure tenure

has been demonstrated to facilitate access to and investment in space improvement, basic infrastructure, and services such as water, sanitation, and hygiene facilities that can promote people's physical health [56,99,101,102,104,130–132]. Finally, land tenure security has been shown to be a socially empowering intervention that empowers people with environmental rights, instills environmental responsibility, and imposes environmental restrictions, which collectively enable individuals to lessen their environmental burdens or improve resilience against environmental ills and injustices. Thus, land tenure security empowers people to protect their living environments, while using their own environs responsibly and within permissible limits to improve environmental health [109–112,114]. Land tenure security influences health outcomes by tapping into the socio-physical environment and distal factors such as environmental justice, psychological security, social cohesion, and infrastructure access to modify health outcomes of neighborhoods and individuals. Our conceptual framework linking land tenure security and health was informed by social determinants of health thinking, underscored by three theories of social production of health—psychosocial theory [88,89], social production of disease theory [90], and eco-social theory [60].

From Figure 2, land tenure security, a socio-environmental intervention, guarantees psychological security to promote mental health. It does this by reducing psychosocial stresses and anxieties associated with tenure insecurities and threats of evictions, be it by state authorities through expropriation, planned land uses, development controls, building codes/standards, others claiming rights to land or natural disaster-induced tenure insecurity. Land tenure security ensures environmental justice, enabling a rights-based empowerment to individuals and neighborhoods to take transformative environmental actions against environmental injustices, such as pollution and insanitary conditions, to promote environmental health. Similarly, land tenure security promotes physical health through an infrastructure and service pathway by providing legitimacy and entitlement to use existing state-provided infrastructure or incentivizing individuals and households to undertake private investment in basic infrastructure and life-sustaining services. Finally, land tenure security promotes social health through social cohesion, leveraging on the sustainable social ties and networks afforded by residential stability. Improvements in any dimension of health is improvement in other dimensions of health. With appropriate tenure responsive interventions and policy, land tenure security will ensure good sanitation, access to basic socio-economic amenities, create a sense of place and social identity, and access to nature and green space. Good sanitation impacts environmental and physical health, basic socio-economic amenities impact physical and social health, a sense of place and social identity affects social and mental health, and access to nature and green space affects mental and environmental health.

#### **6. Conclusions, Implications, and Recommendations for Further Research**

To tackle the health burden of urban areas, there is the need to address the health risks, challenges of urbanization which define the social context within which people live, and the stratified social positions assigned to individuals and neighborhoods by these risks, challenges, and opportunities. Poor health and health inequalities can be addressed by focusing attention on the creation, management, and improvement of the socio-environmental settings in which people live [48]. In this paper, we set out to explore land tenure security both as a socio-environmental setting and a social position and its connection to health. Drawing upon results of 95 gray and peer-reviewed articles, this paper demonstrated that land tenure security influences health via four pathways—providing psycho-ontological security, enabling environmental justice, infrastructure access and fostering social cohesion. These four pathways promote four dimensions of health namely mental, environmental, physical, and social health. Underscored by social production of health theories, we framed land tenure security as a social determinant of health and accordingly proposed a conceptual framework for understanding the nexus between land tenure security and health.

The paper addressed a critical gap in land management, urban and global health literature, where the health impacts of land tenure (in)security are less understood and understudied, despite policy and intellectual discourses in the wake of coronavirus disease 2019 (COVID-19) which points to greater health burden of areas characterized by smacks of land tenure insecurity. The connection between land tenure security and health is a reality we live with, manifest in our daily encounter and interaction with informal settlements, and unsightly scenes of filth, and continuous (re)emergence of communicable and noncommunicable diseases in our cities. This paper and subsequent studies advance a course for achieving the new urban agenda and key sustainable development goals including no poverty, zero hunger, life on land, sustainable cities, and clean water and sanitation, all of which feed into health and well-being.

Advancing the course of land tenure security and health nexus implies abandoning the mono-disciplinary silo approaches and opt for integrative inter-disciplinary approaches, which connect land tenure security and health. Land tenure policies and interventions must be designed to target and achieve health specific goals and outcomes. Similarly, health policies must integrate tenure security in the design of health interventions in a bid to deliver health equity. This means in practice that health and land professionals and institutions must collaborate and work together to deliver a common goal of good health. Thus, cities must work towards adopting health-in-all-policies with the ultimate objective of redressing social structures and factors such as variations in land tenure that generate inequalities in health and health outcomes.

The findings from the current study also open up further research avenues. First, despite the emerging evidence of a link between land tenure security and health, there are still no studies that empirically measure this connection. Hence, there is the need to go further to investigate empirically if there is a connection between land tenure and health and if tenure variations explain variations in health outcomes and disease outbreaks. Secondly, the findings open avenues for exploring tenure security and environmental health justice in cities. Land tenure security is a rights-based approach to justice. Therefore, wherever land tenure insecurities are served, environmental injustices are served as well. A third research avenue is the prospect of this study to inspire research into the mediating role of urban redevelopment, urban greening, and health in cities. Whereas urban greening and redevelopments have health justifications and benefits, they also carry the risk of gentrification and inequities in access, where there are insecure tenure rights. Thus, research is needed to understand how secure tenure can help mitigate the unintended health effects of urban redevelopments and associated gentrification. The findings also open up a fourth avenue for investigating variations in land tenure security in connection to health inequalities in cities. To this extent, neighborhood land tenure security patterns could be studied and analyzed spatially to understand health and disease patterns and distribution in cities. A key driver for activating the link between land tenure security and health is policy. Thus, the study also opens a fifth research dimension that would seek to understand the interactions of urban land tenure policy, urban planning policy and health policy to deliver equitable health outcomes in cities.

This study is only the beginning of a new research agenda to rethink urban health from a land tenure security lens. Moving beyond theory, a further step of this study is to develop a tenure security "health insults" index based on which an empirical investigation of the connection between land tenure security and health outcomes is possible.

**Author Contributions:** This manuscript is a part of ongoing PhD. research. The PhD. candidate (W.D.) and the supervisor (W.T.d.V.) made their respective contributions to the manuscript as follows: Conceptualization, W.D.; methodology, W.D.; validation, W.T.d.V.; formal analysis, W.D.; investigation, W.D.; resources, W.D. and W.T.d.V.; data curation, W.D.; writing—original draft preparation, W.D.; writing—review and editing, W.T.d.V.; visualization, W.D.; supervision, W.T.d.V. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Not applicable.

**Appendix A**

**Acknowledgments:** This study was carried out while undertaking a Ph.D. research program at the Chair of Land Management, Technical University of Munich (TUM). We wish to express our appreciation to the Konrad Adenauer Stiftung (KAS) for funding the doctoral studies. We would also like to thank the mentor of the Ph.D. candidate (U.E. Chigbu) for his mentorship, E.D. Kuusaana, fellow doctoral candidates, and reviewers whose intellectual discussions and constructive comments helped to improve the paper.

**Conflicts of Interest:** The authors declare no conflict of interest.
