*2.2. Framing Land Tenure Security as a Social Determinant of Health*

Although vigorously speculated in intellectual and policy discourses, land tenure security and health are two distinct concepts that are hardly investigated together. There is literature evidence that hints at linkages between land tenure security and health [50–53,78,79]. The connections between land tenure security and health are mostly investigated without mono-disciplinary theoretical and conceptual frameworks for testing the associations or causal pathways that link land tenure security to health outcomes. On one hand, there are health frameworks [80,81] that link health outcomes with environmental factors, but land tenure security is hardly one of such factors that are linked to health outcomes. On the other hand, there are land management frameworks including sustainable land management framework [82,83], responsible and smart land management framework [84], land governance assessment framework [85], land tenure security and spatial justice framework [86], and tenure responsive land use planning [87] which address land and land tenure security issues but rarely include health matters. Evidence from preliminary reviews of land tenure, urban and environmental health literature, and daily urban life and urbanization experiences suggests that there must be an inter-relation between land tenure security and health diseases. The manifestation of this inter-relation is that land tenure patterns dictate housing patterns and neighborhood conditions which directly affect health outcomes. Similarly,

land management interventions such as slum upgrades, resettlement, and tenure formalization have delivered improved health and well-being as outcomes through improved tenure, housing, and environmental conditions [56]. Therefore, if land tenure influences housing and environmental conditions and housing and environmental conditions influence health outcomes, there must be a relation between land tenure security and health outcomes. In fact, this relationship exists and manifests in urban informal settlements, but has been given little attention, which has led to some implications on the health burden of urban areas. This makes it compelling to revisit this relationship. However, an understanding of this relation requires an inter-disciplinary integration of theories that combine society, environments, and health. One domain that presents an opportunity for such integration is social production of health and disease theories which combines ecology, biology, and social context to understand distal social and environmental determinants of health.

Three social epidemiology theories which are relevant for understanding health outcomes and socio-environmental context are psychosocial theory, social production of disease theory, and eco-social theory [18]. The three theories agree that health outcomes are results of an interplay between society and biology but differ in their respective emphasis on different aspects of social and biological conditions and how they integrate to shape population health and disease patterns.

The psychosocial theory hypothesizes that the social environment changes host susceptibility by affecting neuroendocrine function [88,89]. It emphasizes endogenous biological responses to human interactions by focusing on responses to stress and on stressed people in need of psychosocial resources but ignores who and what generates psychosocial insults and buffers as well as how their distribution is shaped by social, political, and economic policies [60]. In relation to this study, the theory offers insights for investigating the social and psychological stresses imposed on people by the presence or absence of land tenure security, and the consequences on health outcomes.

The social production of disease theory [90] posits that economic and political institutions and decisions that facilitate economic and social privilege and inequality are the "fundamental causes of inequalities" in health [91]. It focuses on the health impacts of state policies but offers few principles for identifying and investigating what the actual social determinants of health are [60]. Hence, the theory resonates with policy thinking, and in the case of this study, how land and tenure policy set broad social contexts that influence health outcomes.

The eco-social theory embraces the social production of disease approach while engaging a comparable analysis of biology and ecology [60]. The eco-social theory of disease distribution seeks to answer the principal question—what is responsible for population patterns of health, disease, and well-being, as manifested in the present, past, and changing social inequalities in health? [60]. It integrates social and biologic reasoning along with a dynamic, historical, and ecologic perspective to develop new insights into determinants of population distributions of disease and inequalities in health [92]. The key construct of the eco-social theory is embodiment—how humans biologically incorporate the material and social world in which we live, from conception to death.

Two propositions of the eco-social theory are key for relating land tenure and tenure security to health outcomes:


In the context of this study, these propositions are relevant for understanding the role of land tenure in health, particularly how variations of land tenure security stratify society, impose differential access to resources, rights, and power that shape health burdens and outcomes of populations and individuals.

Together, the three theories above emphasize the concept of "social position" which underscores social determinants of health [18]. Within this purview, we framed land tenure (security) as a social position, which shapes people's living conditions and health outcomes. In other words, viewed as a social determinant of health, land tenure creates a social structure or relations in society; variations in the nature of tenure and security of tenure create social stratification and assigns individuals to different social positions and circumstances that affect their health.

#### **3. Materials and Methods**

#### *3.1. Study Design*

Methodologically, this study adopted a narrative review approach [93]. Narrative reviews are less discriminatory in the identification, assessment, and inclusion of studies, which allows for pooling ideas and evidence from studies of varying scientific quality [94]. Unlike systematic reviews, a narrative approach enables searching more broadly across disciplines [95], which allowed us to search interdisciplinary trends in land tenure, urban health, environmental management, urban planning, land management, and health issues. In addition, new topics such as that under consideration in this study do not have enough primary research data upon which to base conclusions, which makes a narrative review appropriate for approaching both scientific and gray literature to derive new knowledge. Admitting that narrative reviews suffer the criticism of potential bias in literature selection, such bias is not spared in an individual-conducted systematic review. Hence, given the relatively new nature of this study, its interdisciplinarity, and the breadth of related literature across disciplines, we find a narrative review approach more appropriate for this study. Therefore, following Green et al.'s [93] methodological framework for writing narrative reviews, we conducted a narrative review of urban planning, health, and land tenure literature to understand the role of land tenure security in health outcomes. According to Green et al. [93], a narrative review comprises four stages—identification of sources of information, setting parameters and delimiting search terms, defining selection criteria, and summary and synthesis of results.
