**1. Introduction**

City life is a reality for many and is rapidly becoming so for most of the world's population [1–3]. The world today is experiencing a fast pace of urbanization with nearly 70% of the global population projected to live in urban areas by 2050 [4]. Conventionally, urbanization has been linked to development, and development with health, but in the face of development is the growth of slums, which are characterized by poor health [5]. Cities are therefore characterized by three processes, namely the movement of people into urban centers, development of informal settlements due to lack of tenure, and emergence of environmental and health problems. Thus, while urbanism is idealized to entail social improvements with consequential better quality-of-life for urban residents, on the contrary, in many low-income and some middle-income countries, urbanization conveys inequality and exclusion. This creates cities and dwellings characterized by poverty, overcrowding, poor housing, severe pollution, absence of basic services, and poor health which is defined by the unequal social context that surrounds the daily life of the disadvantaged, and often, socially excluded groups [6]. The rise of urban populations has rendered cities in both developed and developing countries vulnerable to poor health and diseases that are associated with urban living conditions and environments [3]. In response, there is a wealth of literature that recognizes the need to understand the impacts of urban environments and living conditions on the health of urban populations [5,7–13]. There is

**Citation:** Dachaga, W.; de Vries, W.T. Land Tenure Security and Health Nexus: A Conceptual Framework for Navigating the Connections between Land Tenure Security and Health. *Land* **2021**, *10*, 257. https://doi.org/ 10.3390/land10030257

Academic Editor: Liz Alden Wily

Received: 11 February 2021 Accepted: 28 February 2021 Published: 3 March 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

now a growing consensus that while personal factors are critical in determining health, the urban environment exacerbates or mitigates health and well-being outcomes [14,15]. This is because cities are so ubiquitous and their impact so pervasive that it is difficult to consider any aspect of health ignoring urban settings [16]. To emphasize this, Corburn [17] posits that if the global community is serious about the Sustainable Development Goals (SDGs), greater attention must be paid to understanding and acting to improve urban places, living conditions, and the social and economic conditions that can promote health equity. Hence, the solution for improving health outcomes in urban settings lies in addressing urban environments and associated land–people relations than narrowly focusing on healthcare systems—a stance aligned with socio-environmental determinants of global health [18].

The literature on addressing urban environments to promote health connections is diverse but distributed in professional silos. Most of the literature has subscribed to a planning approach and either praised or blamed urban planning approaches or their absence for the health conditions in urban areas or advocated urban planning as a solution to urban health conditions [13,19–21]. Many have attributed urban health conditions to urban green spaces [22–26], urban density [27,28], transport planning [29,30], environmental pollution including air, water, and noise pollution [31–33], urban land use changes [34–36], and lack of basic infrastructure and water and sanitation facilities [12]. For many, the picture that comes to mind at the mention of urban health is the striking informal settlement that comes with urbanization in most developing countries. The mention of informal settlements creates a picture of poor health and high disease burden and informality which is identified with lack of space and tenure insecurity [13,37,38].

People to land relations and land tenure security are central to the informality, high disease burden, environmental pollution, density, blue-green spaces, land use change, sanitation, and basic infrastructure which are identified with health in urban areas. Land tenure security provides rights that enable access to blue-green spaces, urban infrastructure, and services, while also providing the incentive for environmental stewardship and investment in household infrastructure such as water and sanitation facilities to improve living conditions. Yet, urban planning literature [13,19,21] has made implicit the complex role of land tenure and tenure security in understanding urban environments and health. Some scholars [13,20], in advancing an urban planning course, have argued in the wake of recent pandemics that urban planning, a profession that emerged in the late nineteenth century with a goal of improving the health of the least well-off urban residents, has lost its focus throughout the twentieth century. However, we think that urban planning has not necessarily lost focus, rather it has failed to explicitly leverage the role of land tenure security in urban planning to unleash the full health benefits. While the urban planning and health nexus articulated in literature cannot be underestimated [13], we argue that underlying planning is land tenure which, when combined with planning, leads to improvement in livelihoods [39], quality of life [40] and health. Therefore, focusing on urban planning as a solution to urban health conditions without tenure is a recipe for gentrification [41], which in itself has implications on health [42–44]. Planning and land tenure have land use in common, and while planning organizes space according to uses, tenure connects people to these organized spaces. Therefore focusing on planning alone leads to "urban planning dilemma", where those with legitimate rights to land are different from those deciding how and what to use the land for [45]—a situation which has implications for urban environmental outcomes and health.

Land tenure security is a socio-environmental factor of health that is hardly referenced in the debates about urban built environments and health connections. Nevertheless, it plays an obvious role in shaping urban environments, housing conditions, and for that matter health. Made explicit, Watson [46] emphasizes the importance of land tenure and health in the following excerpt:

"Our identity as human beings remains tied to our land, to our cultural practices, our systems of authority and social control, our intellectual traditions, our concepts of spirituality, and to our systems of resource ownership and exchange. Destroy this relationship and you damage—sometimes irrevocably—individual human beings and their health."

Although this quote clearly recognizes that land tenure is a determinant of health and well-being, the pathway for such association is multi-directional [46] and less understood. In fact, it still sits at the heart of much academic and policy debates which promote tenure choices to deliver certain outcomes including sustainable cities and housing, green cities, clean cities, land degradation neutrality, environmental conservation, and various SDGs [4,38,47–49]. A growing land tenure insecurity correlates with a growing poverty level and volume. A growing poverty level and volume correlates with an increase in compromising of health issues. An increase of compromising of health issues increases the amount of disadvantaged urban population. Yet, it remains unclear how, where, when, through which mechanisms, and under which conditions land tenure insecurity drives and affects health issues. A fundamental issue in land management literature is that there is little reference to health. Likewise, health literature hardly refers to land tenure or land tenure security. In effect, there are insufficient provisions for health in the formulation of land policies and insufficient provisions of land tenure in health policy formulation. Hence, health issues are never a comprehensive part of land policy formulation or are the immediate objectives of land tenure security interventions. Consequently, there are no explicit formal connections between land tenure security and health, which is an omission in both science, policy, and practice. There is no comprehensive study that connects land tenure security with health despite several studies which suggest potential linkages between the two variables [49–54]. The ones that have attempted this connection [47,50,51,55,56] have either ended up alleging a link between land tenure security and health without showing the mechanisms and pathways of this link [51], are not grounded on theoretical and conceptual frameworks [50], or based on a limited scope of what constitutes tenure [47].

This study fills this gap by a process of inferring from existing documentation what the connections between land tenure security and health could be and how this could translate into a land tenure security and health nexus conceptual framework. Such a framework would make the pathways through which variations in land tenure security on the one hand and health issues on the other hand influence or affect each other. The objective of this inference review is to derive the scope, extent, nature, and gaps of existing research on urban environments and health from a land tenure lens/perspective, to identify the pathways through which land tenure security and health are linked, and to develop a land tenure security and health nexus conceptual framework for understanding these linkages. The study sets the stage for further investigation for measuring and empirically investigating the relationship between land tenure security and health outcomes and diseases.

In the next section, we demystify the concepts of health, tenure security, and theoretical foundations of the land tenure security and health nexus. Section 3 describes the methods used in this review. In Section 4, we synthesize findings on the land tenure security and health nexus highlighting the existing evidence of the potential linkages between land tenure security and health. We then present, in Section 5, the land tenure security and health nexus conceptual framework and conclude with implications and recommendations for further research.

#### **2. Land Tenure Security and Social Determinants of Health: Theoretical Framing**

Ansari et al. [57] argue that there is a need for (inter-disciplinary) theoretical frameworks that encompass the role of social and environmental determinants of health while acknowledging the crucial inter-connectedness of social context, behavior, and biology. Subsequently, theoretical models such as that by Barton [15] emphasize this need by showing the determinants of health in urban settlements which go beyond the individual to encompass social context in which people live. Although theory by itself is not a panacea, it can help to select key goals and measurable indicators needed to formulate health policies [58]. The strong correlation between proximate determinants of health often obscures the impact of distal social factors, including land tenure security, that can

influence the causal pathways for health outcomes within populations. Therefore, theories guide the selection of key constructs and concepts thought to have influence on health and to explain the multiple social and biological processes that result in embodiment and consequent manifestation in the disease burden and health outcomes of populations and individuals. This new thinking conforms to the ideals of modern social epidemiology—a branch of epidemiology concerned with the way that social experiences, social structures, institutions, and relationships influence health [59]. Current dimensions of health call for integrative and cross-disciplinary research strategies or systems, each directed towards some aspects (including land tenure security) of the complex relationship of health and diseases to society and the individuals [57]. Theories underpin such research and provides the basis for explaining the connections between specified phenomena within and across specified domains by using interrelated sets of ideas whose plausibility can be tested by human action and thought [60]. Before delving into what theory is relevant for advancing the cause of land tenure security and health, it is important to understand what the two concepts denote.
