Introduction

The USA is experiencing an affordable housing crisis. In 2021, approximately one-third of households spent more than 30% of income on housing expenses, with surging housing prices further increasing the national share of cost-burdened households [1, 2]. Many government protections enacted during the COVID-19 pandemic have now ended, and eviction rates are climbing back to pre-pandemic levels while many homeowners are still precariously close to foreclosure [2].

Housing is also a well-established social determinant of health [3]. Housing cost burden reduces households’ ability to pay for necessary health services, food, and transportation and is associated with worse self-rated health conditions [4, 5]. Displacement due to eviction or foreclosure is associated with worse self-rated health and healthcare access as well as increased psychological distress [6,7,8,9]. Soaring home prices and rents also contribute to the concentration of families in neighborhoods with higher poverty rates, which are characterized by unhealthier housing conditions, worse access to amenities, and an increased risk of injury and violence [10]. Considering this evidence base and the ongoing national shortage of affordable housing units, housing and health policymakers are seeking urgent and innovative solutions.

Community land trusts (CLTs) have been touted as an effective strategy to secure long-term affordable housing. CLTs, which emerged in the USA during the Civil Rights era, acquire land in gentrifying areas, develop housing units for low-income residents, and then place these properties into a trust with resale restrictions so that affordable homeownership can be sustained in perpetuity [11]. CLTs also emphasize community control of development through a tripartite governance board typically consisting of residents, community members, and technical experts [11]. Lastly, CLTs may support residents with services and supports as well as community organizing and advocacy [11, 12]. This combination of features distinguishes CLTs from other affordable housing strategies.

While the CLT model has spread to every US state, CLT units still comprise a small part of the national affordable housing portfolio, with an estimated 12,000 units across 300 CLTs [13, 14]. Accordingly, the literature on CLTs is still developing, with most case studies focusing on how CLTs develop affordable housing and shape local housing markets. For instance, CLTs may buffer their residents against foreclosures or stem the negative impacts of gentrification by maintaining housing affordability and racial diversity [15, 16]. Other research indicates that shared equity homeownership programs, of which CLTs are the most prominent, preserve long-term affordability and generate modest wealth gains for lower-income households [17,18,19]. However, despite the link between homeownership, wealth-building, and better health [20, 21], to our knowledge, no studies have directly investigated the role CLTs play in shaping the health and well-being of their residents.

Using semi-structured interviews, we explored how stakeholders with expertise in the CLT model perceive the pathways between CLTs and the health of their residents. We sought to generate new theoretical insights, elucidate mechanisms, and inform how public and private entities, including housing agencies and healthcare systems, consider investments in housing as a determinant of health.

Methodology

We used thematic analysis of semi-structured interviews with a hybrid process of inductive and deductive coding [22]. Drawing from a national directory of CLTs [14], we used purposeful sampling of CLT staff in geographically diverse regions across the USA. To recruit residents, we used snowball sampling techniques, in which staff referred us to residents who were living in CLT units and in most instances were serving on the CLT’s board. Participants were recruited until thematic saturation was reached. The interview guide grouped questions into three domains: (1) characteristics of the CLT’s housing model and context, (2) general perceptions of how CLTs impact health, and (3) perceptions of specific pathways through which CLTs might impact health (Appendix A). Probes and clarification questions were added when needed. Interviews were performed by videoconferencing software or by phone and lasted approximately 45 min. Participants also completed an optional demographic questionnaire. The study team then became familiar with the verbatim interview transcripts, created preliminary codes using NVivo qualitative analysis software, and iteratively refined the final themes and subthemes. Each transcript was coded independently by two trained coders, who met regularly to resolve any discrepancies. The Johns Hopkins Bloomberg School of Public Health Institutional Review Board approved the study.

Findings

Of the 30 CLTs that were invited, 15 responded and agreed to participate, including professional staff (n = 16) and residents (n = 10) (Table 1). Most participating CLTs were in medium to large metropolitan areas.

Table 1 Characteristics of stakeholders
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Five major themes emerged concerning how participants viewed the connection between CLTs and health: (1) the stability of CLT housing improves the mental health of lower-income homeowners; (2) CLT units are of a higher physical standard compared to residents’ previous housing; (3) the context of CLT housing improves access to health-promoting amenities; (4) CLTs offer health-promoting services and supports to residents; and (5) CLT residents can influence organizational decision-making to varying degrees but with an inconclusive relation to health  (Table 2).

Table 2 Main themes and representative quotations
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Theme 1: the Stability of CLT Housing Improves the Mental Health of Lower-Income Homeowners

In general, participants conveyed a holistic understanding of the importance of housing security to one’s health and well-being, though this was expressed mainly as improved mental health. Both staff and residents consistently perceived the stability provided by homeownership in a CLT unit, coupled with lower monthly housing costs, to reduce the chronic stress and anxiety that low-income residents experience related to housing insecurity. As one staff member summarized:

[Residents] are now feeling a sense of relief because their mortgages are now way less than what they were paying in rent, and now they can pay their mortgage and have money left over for things like food, car maintenance, gas, vacations. That also contributes to positive health.

Nearly all resident participants, as well as a few staff, spoke to this dynamic plainly: at some point in their life, they had experienced housing insecurity or homelessness. Before moving into a CLT unit, most residents we spoke with had struggled to make ends meet in the private, unsubsidized rental market. One resident commented on the stress of “getting moved out of rentals”:

It is always a thing that at any moment, you could lose your housing. So, you know, in my family, we didn’t get any pets, because you can’t get a dog if you don’t know how long you’re going to be able to live in the house you’re in. […] the stress that working class and poor families have is a constant low burn, because they never know if they really have any ownership over their home or their neighborhood. And to me, that’s a really huge component.

Another resident highlighted how CLTs lifted the financial stress of sudden life emergencies:

Previous to us getting in here, we were definitely counting our pennies. And of course that is also a chronic low level stress all the time. What if the car breaks down? You know, how are we going to fix that? What if my dad gets sick and we need to fly home? You know, what if anything, right? I mean, what if, what if, what if, obviously. So now that we have a little bit more of a cushion […] I’m not worried about how I would fund my response to those events.

Staff participants, who were more familiar with the details of the application and screening process, argued that CLTs are often the only way for lower- and, increasingly, middle-income residents to own a home and avoid displacement in rapidly gentrifying areas. A few residents also saw CLT homeownership as beneficial for the mental health of children in families vulnerable to displacement as well as for older adults worried about financial security during retirement.

Lastly, some staff participants saw the wealth-building aspect of homeownership in a CLT home as a way for lower-income residents to weather financial challenges. However, most participants did not comment on how building home equity might impact the long-term health of new homeowners. Instead, more attention was given to the chronic stress that is alleviated by attaining short-term housing security. One staff member said:

Having a place matters, and I think the CLT model addresses, provides the access to that stability, and cost savings, which I think certainly helps the mental well-being of the individuals under that roof.

Theme 2: CLT Units Are of a Higher Physical Standard Compared to Residents’ Previous Housing

Staff and residents almost unanimously spoke of CLT units being of a high-quality standard because of new construction, extensive building renovations, and attention to ongoing maintenance. The most mentioned improvements were better indoor air quality, higher quality materials, new appliances, and energy efficiency. Multiple CLTs reported making major investments to acquire and extensively rehabilitate vacant properties.

Several residents described how their CLT home was of a much higher standard compared to their previous housing situation and furthermore how the CLT supported ongoing maintenance and upgrades to their home, with referrals to contractors or renovation loans as needed. As one resident described:

[The CLT] helps individuals like myself to eventually be able to purchase a home, and they fix the homes before they sell it. So, it’s not like you’re getting a crappy tear down when you’re moving in. It’s more of a, ‘We’re going to fix the house. It’s going to be safe for you.’

Some staff participants also commented that residents of color were more likely to report suffering from poor conditions in their pre-CLT housing. Lastly, in two cases, the CLT worked with its developer partners so that the home accommodated the needs of residents with physical disabilities.

The theme of improved housing conditions was also frequently mentioned alongside the benefit of affordability, since residents were previously unable to afford necessary repairs or were living under a landlord unwilling to make them. One staff member described the dynamic this way:

So, again, on an anecdotal basis, their health outcomes are going to be a lot better because they’re in a healthy, safe, clean home as opposed to living in a substandard rental situation, where they’re afraid to complain because they’re afraid that the landlord will jack up the rent.

Theme 3: the Context of CLT Housing Improves Access to Health-Promoting Amenities

When describing the context of CLT units, both staff and residents frequently mentioned the array of health-promoting amenities available to residents. The most mentioned amenities were proximity to green space, community gardens, and walkable and transit-friendly neighborhoods. One resident described the importance of convenient access to work and neighborhood amenities:

The main thing is, I get off of work, and I get home very quickly. And in just a few mile radius, there’s stores and restaurants and bars and just everything I need. I don’t have to go very far for anything.

In some contexts, proximity to amenities coincided with opportunities for residents to participate in health-focused programming organized by other groups. For example, one resident spoke of being able to walk to two parks, one of which regularly held meetups where residents could go on a walk with a physician and receive a free health consultation:

Monday through Friday at one of our parks we have, it’s called walk with a doc, from seven to nine […] you get to kind of like ask the doctor whatever kind of questions you may have. You know, like if you have a question for a doctor, whatever you can come up with […] it’s kind of cool that we have like a little incentive to go walking and you can actually speak with a physician.

One CLT engaged the larger community, CLT residents, and board members in reducing vacancy in the neighborhood by maintaining a garden:

It used to be a row of irrecoverable row homes, all vacant behind this church. And they were deconstructed or demolished and [now] there’s a rain garden that houses stormwater remediation, there’s a prayer labyrinth […] and there are a lot of raised beds that community members can […] develop food on, and so it is a food production hub right now […] We have usually volunteers […] who work in the land trust or with the land trust. We then bring [them] onto the board because they have a very direct, you know, stake in what the land trust is doing.

In two other cases, residents mentioned that their CLT home provided more convenient access to their healthcare provider. Interviewees commented on the importance of affordable CLT units in neighborhoods with amenities, especially as many of these neighborhoods rapidly gentrify.

In three contexts, CLTs had a nascent partnership with a local healthcare system. In these cases, the healthcare partner was financing CLT projects through grants, donations, and property transfers. In one city, the CLT was developing a mixed-used residential project designed with a community center where local clinics could provide health screenings. In two other cases, CLT staff participants expressed interest in partnering with their regional hospital but had not yet secured funding. Formal partnerships with local healthcare systems and providers symbolize a shared value that housing is health, as one staff described:

So we had started to forge a really strong partnership with [healthcare partner] because they are very active in giving back to the community and to help the neighborhoods that they’re in. They have a strong presence in [city], and they are very committed to what they believe is a direct benefit to residents, when they have housing that affects […] everyone’s health.

Theme 4: CLTs Offer Health-Promoting Services and Supports to Residents

Most participants described a variety of ways that CLTs support the health and well-being of residents beyond their central mission of providing an affordable home. Of these, the most frequently mentioned by staff and residents were homeownership and financial counseling. These services were typically mentioned in the contexts where a resident is moving into the CLT or falling behind on payments. As one new CLT resident described:

I am not good at financial literacy whatsoever. Didn’t know what a mortgage was […] And then like, two years ago, I learned what a mortgage was […] And so to do the mortgage process was like, incredibly rewarding in that, like I learned a lot. I had to take a homebuyer education course which I was just like, sign me up, fuck yes, I want that. But I learned a lot, and it’s complex stuff, but it’s not because it’s hard.

Less frequently mentioned was outreach during the COVID-19 pandemic regarding testing, vaccination, or arranging transportation to medical appointments. A few staff participants mentioned referrals to health and social services outside the CLT, and one CLT even employed a part-time social worker to facilitate care for older residents. In a couple of cases, residents spoke of how support from their CLT helped them feel connected to the wider community. A resident described the support system for CLT residents in this way:

[The] support is one of the really cool parts because like I said, [as a] single mom, it’s already hard, especially when I haven’t had like the best family support system. When I had COVID last year [the CLT staff] like bought me food and brought it to my door […] there was a gas leak, and they came in and fixed it like immediately. That responsiveness, you feel like you’re not getting taken advantage of. You’re being nurtured and you’re being cared for.

Theme 5: CLT Residents Can Influence Organizational Decision-Making to Varying Degrees but with  an Inconclusive Relation to Health

While all CLTs had some degree of participatory governance, this aspect of the model was seen as tangentially related to residents’ health, if at all. Most resident participants we interviewed either had previously or were currently serving as a lessee representative on their CLT’s board. They spoke of the benefits of participation but did not articulate this role in terms of their own health. As one resident described:

I like the educational component about it […] And I am part of like their policy committee, and I like making sure that [there are] voices out there for people like me that, you know, they don’t know a lot about building a community or being part of a community […] you learn that, you know, it’s possible and you can be part of it. And you can make a difference though, definitely. It has taught me a lot, and I try to share it with as many people as possible.

In general, participants indicated that residents’ ability or desire to participate in governance or community-facing activities varied widely. Staff and residents cited multiple reasons for this, including inadequate staff capacity for outreach and organizing and the fact that residents are busy with other pursuits. CLTs that were engaged in policy advocacy tended to focus on practical local issues, such as property tax reform, again with varying degrees of resident involvement.

Discussion and Conclusion

By focusing on community land ownership and long-term affordability, CLTs offer a range of mechanisms that may impact health and well-being. Stakeholders most frequently identified improvements in mental health that come through increased housing stability and affordability. Other factors—including the ways that CLTs promote wealth generation, higher housing quality and access to neighborhood amenities, services and partnerships with healthcare organizations, and the democratic nature of CLT decision-making—were raised by respondents though less frequently tied to health benefits. Together, the findings contribute to the emerging literature on a unique affordable housing strategy.

Our primary thematic finding is that stakeholders perceive a clear pathway between CLT homeownership and mental health benefits for residents in the form of reduced stress and anxiety. Housing instability—including the fear of losing one’s home, needing to move multiple times, and the need to double up on housing—has been identified as a key predictor of poor mental and physical health across a range of studies [3]. The lack of consistent housing creates tremendous uncertainty and precarity that, in turn, has been found to reinforce stress and anxiety [23, 24]. Improved housing affordability through CLTs both promotes housing stability and thereby reduces stress. Meanwhile, the day-to-day trade-offs that people make with respect to housing costs and health, which have been documented in other contexts [6], were not emphasized by participants compared to the shorter-term mental health benefits.

Participants were inconsistent when discussing how the opportunity to build wealth for first-time homebuyers may influence residents' health, though clearly some saw this aspect of the model as an important source of financial security. In the traditional homeownership setting, there is some evidence suggesting that homeowners (versus renters) and households with higher levels of wealth have better health [20, 25]. This relationship may be less salient in a shared equity setting, where long-term affordable homeownership is prioritized over maximizing returns on equity, though we cannot conclude this without further empirical analyses. Many CLTs we spoke with were also established within the past 5–10 years and were likely unable to gauge the long-term health-related impacts of building wealth for homeowners. As the CLT model likely expands in the coming years, it will be important to assess this unique wealth-building opportunity for low-income homeowners.

CLT residents referenced improved housing conditions benefiting their health, consistent with an extensive literature linking housing quality and health [3]. The improved housing conditions residents experienced in CLTs may partly be a function of homeownership, which is thought to incentivize owners to invest more in the maintenance of their own homes [26]. However, CLT’s shared equity model, in which homeowners only keep a portion of the housing’s increased value at resale, may dampen this maintenance incentive. There is also evidence that for lower income households, homeownership may be associated with less safe housing conditions, as the homes one can afford to buy may be older or of poorer quality than the homes one can afford to rent [27]. Improved housing conditions in CLTs may be less a function of homeownership itself than of other CLT factors. The CLTs interviewed generally favored new construction over older properties to guarantee quality and keep repair and energy costs affordable for lower income residents. This approach can reduce the heating, pest, and mold issues associated with poorer health. It is unclear, however, whether the construction of newer or higher quality homes is true across CLTs or whether housing quality will remain as the CLT housing stock ages.

Several other pathways were mentioned by stakeholders, albeit less frequently so. Residents living in CLTs may have access to health-promoting resources, such as on-site medical services and healthier food options. However, among our participants, direct provision of health services within CLTs appears to be relatively rare. This represents a largely untapped opportunity to augment the upstream health-enhancing impacts of CLTs with downstream supports to address immediate health needs. This opportunity is especially salient for health systems partnering with CLTs as part of a place-based community health strategy, since they often already have resources and programs to provide direct clinical and community health programs to CLT residents.

Lastly, CLTs’ participatory decision-making structure was seen to be a vital aspect of the model but was the least salient pathway to health, including among the residents actively serving as lessee representatives. Residents’ participation in decision-making likely fosters both social cohesion and collective efficacy among CLT residents, which may contribute to improved health in urban neighborhoods [28]. However, participation varies significantly according to organizational mission as well as the capacity of both staff and residents. Indeed, widespread resident engagement may not be required for CLTs to fulfill their mission of creating an alternative to capitalist property relations [29]. Overall, the importance of democratic participation for CLT residents’ health may not be readily apparent, speaking to the indirect ways that these factors may function.

Our study should be considered within the established limitations of qualitative research. First, the study was designed to generate hypotheses as to the potential links between CLTs and health. As such, we used purposeful sampling designed to have broad geographic and sociodemographic diversity. However, the sample was not designed to be representative, and the limited sample size precluded us from exploring how views varied across characteristics of respondents and of CLTs. Future studies should consider quantitative approaches to measuring changes in health status as households move into CLTs over time. Second, in obtaining resident perspectives, we focused on those who served as lessee representatives on the governance board. The views of these homeowners may not be representative of other residents living in the CLT. Third, the views expressed by participants may be subject to recall and social desirability bias. Finally, interviews did not explore in detail the mechanisms through which CLTs may benefit the broader neighborhood. Considering the spillover effects on the community is an important future direction for research on CLTs.

Our findings have important implications for practitioners as well. For CLT staff, our study can help tailor their efforts to focus more explicitly on residents’ health and well-being. Multiple CLTs we spoke with were tracking various performance measures to meet organizational goals, but health-oriented outcomes had for the most part remained anecdotal. Additional efforts by CLTs to collect information on how their residents’ health is impacted during the process of moving into and settling in a CLT unit would be worthwhile, particularly for tailoring outreach and services.

For potential CLT funders, especially health systems and housing agencies, our findings suggest multiple ways to enhance the public health benefits of the CLT model. In contrast to narrower investments in affordable housing, each dollar invested in a CLT has the potential to activate multiple health-enhancing pathways that include long-term affordability but also stability, quality, wealth-building, and collective efficacy. Additionally, health systems have an opportunity to deepen the health impact of CLTs by providing health services and other health-promoting resources for CLT residents. Most CLT staff participants indicated that health system partnerships were highly desirable but not yet realized. Our analysis indicates this may be changing, with two CLT respondents already engaged in fruitful, multi-year partnerships in which their healthcare system acted as a funder or co-developer.

The current affordable housing crisis demands innovative models and cross-sector partnerships. The CLT model offers varied mechanisms to address housing inequity and  the health and well-being of low-income residents, representing a promising area for future research on housing’s impact on health.