Climate Change, 24-hour Movement Behaviors, And

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Zisis et al. Global Health Research and 021) 6:15Global HealthResearch and PolicyREVIEWOpen AccessClimate change, 24-hour movementbehaviors, and health: a mini umbrellareviewEvaline Zisis1, Shawn Hakimi1 and Eun-Young Lee1,2*AbstractBackground: The worsening climate change and alarming prevalence of communicable and non-communicablediseases continue to threat human life and existence. Accumulating evidence suggests that favorable patterns of24-h movement behaviors, high physical activity, low sedentary behavior, and adequate sleep, may positivelycontribute to achieving dual benefits of climate change mitigation and disease prevention. The purposes of thismini umbrella review were to summarize the most up-to-date, high-level evidence exploring the relationshipsbetween climate change, 24-h movement behaviors, and health and elaborate on the mechanisms linking thethree variables of interest.Methods: A systematic search of electronic databases was performed in PubMed and Google Scholar duringMarch–October 2020. Inclusion criteria were: (1) systematic review; (2) reviewed relationships between climatechange and movement behaviors and/or health in any directions; (3) written in English; (4) published in 2010–2020.Narrative synthesis was conducted to highlight the main relationships observed and address the current state ofknowledge and priorities for future research. In order to illustrate the potential mechanisms between climatechange, movement behaviors, and health, the main results from included systematic reviews were summarized anda conceptual framework was developed for future research.Results: Based on the evidence from eight systematic reviews published in the past decade, multi-directional (i.e.,uni-, bi-, or U-shaped) links were observed between climate change and varying human health outcomes. However,little is understood about the association between climate change and 24-h movement behaviors. Two reviewssuggested the negative impact of climate change on sleep and bi-directional relationships between climate changeand physical activity/sport. One review included two studies suggesting the unfavorable impact of climate changeon sedentary behavior; however, the evidence was limited. Finally, no reviews examined the mechanisms by whichclimate change, movement behaviors, and health impact one another. Based on the findings of this mini umbrellareview, a conceptual framework is proposed that could guide future work to unpack mechanisms between climatechange, movement behaviors, and health.Conclusions: This mini umbrella review highlights the importance of better understanding the mechanismsbetween climate change, movement behaviors, and health in developing effective mitigation and adaptationstrategies to climate change, while paying close attention to vulnerable countries/communities/population groups.Keywords: Population health, Chronic disease, Global warming, Natural disaster, Physical activity* Correspondence: eunyoung.lee@queensu.ca1School of Kinesiology and Health Studies, Queen’s University, KHS 307, 28Division St, Kingston, ON K7L3N6, Canada2Department of Gender Studies, Queen’s University, Kingston, ON, Canada The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Zisis et al. Global Health Research and Policy(2021) 6:15BackgroundSince the Industrial Revolution, economic activities haverelied on the burning of fossil fuels, which has led to anincrease in atmospheric carbon dioxide concentrationsand other greenhouse gas (GHG) emissions [1]. As a result, an increased greenhouse effect has led to warmingof the earth’s atmosphere. Climate change poses a greatthreat to several aspects of human life including sustainability [2], economy [3], and health [4]. For example,yearly deaths attributable to climate change are expectedto surpass 250,000 between the years 2030 and 2050 [5].Climate change may also impact human health indirectlyby affecting the availability of resources necessary forhuman life such as local food, safe outdoor environments, or health-related behaviors such as active commuting [6, 7]. Given this startling evidence, minimizingnegative impacts of climate change on human health hasbeen a focus of public health [8].In addition to the threat from climate change to human health, lack of physical activity (PA), sedentariness,and inadequate sleep have been associated with varyinghealth outcomes [9–11]. PA, sedentary behavior (SB),and sleep are three main movement behaviors that occurin a 24-h period, known as 24-h movement behaviors[12]. In general, global populations, particularly thoseliving in rapidly developing and developed countries,have shown low levels of PA (also known as physical inactivity), increased reliance on motorized vehicles, andelectronic screen-based home entertainment, and fewerphysically demanding professions [13]. These behavioralchanges as a result of industrialization and urbanization,along with improved technology and resources havecontributed in reducing the physical demands of day-today life [14, 15]. Together, all these developments andsubsequent lifestyle changes likely led to increased energy consumption and GHG emissions, and have ultimately exacerbated climate change [16].Though limited to observational studies, the recenttime-use epidemiology literature emphasizes that reallocation of time between PA, SB, and sleep (e.g., reallocating 30 min of screen time with PA) is favorably associated with weight change [17], body mass index [18],waist circumference [19], obesity [20], executive functioning [21], cardiometabolic health [22], symptoms offatigue [23], and all-cause mortality [24] in varying ageand population groups. In addition to the known healthbenefits of re-allocating movement behaviors (e.g., replacing 30-min of SB with PA), the IntergovernmentalPanel on Climate Change report highlighted that lifestylebehaviors and cultural change have great potential forclimate change mitigation and adaptation efforts [25].Given that climate change mitigation and health promotion efforts can go hand in hand, a better understandingPage 2 of 14of the associations between climate change, 24h movement behaviors, and health is important.Research on climate change and human health hasbeen gaining traction over the past few decades; however, mechanisms between climate change, 24h movement behaviors, and health inclusively, and therole that 24-h movement behaviors may play in moderating or mediating the relationship between climatechange and health are largely unexplored. Better understanding of such complex mechanisms may inform future climate change mitigation and adaptation strategies.The purposes of this mini umbrella review were 1) tosummarize the findings of systematic reviews exploringthe topics of climate change and 24-h movement behaviors and/or health and 2) to elaborate on the mechanisms linking the three variables of interest (i.e., climatechange, 24-h movement behaviors, and health).MethodsThis review is in a form of mini-review which summarizes “the most salient concepts related to a topic whilereporting the most relevant and current findings” [26].Furthermore, umbrella review was utilized to offer possible solutions and future directions that could address abroad scope of issues related to climate change andmovement behaviors and/or health [27]. To conduct amini umbrella review, peer-reviewed systematic reviewsexplaining the associations between climate change and24-h movement behaviors and/or health outcomes published in the past 10 years were systematically examinedand summarized, using Preferred Reporting Items forSystematic Reviews and Meta-Analyses (PRISMA) guidelines [28]. Only systematic reviews were consideredgiven the vast scope of the topic and heterogeneity thatexist in each variable of interest across different studieswith the following definitions for each variable of interest. Climate change is operationalized as one of the biggest issues of our time due to anthropocentric activities,including shifting weather patterns, rising sea levels,greenhouse gases effect, poor air quality and air pollution, patterns and intensities of natural disasters (e.g., extreme rain falls, droughts, floods, storm, bushfires),extreme weather events, and allergens and disease vectors (e.g., ticks, bugs, blackflies, mosquitoes) [29, 30].Based on the time-use epidemiology thinking in recentyears [12, 31], 24-h movement behaviors indicate threekey movement behaviors that individuals engage withina 24-h period, which includes PA, SB, and sleep. Additionally, for this review, physical, mental, and socialwell-being, as well as communicable diseases (CD) andnon-communicable diseases (NCD), were considered ashealth outcomes inclusively [32].

Zisis et al. Global Health Research and Policy(2021) 6:15Literature searchA search for systematic reviews on the topics encompassing climate change, 24-h movement behaviors and/or health was performed (EZ) in PubMed in March 2020using the following keywords: (“climate change” OR“global warming)” OR (“sleep” OR “PA” OR “physical inactivity” OR “sedentary behav*”) OR “health”. The yearrange of 2010–2020 was set to identify only the mostup-to-date systematic reviews. Google Scholar wassearched using similar keywords (SH and EL) to ensurethat all relevant reviews were captured. The list wascross validated with the results from PubMed. A top-upsearch was conducted on June 1, 2020, and expert suggestion was received on October 1, 2020.Inclusion criteriaReview articles were deemed eligible for inclusion if thefollowing criteria were met: 1) systematic review; 2)reviewed relationships between climate change and 24h movement behaviors and/or health (i.e., reviews weredeemed eligible if climate change and any of the three 2h movement behaviors or health were included in theirinvestigation); 3) in English; 4) published in 2010 and2020.Page 3 of 14suggested by an expert in October 2020, making up atotal of eight systematic reviews included in this review.Of the eight reviews, six evaluated the relationships between climate change and health [33–38], one examinedthe relationship between climate change and sleep [39],and one evaluated the relationship between climatechange and PA [40]. One systematic review [40] waspublished in the year of 2021; however, it was capturedin our search in 2020, thus, included in our review. Adescriptive summary and the main findings are presented in Table 1. Systematic reviews included in this review [33–40] had a total of 457, non-mutually exclusive,independent articles and the search time frame rangedfrom no set time limit up to the year of 2020. None ofthe included reviews had a specific age group or geographical location of interest; However, one review had aspecific focus on developing countries only, given theirvulnerability to climate change [35]. All systematicreviews captured from our searches that meet the eligibility criteria were included in evidence synthesis regardless of its quality given the explanatory nature of thepresent review. In examining the associations betweenclimate change and 24-h movement behaviors and/orhealth, indicators for each variable of interest used werelargely heterogenous across the reviews.Screening process and data extractionThe screening criteria were established a priori (EL). Duplicates were removed and searched reviews werescreened based on their titles and abstracts then full-textby two reviewers (EZ and SH). Data screening wassupervised by the principal investigator (EL). A data extraction form was developed by the principal investigator(EL) and the main data extractor (EZ) which includedstudy characteristics (e.g., authors, year of publication),number of original articles included in each review, relationships observed, topic of interest, and summary offindings. Data extraction was conducted by the first author (EZ) then verified by the principal investigator (EL).Evidence synthesisNarrative synthesis was conducted (EZ) and verified (SHand EL) to highlight the main relationships observedand to address the current state of knowledge and priorities for future research. In order to illustrate the potential mechanisms between climate change and 24h movement behaviors and/or health, the main resultsfrom the included systematic reviews were summarizedand a conceptual framework was developed (EL).ResultsSearches in PubMed and Google Scholar yielded 276 articles (Fig. 1). A total of six reviews met the inclusioncriteria. Another review was identified through the topup-search in June 2020 and one additional review wasClimate change and healthOf six reviews [33–38], three reviews [34, 36, 37] evaluated the effects of climate change on physical health outcomes. A bi-directional relationship between globalwarming and obesity was noted in one review [34], describing that global warming has a negative impact onthe obesity epidemic through food supply/price andadaptive thermogenesis (i.e., reduced seasonal exposureto colder climate decreases energy expenditure and contributes to adiposity). Conversely, global warming is exacerbated due to obesity epidemic through increasedenergy consumption and GHG emissions [34]. Furthermore, extreme weather events caused by global warming(e.g., heat waves, wildfires, drought), led to increasedmorbidity and mortality [37]. Rising temperatures alsoincreased risk for cardiovascular and respiratory dysfunctions, due to increased concentrations of air pollutants and ozone [37]. Moreover, changes in temperatureand rainfall patterns caused by global warming are expected to increase the spread of infectious diseases [36,37]. Increased temperatures due to climate change wasalso shown to impact occupational health whereby thereis an inverse U-shaped relationship between maximumdaily temperature and daily injury claims among outdoorworkers [36].Two reviews focused on the relationships between climate change-related indicators and mental health. Oneof these reviews [35] found that experiences with natural

Zisis et al. Global Health Research and Policy(2021) 6:15Page 4 of 14Fig. 1 PRISMA flow diagram of the literature reviewing processdisasters due to climate change are associated with increased rates of post-traumatic stress disorder, injury,depressive disorder, and anxiety disorder. In addition,the review [35] suggested that climate change-relatednatural disasters disproportionately affect women, individuals with older age and/or poor health status, andthose who witnessed death/dead bodies. Another review[39] indicated that rising temperature and extreme weather events due to climate change are associated withimpaired sleep due to fear or depression.One review [33] prospectively examined how publichealth and climate change mitigation strategies produceboth health and environmental benefits and risks. Results showed that increased social capital has potentialhealth risks by increasing fear and misconceptionswithin social networks about climate change. The reviewalso suggested that urban design and planning strategiesas a response to climate change (e.g., expanding greenspaces, walkable neighborhoods, bike paths) can have apositive influence on both public health and climatechange mitigation while poor urban planning (e.g., urbanheat island effect) can increase health risks.One review [38] specifically examined the impact ofclimate change-related water disasters on populationhealth. The review highlighted that people in a vulnerable situation (e.g., living in poverty or unstable dwellings, lack of access to health care) are at an increasedrisk for mortality and morbidity. For instance, amongresidents in Southeast Florida, rising sea levels were particularly dangerous for those who are low-income, lowereducation levels, non-English speaker, older age, visibleminority, or those with disability [41].Climate change and 24-h movement behaviorsOne review evaluated the relationship between climatechange and sleep [39] and another review examined therelationship between climate change and PA [40]. Rifkinand colleagues [39] investigated how changes in temperatures, extreme weather events, and natural disasters impact human sleep. Findings from their review showed

Search databasesPubMed, Web ofScience, EBSCO, ScopusPsycArticles, CINAHL,SportDiscus, GreenFILE,GeoRef, Scopus, JSTOR,Transportation ResearchInformation ServicesLast name of the firstauthor (publicationyear)An et al. 2018 [34]Bernard et al. 2020 [40]5063(“obesity”, “obese”,“adiposity”, “overweight”,“body mass index”, “BMI”,“weight”, “waistcircumference”, “waist tohip”, “waist-to-hip”, “bodyfat”) AND (“climate change”,“global warming”)(“exercise”, “sport”. “walk”,“biking”, “physical activity”)AND (“climate change”,“natural disaster”,“greenhouse”, “flood”,“extreme weather”,“drought”)– July 2019–October 2020# of articles inreviewSearch keywordsSearch periodTable 1 Summary of systematic reviews included in reviewClimate change andmovement behavior(physical activity)Climate change(global warming) andhealth (NCD focused)Relationship(s)examined There is a bidirectional relationshipbetween climate change andphysical activity and sport practices Air pollution is associated with aless time spent participating inphysical activity and more timespent in sedentary time Extreme weather conditionsincluding heavy precipitation andheat waves lead to decreasedactive transportation and leisurephysical activity Natural disaster experience isassociated with lower levels ofphysical activity and less activetravel Active transportation reducescarbon dioxide and othergreenhouse gas emissions Participation in sport is related to alarger carbon footprint, particularlyin elite sports. This carbon footprintmay be reduced throughinterventions such as carpooling for Four types of relationshipsidentified: 1) global warming andthe obesity epidemic are correlateddue to common drivers; 2) globalwarming influences the obesityepidemic; 3) the obesity epidemicinfluences global warming; 4)global warming and the obesityepidemic influence each other A fossil fuel-based economy, population growth, and industrializationhave contributed to climate changeand obesity through land use andurbanization, motorized transportation, and agricultural productivity Climate change influences theobesity epidemic through foodsupply and food price and adaptivethermogenesis The obesity epidemic influencesglobal warming through increasedenergy consumption (motorizedtransportation and over nutrition)and greenhouse gas emissionsSummary of findingsZisis et al. Global Health Research and Policy(2021) 6:15Page 5 of 14

Search databasesMedline, Web ofScience, GEOBASE, greyliterature (e.g., IPCC,WHO)PubMedLast name of the firstauthor (publicationyear)Cheng and Berry [33]Franchini and Mannucci[37]22(“climate”, “climate change”,“adaptation”) AND (“healthstatus”, “public policy”,“health co-benefits”, “healthrisk”, “public health”)“climate change”, “climatevariability”, “globalwarming”, “meteorologicalfactors”, “weather”,“atmosphere”, “heat waves”,“extreme weather”,“ambient air pollution”,“outdoor”, “particulatematter”, “PM”, “airpollutants”, “mortality”,“human health”, “healtheffects”, “infectious disease”,“diarrheal disease”,“cardiovascular disease”,“ischemic heart disease”,January 2000–March2012–November 201477# of articles inreviewSearch keywordsSearch periodTable 1 Summary of systematic reviews included in review (Continued)Climate change andhealth (both NCDand CD focused)Climate change andhealth (NCD andmental healthfocused)Relationship(s)examined Extreme weather events caused byglobal warming, including heatwaves, wildfires, and drought, leadto increased rates of morbidity andmortality in affected regions. Forexample, there is a link betweenhigher incidence of myocardialinfarction and higher temperature Decreased winter temperaturescaused by global warming in midlateral regions could lead to healthbenefits such a decrease in mortality from respiratory and cardiovascular diseases, however, thenegative health consequences of Climate change adaptationstrategies involving increased socialcapital have been shown to havehealth benefits and reducevulnerability to negative healthimpacts of climate change Increased social capital also haspotential health risks (by increasingfear and misconceptions withinsocial networks) for facing climatechange and must be furtherstudied to improve understandingof risks and benefits Urban design and planningstrategies, such as green spaces,walkable neighborhoods, and bikepaths, can have a positive effect onboth public health and climatechange mitigation Poor urban planning (e.g., urbanheat island effect) can increasehealth risks in the era of climatechangetransportation Leisure physical activity and sportinfrastructure and facilities mayhelp communities’ recoveryfollowing a natural disaster In the future, sports organizationsand facilities will have to prepare,and make accommodations forclimate changeSummary of findingsZisis et al. Global Health Research and Policy(2021) 6:15Page 6 of 14

Search databasesPubMed, EMBASE,SCOPUSLast name of the firstauthor (publicationyear)Levi et al. [36]January 2000–June 2017Search periodTable 1 Summary of systematic reviews included in review (Continued)Climate change(temperatures) andhealth (both NCDand CD focused) There is an inversed U-shaped relationship between maximum dailytemperature and daily injury claims Increased temperatures putoutdoor workers at greater risk forvector-borne infectious disease When daily temperature exceeds32 degrees Celsius, daily laborproductivity is reduced by up to14% in agriculture and construction165Summary of findingsFocused on i) “heat-relatedillness”, “cardiovascular”,“respiratory and kidneydiseases”, ii) “traumaticinjuries”, “acute death”; iii)“vector-borne diseases” or“vectors distribution”.“climate change”, “worker*”AND AND (“health” (healthOR injur* OR disease*))Relationship(s)examinedrising temperatures have beenshown to far outweigh these potential positive ones Desertification and droughts relatedto climate change limit low-incomecountries’ abilities to maintain adequate food production and cleandrinking water, leading to poorerhealth outcomes and increaseddeath rates Diarrheal diseases will likelyincrease due to climate warming;droughts, massive rainfall andincreasing temperatures as thesereduce the availability of safedrinking water Increased temperatures alsoincreased risk for cardiovascular andrespiratory dysfunctions, due toincreased concentrations of airpollutants and ozone Higher levels of carbon dioxide andhigher temperatures resulting fromglobal warming are expected toincrease the prevalence of allergicdiseases globally Through changes in temperature,rainfall patterns, and extremeclimate events, global warming isexpected to increase the spread ofinfectious and vector-bornediseases There is a relationship betweenclimate change, mean temperatureincrease, and humidity variations,and visits to the emergency roomdue to atrial fibrillation, renal colic,and psychiatric issues# of articles inreview“cancer”, and “respiratorydisease”.Search keywordsZisis et al. Global Health Research and Policy(2021) 6:15Page 7 of 14

Search databasesMedline, Embase, Webof Science, PsycINFO,CAB Direct, PILOTS;Hand search in GlobalEnvironmental Changeand Climatic Changejournals; Google Scholar,WHO’s Virtual HealthLibraryPubMed, Scopus,Cochrane databasesPubMed, CINAHL,Embase, Scopus, Web ofScienceLast name of the firstauthor (publicationyear)Rataj et al. [35]Rifkin et al. [39]Veenema et al. [38]2006–20161647(“climate change”, “climaticprocesses”, “El Niño”,“global warming”,“Disasters”, “naturaldisasters”, “floods”, “flashfloods”, “coastal floods”,“flooding”, “cyclone”,“hurricane”, “heavy rainfall/precipitation”, “sea-levelrise”) AND (“health”(“population”, “public”, OR“community)))17# of articles inreviewDirect linkDirect link–April 20141980–2017Search keywordsSearch periodTable 1 Summary of systematic reviews included in review (Continued)Climate change(water disasters) andhealth (NCD, CD, andmental healthfocused)Climate change andmovement behavior(sleep)Climate change(extreme weatherevents) and health(NCD and mentalhealth focused)Relationship(s)examined Climate change-related water disasters directly impact human healthby causing drowning, electrocution,cardiovascular events, and mentalhealth effects Displacement by flooding may putindividuals under close quarterswith potentially unsanitary livingconditions which perpetuate thespread of infectious diseases Increases in water temperature,precipitation frequency and severity Increased temperatures lead todecreased time and quality of sleep A 1-degree Celsius deviation inmonthly night-time temperatureswas associated with an increase ofthree nights of insufficient sleepper 100 people Studies examining the relationshipbetween wildfires, floods, and sleepfound that people exposed tothese natural disasters haddisrupted sleep following theevents Decreased sleep time andincreased sleep disruption arecommon and appear to effectmore vulnerable populations (i.e.,elderly and low-income persons)more severely Following a natural disasterexperience, there are increasedrates of post-traumatic stress disorder, injury, depressive disorder,and anxiety disorder Risk factors for these healthproblems following naturaldisasters consistently included priortraumatic events, female sex, higherage, poor health status, andwitnessing death or dead bodiessectors Overall, as temperatures increasedue to climate change, workerhealth and productivity in outdoorprofessions is expected to declineSummary of findingsZisis et al. Global Health Research and Policy(2021) 6:15Page 8 of 14

Search databasesSearch periodCD Communicable diseases, NCD Non-communicable diseasesLast name of the firstauthor (publicationyear)Table 1 Summary of systematic reviews included in review (Continued)Search keywords# of articles inreviewRelationship(s)examinedand other water disaster-causedconsequences result in increasedwaterborne, vector-borne, and zoonotic diseases Climate change-related water disasters are also associated with negative psychiatric and mental healthoutcomes such as post-traumaticstress disorder Climate change-related water disasters likely disproportionately affectindividuals in vulnerable positions(e.g., low income, % of minority residents, lower education, lack ofEnglish fluency, low take up ofmedical services, age, disabilitystatus). Lower income countries are moresusceptible to water-related disasters with poorer post-disaster outcomes compared to higher incomecountries Disruption in food or water sourcespost water-related disasters canlead to chronic communitymalnutrition Water-related disasters also disrupthealth infrastructure and affect thecontinuity of healthcare servicesduring the recovery period, and thisis hampered by a lack of health services and adequate health professionals in affected communitiesSummary of findingsZisis et al. Global Health Research and Policy(2021) 6:15Page 9 of 14

Zisis et al. Global Health Research and Policy(2021) 6:15that increased temperatures lead to decreased sleepquality. Additionally, people who experienced natural disasters were more likely to experience disrupted sleepfollowing the events. In another review [40], a bidirectional relationship between climate change and PA/sport was identified. Varying indicators of climatechange were associated with low PA with disproportionate impact on individuals with chronic diseases andolder people. The review also suggested that PA contributes to intensifying or mitigating climate change throughactive/passive modes of commuting and subsequent reductions/increase in GHGs. It was also discussed thataccess to PA/sport infrastructure may be important factors for recovery in communities affected by natural disasters; however, at the same time, mega sportingevents, the professional sport industry, and related airtravels by athletes and spectators are major sources ofGHGs.No systematic reviews were focused on the associations between climate change and SB; however, one review on climate change and PA [40] included twostudies which examined the unfavorable impact of climate change related indicators on sedentary time. Specifically, one study observed a high level of sedentarytime among those who experienced Hurricane Ike, as asymptom of post-traumatic stress compared to nondisaster samples [42]. Another original study that wasincluded in the review [40] showed higher levels of sedentary time in the areas of Beijing that exhibit highlyconcentrated air pollution [43].Climate change, 24-h movement behaviors, and healthNone of the identified reviews examined the relationshipbetween all three variables of interest (i.e., climatechange and 24-h movement behaviors and/or health) together. One paper [39] alluded to the emerging threatsof climate change on sleep duration and interruption,and consequently, increased risk for NCDs given thestrong evidence suggesting the association betweenshortened sleep durat

REVIEW Open Access Climate change, 24-hour movement behaviors, and health: a mini umbrella review Evaline Zisis1, Shawn Hakimi1 and Eun-Young Lee1,2* Abstract Background: The worsening climate change and

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