Introduction
Climate change poses a significant challenge to humanity, affecting various aspects of human life, including public health [1, 2]. Rising temperatures lead to more frequent extreme climatic events and changes in ecosystems. Understanding the effects of climate change on human health is crucial for developing effective strategies to address these challenges [3-6]. A proper understanding of the negative effects of climate change on the environment, such as sea level rise, global warming, intensification of weather phenomena, severe droughts and forest fires, is very important as these changes also greatly affect human health and well-being [7, 8].
The latest Lancet report, which examined 43 indicators of the relationship between climate change and human health, emphasized that the impact of climate change on human health is worsening by the day [8]. The impact of climate change on human health occurs through multiple direct and indirect ways [9]. An adverse health impact is defined as the creation, promotion, facilitation and/or exacerbation of a structural or functional abnormality that has the potential to reduce quality of life, contribute to a debilitating disease or lead to premature death [10]. Human health is significantly affected by climate change, resulting in direct health problems such as heat-related death, cardiovascular and respiratory diseases [8, 11-13]. Moreover, the indirect impact of climate change include the spread of disease-carrying insects, forced migration, shortage of resources, and inadequate access to food and clean water [14]. Iran is susceptible to the effects of climate change because of its distinct geographical and climatic conditions [15, 16]. It is exposed to a range of climate-related hazards that can have a significant impact on public health [17]. Due to factors such as urbanization, demographic changes, and socioeconomic conditions, the Iranian population is at risk of health problems caused by climate change [18, 19]. 
Research has shown that extreme temperature is contributed to the increased death cases from cardiovascular and respiratory diseases [20]. The occurrence of trauma-related deaths tends to rise at higher temperatures and lower humidity levels [21]. Furthermore, environmental factors, such as temperature and humidity, have a significant impact on the prevalence of common communicable diseases such as malaria, leishmaniasis, and Crimean-Congo hemorrhagic fever (CCHF) in Iran [22, 23]. A comprehensive review of studies on the effects of climate change on human health is necessary to guide future actions [24]. Systematic reviews can help identify specific effects such as wildfires or occupational hazards, in specific countries, such as Iran [25, 26]. Therefore, the present study aims to systematically review the impact of climate change on the health of Iranian population. This research provides valuable insights for the development of health policies and interventions that can suggest a comprehensive and evidence-based approach to address the health challenges caused by climate change in Iran.

Materials and Methods
This is a systematic review study conducted according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines and based on a step-by-step method (Table 1): Formulating the research question, searching and evaluating the literature related to the research question, and finally conducting a comprehensive and systematic evaluation and synthesis of the information [27]. 



To find the articles related to the impact of climate change on human health in Iran from 2000 to December 2023, databases and academic search engines (PubMed, Scopus, Web of Science, MagIran, and SID) were searched by two researchers (SVE and AA) using keywords related to climate change and health (Table 2). All articles that accurately reported at least one impact of climate change (direct or indirect) on the health of the Iranian population and published in English or Persian were included. The editorials, notes, and letters to the editor were excluded. In addition, the studies that focused on countries other than Iran, not related to the impact of climate change on public health outcomes, and those with insufficient data or methodology, narrative reviews, and non-systematic and systematic reviews were excluded.



To select the studies, two trained researchers first independently screened the titles and abstracts based on the inclusion criteria. These two researchers then independently reviewed the full texts of articles. A senior researcher resolved any conflicts or disagreements. From 9035 articles found by the database search, 2948 were removed due to being duplicates. After screening the full texts and removing irrelevant articles, 52 eligible studies were finally selected for the review. Figure 1 shows the flowchart of the study selection process.



The next step was to extract key information from the articles, including the first author’s name, year of publication, study design, study area, measured climate change variables, measured health outcomes, and key findings. To summarize the results of the studies found, they were first categorized according to climate change impacts and health outcomes. Then, they were categorized according to the direct and indirect effects of climate change on health. 

Results
Climate change, including temperature rise, precipitation changes, and monsoon flow changes, can directly and indirectly affect the physical and mental health of people. A summary of the most important findings of various studies related to the impact of climate change on public health is available in Appendix 1

Impact of climate change on physical health

Direct impact on morbidity
Climate changes can have a direct impact on the activity of human body systems. Direct impacts of climate change include the changes in pregnancy [28, 29], prevalence of preeclampsia [30], skin cancer [31, 32], and pterygium [33]. However, the results of a study in Kerman showed no clear association between the occurrence of congenital hypothyroidism and climatic factors [34]. More precipitation, higher temperatures, and less evaporation lead to fewer hospitalizations for asthma patients [35] and reduce the prevalence of exercise-induced asthma [36]. Other studies also showed a significant and direct association between the incidence of chronic rhinosinusitis [37] and severe acute respiratory syndrome (SARS) [38] and climatic factors such as temperature, precipitation and humidity. The results of Roshan et al. in Tabriz showed a direct and significant association between the increase of temperature and the admission rate of cardiovascular patients [39]. The studies conducted in Ahvaz and Sari cities also confirmed these findings [40, 41]. This indicates that there is a direct association between changes in temperature and precipitation and the increase in heart diseases in many areas of Iran. A study in Mashhad showed that humidity (positive correlation), temperature (positive correlation), wind speed (negative correlation) and particle matter (PM2.5) concentration (negative correlation) had a significant impact on the increase of the cardiovascular disease (CVD) cases [42].

Direct impact on mortality
The negative effects of heat waves on mortality were demonstrated in a study conducted in 8 Iranian cities [43]. Rising temperatures and heat waves can have detrimental effects on health and lead to deaths even in populations that have adapted to extreme heat [44]. The results of a study in Kerman also showed that men over age of 65 were at higher risk of death and had higher lost days of life due to temperature changes and heat waves [45]. In a study conducted by Ahmadnezhad et al. in Tehran, the results indicated an increase in mortality rate due to temperature fluctuations in the hot seasons after controlling confounding factors such as ozone and pollution [46]. On the other hand, the results of a study in Shiraz showed no significant association between temperature changes and deaths from CVDs [47]. Meanwhile, the results of a study conducted in Mashhad showed that a 1 °C increase in maximum temperature was associated with a 4.27% increase in the CVD mortality rate [48]. The results of another study in Mashhad also showed that the risk of mortality from respiratory diseases increased by 1.36 for every 10 °C decrease in temperature [49].

Indirect impact on pathogenic and infectious diseases
The indirect effects of climate change on human health can be seen in changes in the reproductive health and spread of insects such as malaria and human-associated pathogens such as cholera outbreaks [50] and dysentery [51], as well as in the spread of diseases. For example, the results of Abbasi et al. and Mohammadkhani et al. in southern Iran showed a significant relationship between the monthly density of Anopheles stephensi larvae and the amount of rainfall, humidity and temperature, which may lead to an increase in malaria cases [52, 53]. An increase in temperature may affect the seasonal changes of COVID-19 [54] and have a negative impact on the number of positive cases of COVID-19 [55] and the related death cases [56]. In addition, the results of a study showed that the decrease in wind speed, humidity and solar radiation led to the increase of infections caused by COVID-19 [57]. Ansari et al. also showed that climatic variables such as average temperature, rainfall, and maximum relative humidity were significantly associated with the monthly incidence of CCHF in southeastern Iran [23]. Also, Faramarzi et al.’s study in Fars Province showed a direct and significant relationship between the incidence of malaria in humans and maximum relative humidity (+0.67) and rainfall (+0.48) [59]. In the study by Kanannejad et al., the geoclimatic factors including altitude, slope and rainfall were negatively associated with Malta fever [60]. Dadar et al. also indicated a significant negative relationship between average temperature and the incidence of brucellosis [61].
The effects of climate change, especially in tropical and subtropical regions, on Leishmaniasis had also been investigated in numerous studies. In a study in Fariman County, no significant relationship was found between climatic variables such as temperature, humidity, precipitation, and altitude and the incidence of leishmaniasis [62]. In Qom Province, a positive and relatively strong relationship was found between the incidence of cutaneous leishmaniasis (CL) and the temperature and hours of sunshine, while there was a negative correlation between the incidence of CL and soil moisture [63]. In Ardabil, a positive relationship was found between temperature and humidity and the prevalence of visceral leishmaniasis (VL) [64]. In Isfahan, Golestan, Lar, and Khuzestan cities, there was a positive relationship between the average temperature, relative humidity, and its slope with the incidence of CL and a negative relationship between the maximum wind speed, precipitation, altitude and vegetation with the incidence of CL [65-68]. In a study conducted in southwestern Iran, temperature and precipitation were the most effective climatic factors for VL [69]. On the other hand, contrary to expectations, the study by Soltan Dallal et al. on human salmonellosis, which is one of the most common causes of foodborne disease outbreaks in developing countries, found no significant relationship between average monthly temperature, rainfall, or humidity and the incidence rate of salmonellosis [70].

Impact of climate change on mental health
The impact of climate change on mental health is still not clearly understood. According to recent studies in Iran, changes in weather conditions, specifically air temperature, precipitation, clouds, and solar radiation, have adverse effects on people’s mental health. These effects include mood swings, depression, increased tendency to immigrate, anger, frustration, conflicts, decreased compassion [71, 72]. The findings from the study by Mirzakhani and Poursafa revealed a higher prevalence of depression in regions of Iran with cold and rainy weather [73]. Another study in Hamadan indicated the significant positive association of dusty, rainy, snowy, foggy, or cloudy days or days with weather conditions causing a visibility below 2 km, with hospital admissions due to causing depression, schizophrenia, and schizoaffective disorder. Moreover, air pressure had a negative impact on hospital admissions for patients with schizophrenia while admissions of bipolar patients exhibited a negative correlation with rainy days and a positive correlation with dusty and cloudy days [74].

Discussion
The purpose of this study was to systematically review the studies on the impact of climate change on the public health of Iranian people. This study delved into the direct and indirect consequences of climate change on physical and mental health. The review of studies revealed a broad range of adverse effects on various health indicators due to changes in climatic parameters [14, 24, 39]. These effects exhibited complex and non-linear patterns when interact with each other. Moreover, contradictory associations between weather effects and the health outcomes were reported.
Numerous scientific reported the direct and indirect impacts of climate change on the occurrence or severity of various diseases. Rising temperature and changes in precipitation and humidity can disrupt the physiological mechanisms which can increase the risk of contracting a wide range of diseases, including cancer, infectious and inflammatory diseases, and psychological disorders. Substantial evidence suggests that the increase in temperature and humidity can increase the risk of premature birth and preeclampsia by subjecting pregnant women to heat stress. Therefore, there is a need for prenatal care during climate change. Changes in sunlight patterns as well as prolonged and intensified exposure to ultraviolet rays due to global warming, seem to contribute to the rising incidence of skin and ocular cancers. Additionally, elevated temperature and humidity can heighten the chemical reactions in the atmosphere, leading to increased concentrations of hazardous air pollutants. This, in turn, can exacerbate conditions such as asthma, chronic respiratory disease, CVDs, and various forms of cancer [31, 32]. Hence, it is anticipated that the ongoing trajectory of climate change will result in a greater prevalence and onset of infectious diseases, respiratory diseases, CVDs, cancers, and psychological disorders in the future.
Studies have shown that the decrease in wind speed and air exchange rate due to climate change causes an increase in the concentration of suspended particles and pollutants such as ozone, carbon monoxide, nitrogen dioxide in the air. On the other hand, more stability of the atmospheric conditions due to the decrease in wind speed brings longer periods of dust and the occurrence of phenomena such as temperature inversion, which results in an increase in the concentration of PM2.5 and PM10 suspended particles in the air [42, 75]. The increase in the concentration of air pollutants can aggravate the symptoms and complications of respiratory diseases such as asthma, chronic obstructive pulmonary disease, and pneumonia, due to their direct effect on the lungs and the respiratory system [42]. In addition, the risk of heart attack in people with CVDs increases with the increase in air pollution.
Temperature and humidity, as two important climatic factors, play a decisive role in the population patterns and geographical distribution of some insects that carry vector-borne diseases such as malaria and leishmaniasis. For example, some mosquitos called A. stephensi, which is the main carrier of Plasmodium falciparum [the cause of malaria), has the highest growth and reproduction rates at temperatures of 20-30 °C and humidity rates of 50-80% [52, 53]. Therefore, due to the increase in temperature and humidity in some areas, there is a possibility of the increase in the population of these mosquitos and, thus, the increase in the incidence of malaria.
The proliferation and transmission of infectious disease agents (e.g. dysentery) and water-borne diseases (e.g. cholera) are closely linked to variations in temperature and humidity levels [22, 50]. The risk of Salmonella infection increases by 5-10% with every 1 °C increase in temperature [76]. Studies indicated that climate change affects precipitation patterns, sea level, and environmental factors such as surface water temperature, influencing the survival, reproduction, and transmission of waterborne pathogens that consequently endanger human health [77]. It is crucial to investigate the impact of climate change on disease transmission patterns to effectively predict and manage diseases. Numerous studies have shown that higher temperature and humidity caused by climate change can lead to increased survival and spread of viruses, bacteria, fungi, and parasites [14, 54, 57]. Additionally, the recent outbreak of the COVID-19 revealed the connection between climate variations and disease transmission, severity, and incidence [14]. Decreased wind speed and humidity level, along with increased temperature, heighten the risk of contraction and death from such diseases.
Climate change and the occurrence of disasters such as storms, floods and droughts can cause or intensify the stress and anxiety of people [71, 72]. The continuation of climate change and the uncertainty about the future can cause a psychological stress in people, which can lead to the emergence or exacerbation of psychological disorders such as depression, anxiety, panic attacks, and even suicidal ideation in people who are more psychologically vulnerable [72, 74]. However, the severity of these psychological effects depends on the underlying psychological conditions of people, the amount of social support for them, and coping mechanisms [26]. In addition, climate change can increase the risk of alcohol and drug addictions due to exposure to stressful conditions [24]. People who are exposed to severe and long-term stress may turn to alcohol and drugs to escape from pressure. These high-risk behaviors, in turn, can cause other individual and social problems. Therefore, preventive measures for the mental health of people against the effects of climate change are of particular importance, and health officials should develop and implement educational programs to teach coping skills and provide psychological support to the at-risk people. Positive psychology and psychosocial support can also be effective in reducing mental health problems caused by climate change. Investigating solutions to increase public awareness of the dangers of climate change on health is also necessary. It is also possible to improve the knowledge, attitude, and skills of people regarding how to deal with climate change impacts through the mass media and social networks, or in educational and cultural institutions by using innovative methods such games and animations.
Despite the existence of studies in the field of the relationship between climate change and human health, there is still a need for more and deeper research in this field for determining the exact effects of climate change on the occurrence and spread of various diseases and disorders, identifying vulnerable groups, examining the effectiveness of various preventive measures, and estimating the economic costs caused by this phenomenon. In addition, the association between some parameters of climate change, such as temperature, and some adverse outcomes, such as hospital admission due to psychiatric reasons, suicide, or exacerbation of previous mental health conditions, has received less attention [78]. In this regard, the future studies should examine the relationship between weather patterns and the incidence or severity of CVDs, respiratory diseases, neurological diseases, psychological disorders, and skin diseases. Also, investigating the impact of climate change on water-borne and food-borne diseases that are transmitted by insects is needed. In addition, it is very important to study the effects of climate change on the health of pregnant mothers and infants and identify and prevent possible complications for them. In addition, future studies can focus on determining the possible differences in the degree of vulnerability to climate change in different groups and subgroups in society, such as low-income families, homeless people, and outdoor workers. People who are more vulnerable due to specific physical characteristics, age, gender, race, place of residence, and socio-economic conditions, should be given special attention because the amount and type of vulnerability to warm weather, cold weather, air pollution, insect-borne diseases may vary. Future studies can also investigate regional differences because the effects of climate change is not completely the same in different regions. Comparative studies on the experiences of successful countries in the field of managing health-related consequences of climate change and adapting appropriate solutions for their application in Iran can help identify and implement effective solutions based on the characteristics of each region. Accordingly, for targeted and integrated responses to the health-related consequences of climate change at the national and regional levels, there is a need for special attention, large investments, and long-term planning for preventing humanitarian and health-related crises in the future.
This systematic review had some limitations such the lack of data and statistics on the prevalence of certain diseases and different methodologies of studies. Despite these limitations, this review study offers valuable information.

Conclusion
Climate change has negative effects on Iranian people’s physical and mental health. The direct effects of climate change include the increase in the incidence of infectious diseases, CVDs, respiratory diseases, changes in women’s pregnancy patterns, and the prevalence of preeclampsia, skin cancer, pterygoid disease, congenital hypothyroidism, and mortality. The indirect effects of climate change include changes in the reproduction pattern and the spread of insect-borne and human diseases such as malaria, brucellosis, leishmaniasis, human salmonellosis, cholera, dysentery, CCHF, and COVID-19. The impact of climate change on mental health of people include increased mood swings, depression, schizophrenia and schizoaffective disorder, and bipolar disease. The impact of climate change on public health varies depending on geographical and demographic factors. The climate change and its consequences for the health of people will be one of the biggest challenges facing health policymakers and planners in Iran in the coming years. Therefore, it is necessary to develop and implement national strategies and plans with interdisciplinary approaches to prevent and deal with this phenomenon.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the Ethics Committee of Ardabil University of medical sciences (Code: IR.ARUMS.REC.1402.153).

Funding
This research was supported by the part of a Research Project, and was funded by Ardabil University of Medical Sciences (No.: 400000583). 

Authors' contributions
All authors equally contributed to preparing this article.
Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank for supporting from Social Determinants of Health Research Center, School of Health, Ardabil University of Medical Sciences, Ardabil, Iran.




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