Reporting evidence on the environmental and health impacts of climate change on Indigenous Peoples of Atlantic Canada: a systematic review

While evidence of Indigenous Peoples’ climate knowledge and adaptation practices is readily available in Canada, regional variations are poorly understood, and proper representation and recognition in academic and planning contexts is scarce. Much less still is known about the health and environmental impacts of climate change on these communities. This review sought to report and assess the evidence of such impacts on Indigenous Peoples in Atlantic Canada over the past two decades. Current published studies focused on Indigenous Peoples’ knowledge and perceptions and highlight government policy for adaptation measurements. We systematically searched publications between January 2002 and March 2022 from the Web of Science, PubMed, Google Scholar, and Science Direct databases, screening for (1) environmental and (2) health impacts of climate change on Indigenous Peoples. Fifty-six articles were selected and thoroughly reviewed using the GRADE approach to assess the quality of the evidence. The quality of evidence ranged from low to moderate, and the evidentiary foundation for links between climate change and health effects was weak. We thus find an opportunity for future research to focus on climate-related effects on the health and lands of Indigenous Peoples within Atlantic Canada, especially concerning impacts on mental health.


Introduction
Climate change is the biggest threat of our century, and it is threatening all nations in the world [1][2][3]. Over the last several decades, an undeniable body of research has accumulated, demonstrating the wide-ranging effects of climate change on health and the environment [2,[4][5][6][7]. While most cited sources reported on the health impacts of climate change such as cardiovascular and respiratory illnesses [8][9][10], environmental impacts, globally, included floods, drought, heatwaves, and sea-level rise [11][12][13]. These environmental changes are both harmful to human health and at the same time, they provide an opportunity to develop adaptive and creative solutions for those who are most vulnerable [14][15][16][17][18]. These solutions have an impact on land-based activities that are important for Indigenous Peoples' livelihoods, as well as factors that help safeguard them from climate change [19,20].
Seasonal variations have a direct impact on the migration patterns and distribution of subsistence-hunting species for certain Indigenous communities [21][22][23]. Indirect effects enhanced Indigenous populations' vulnerabilities by bringing intangible losses related to place attachment, culture, food security, and other socio-economic disadvantages [15,18,24]. These drawbacks, if not handled in a timely and appropriate manner, may cause future Indigenous generations to face difficulties. All over the world, including across Canada, Indigenous and local peoples have noted recent changes in weather patterns and have observed their effects on species' life cycles, productivity, and interrelationships [25,26]. These changes (e.g. coastal erosion, sea-level rise, flooding) are difficult to document systematically because they are diverse and play out over different scales of time and space [27]. Nevertheless, the consensus is that change is occurring, and everywhere people are concerned and anxious about its effects on the land they continue to rely upon [28]. Very recently, however, Indigenous Peoples have noted signs of greater environmental changes and challenges to their resilience than they have faced in the past such as species declines and new appearances; anomalies in weather patterns; and declining health of forests and grasslands [27,29,30]. In scientific debates and concerns of climate change policy, it is crucial to integrate these observations and viewpoints from Indigenous Peoples.
Apart from environmental concerns, the link between Indigenous populations' mental health and climate change is apparent at varying levels around the world, but it remains a challenging and overlooked subject [29]. The experience, degree of impact, sensitivity, perception, and response to mental health problems caused by climate change must be reported and further investigated by climate and health scientists in order to document the links. There is numerous research on Indigenous groups and the effects of climate change on their regions and health around the world and in Canada [22,25,26,31,32], but there is not much data on Indigenous communities of Atlantic Canada. Future climate and public health professionals will be expected to devote considerable time and resources to research and development in this region and this population as the impacts of climate change are evident and alarming in this region, especially for Indigenous Peoples. To investigate, this review aims to report the evidence on the environmental and health implications of climate change on Indigenous Peoples in Atlantic Canada, as well as Indigenous adaptation activities (figure 1).

Study design
Objective: We carried out a methodical assessment and evidence synthesis of published literature in Atlantic Canada on Indigenous Peoples and climate change adaptation, including health implications. The goal of the literature search was to find publications that (I) documented climate change's environmental implications (coastal concerns, ecosystems and biodiversity) and (II) provided evidence of health impacts (physical and mental health).
Inclusion criteria: Several methods of analysis were used in the studies, including cohort studies and experimental evidence, as well as systematic assessments of various Indigenous groups in various parts of Canada. Nonetheless, Indigenous Peoples and existing literature on Atlantic regions (Prince Edward Island, Nova Scotia, New Brunswick, Newfoundland, and Labrador) were prioritized and thoroughly screened (figure 2).  To evaluate whether generic search terms may have missed more literature that was specific to the focus groups of this review, the terms 'Mi'kmaq' and 'First Nation' were added as part of a separate search. The search was conducted in English only which returned many off-topic articles, as evidenced by their titles and abstracts. This review sought to report the evidence with the most important, relevant, and novel publications (n = 56).

Screening and eligibility
The review identified and critically appraised relevant research under two main categories: (I) environmental impacts of climate change (with sub-categories as flooding, coastal erosion, and impacts to ecosystems (n = 21) and (II) health impacts (with sub-categories: mental health, anxiety and well-being and physical health repercussions (n = 35)). Each sub-category of intervention was rated according to the GRADE approach [33]. Study design, study quality, consistency across studies, directness of population, intervention, or outcome, and accuracy in impact and/or effect size estimates all influenced decision-making when it comes to the quality of evidence. Using the GRADE approach, the evidence was categorized into two categories: high (if trials were randomized) and poor (if they were observational studies). The GRADE method incorporates five elements to assess if evidence should be downgraded: individual studies can be biased if they contain flaws in their design or conduct, which are referred to as 'study limitations' or 'bias risk,' and (b) inconsistency of findings among research: impact estimates vary, (c) indirect evidence: the focus group is unclear or the evidence is indirect, (d) imprecision: when the studies were meta-analyzed, the results were not statistically significant, but the effect was substantial, and (e) studies that do not suggest a statistically significant effect are less likely to be published, resulting in a biased outcome [34,35].
Articles were considered eligible only if: Indigenous population was the focus or was partially involved, however, some articles were included in this review if Elder (an Elder is someone who through life experiences has gained much knowledge in a specific area, i.e. healing or ceremony or it could be anything involving traditional knowledge. Someone in their thirties could be considered an Elder if they have great knowledge of the traditional language, for instance [36]), traditional values, and adaptation practices were mentioned. A Prisma flow chart was constructed for screening, eligibility, and identification of the resources (figure 3).

Environmental impacts of climate change on Indigenous territories
One of Canada's most vulnerable regions to global climate change is Atlantic Canada [37,38]. Due to rising sea-levels, storm surges, coastal erosion, and flooding, the region will experience more storm events, with increased storm intensity [39,40]. Current climate change intensified Hurricane Fiona and caused a lot of damage in the Atlantic, and once again it is evident that the coastal communities, which account for a large portion of Atlantic Canada's population, are proven to be the most sensitive to these effects that are exacerbated by climate change [41,42]. Climate change will also have a significant detrimental influence on vital infrastructure and industries that support the socioeconomic well-being of Atlantic communities in the next decades, particularly the fishing and tourism industries [43]. The following section will report on the environmental implications of climate change on Indigenous communities in Atlantic Canada in order to better highlight the obvious hazards and repercussions of climate change, as well as the mechanisms of susceptibility, adaptive responses, and coping methods. Understanding the diverse risks, impacts, and responses of Indigenous Peoples in these regions to climate change can influence policymakers and prompt proactive action. The objectives guide the review's primary research questions: (I) what are the environmental consequences of climate change for Indigenous Peoples in the Atlantic region? (II) What impact does climate change have on Indigenous communities' mental health and well-being in focused lands? The existent evidence on climate change's environmental implications will be classified into sub-categories, such as, coastal erosion and flooding and affects on ecosystems.

Coastal erosion, sea-level rise and flooding
Many coastal communities in the Canadian Arctic are experiencing climate change effects, such as melting sea ice, rising sea levels, coastal erosion and permafrost thawing [44]. Yet, little research has been undertaken on the effects and adaptation in coastal zones. Traditional knowledge, on the other hand, is critical for research design and execution because it provides locally relevant outcomes that can aid in more effective decision-making, planning, and management in remote coastal areas.
According to recent studies, climate change is contributing to sea-level rise, flooding, coastal erosion, and increased storm surges in Atlantic Canada, placing areas like Prince Edward Island and Lennox Island First Nation at risk [32,45,46].
The Mi'kmaq have lived seasonally on Lennox Island First Nation for centuries and are now trying to adapt to their changing environment [47,48]. The community, on the other hand, are aware that the island will be flooded in the future and so are looking for other places to migrate/relocate to. Under normal climatic conditions, coastal erosion is unavoidable in Mi'kma'ki (Mi'kmaw territory), but climate change is worsening and hastening the process as sea-levels rise. Storms and storm surges become more powerful, and sea ice patterns vary, providing less winter shelter for the shore. In the area, computer simulations are already being used for studies to determine what the fate of the island will be if it is seized by the water utilized [49]. During Hurricane Fiona, Lennox Island wharf was completely submerged by the storm surge, with the community experiencing flooding and losing electrical power for several days.
There is research on the environmental effects of climate change, but most of the research overlooks Indigenous knowledge and experience. Throughout the literature, the limited evidence showed that the reported data were on coastal concerns and climate resilience of Indigenous Peoples [50]. Environmental impacts on coastal areas also have societal repercussions, such as whether people choose to remain in these towns or relocate (even seasonally) to avoid being stranded by coastal storms. One study contributed by examining the potential implications on Atlantic Canadian society from changes in shellfish fisheries caused by ocean acidification and climate change using an impact assessment framework guided by a biophysical model of future species distributions [51]. Other research has looked at coastal resilience in the Atlantic, and the results have revealed physical changes connected to coastal erosion caused by high wave impacts and storm surges flooding the coastal zone [52]. Residents requested and implemented solutions, such as the construction of protective barriers, are also considered, though they are undesirable because they are not nature based [52]. Research also often highlights the necessity of future work that is required to improve emergency planning and disaster management [40]. Better concerted short-and long-term responses need to be coordinated by local authorities and higher-up in the government to ensure the sustainability of these coastal communities. A scientific report provided evidence on the Atlantic regions of Canada on the environmental impacts of climate change and calls for action to adapt to the changing climate and to build climate resilience, recognizing that coastal, northern and Indigenous communities face unique circumstances [53]. Based on an integrative social-ecological systems perspective, one study looked at various critical factors for successful and sustainable relationships between Indigenous Peoples and oceans. Strategic action is required to address the threats to coastal homes, vital community infrastructure, sacred sites, and plant rich areas. In this section, we aim to present evidence of the environmental impacts of climate change, providing references and discussions following the most studied areas such as coastal erosion, flooding, sea-level rise, and storm surges.

Ecosystems and biodiversity
Eighty percent of the world's remaining biodiversity are found on Indigenous peoples' controlled and valued lands [54]. Environmental factors on Mi'kmaq territory drew attention to rare plant species, making them culturally and biologically significant and vulnerable [55]. In the Atlantic regions of Canada, climate change is also impacting wildlife habitat, such as altering ice and permafrost conditions, higher and more intense wildfires, warming water temperatures, changes in precipitation and water levels, and unpredictable weather [56][57][58]. Another study reported on Indigenous Peoples in the sub-arctic boreal forests of Canada and the United States, who have experienced recent climate changes that have had an impact on their subsistence harvest [59]. In both Canada and the United States, Indigenous Peoples documented the biophysical, nutritional, cultural and social impacts of climate change [60]. One research on marine access issues of Indigenous communities that rely on the marine environment for livelihoods and subsistence reported that the convergence of environmental degradation and climate change will likely increase conflicts over access to scarce resources and newly accessible areas [61]. A research article presented on qualitative data from 53 in-depth interviews (29 in Rigolet and 24 in St. Lewis) and developed a set of values in two remote communities in the subarctic easternmost Canada [62]. The sample included Elders, active hunters and other people who spend considerable time on the land conserving biodiversity around them. The article highlighted the importance of Indigenous knowledge, which has become more widely recognized, identifying areas where change is needed and is becoming increasingly crucial [62]. Despite this, most studies relied on discussions and qualitative approaches rather than quantitative evidence.
One research conducted 443 semi-structured interviews, 20 focus groups/community workshops, and 65 interviews with policymakers at the local, regional, and national levels were performed between 2006 and 2009 [63]. The study highlighted that policymakers must support the teaching and transmission of environmental knowledge and land skills, increase research efforts to identify short-and long-term risk factors and adaptive response options, safeguard critical infrastructure, and increase policymakers' awareness of climate change impacts and adaptation [63] (table 1). Numerous systematic reviews emphasized that more thought must be given to how Indigenous and science-based knowledge systems might be connected across courses, while also considering Indigenous Peoples' distinct place-based demands [64][65][66].
Although research on Indigenous territories regarding climate change impacts is available, the quality of evidence was moderate as most research did not focus on Atlantic regions, it contained primarily observational research with a moderate level of grading because the majority of studies incorporated expert opinion or reviews and reports on the subject. The majority of the available content was either not quantitative or was not primarily focused on Indigenous Peoples in our focus region, and much of the research studies addressed Inuit perceptions and the environmental concerns of the Northern Territories. Systematic reviews and a limited number of research papers were also included, but the quality of evidence was moderate due to a lack of data and some indirectness and restrictions. Future research on Indigenous experiences of climate change's environmental implications is needed, as well as quantitative data on these impacts on their traditional territory in Atlantic Canada.

Health impacts of climate change in Indigenous population
Throughout the literature, while most studies reported on mental health impacts, weather, water quality and infectious gastrointestinal illness [74][75][76][77], other studies mainly informed about food security, place attachment (indirectly linked to mental health burdens) [78][79][80][81] (table 2). Since our focus area is Indigenous populations in Atlantic Canada, we have discovered that data on this population is scarce, with limited research undertaken in Labrador [72,82,83]. Although there was evidence for Indigenous populations in Canada and the effects of climate change on mental and physical health, the quality of the evidence varied from low to moderate, with some studies reporting on Indigenous populations but not specifically mentioning Indigenous Peoples from Atlantic Canada. We will now categorize the evidence on health impacts in two sections: (I) studies that looked into mental health and (II) studies that investigated physical health repercussions.

Mental health, anxiety and well-being
Mental health-related studies are gaining popularity [84]. A growing body of evidence shows that extreme weather events linked to climate change can harm physical and mental health [85,86], leading to an increase in depression and post-traumatic stress disorder and more gradual changes in climatic conditions, such as rising temperatures and poor air quality, can also be detrimental to mental state [5,66]. There is mounting evidence that a considerable proportion of people may be suffering from harmful anxiety because of their perceptions of climate change, yet not much research was undertaken considering Indigenous communities [87][88][89]. The proportion of Indigenous Peoples' health research in North America has decreased over time and is still quite uncommon in the published literature [90]. Although the literature included mostly systematic reviews, some research papers were informative regarding the health impacts of climate change on Indigenous Peoples. Most of the articles, however, noted health impacts with an emphasis on mental health. Changes in meteorological parameters, seasonality, and exposure to both acute and chronic weather events were connected to mental health outcomes, such as intense emotional responses, stress of migration, suicide, depression, and anxiety [91]. While some research included Canada and its Indigenous communities, others mentioned Indigenous mental health impacts and climate change links in general, with limited articles reporting specifically on Atlantic Canada. One research indicated that the Indigenous Peoples would not The book focused on the diversity of governance processes at local and regional scales.
Outcomes: Environmental effects will have societal repercussions, such as whether people opt to stay in these towns or relocate (even seasonally) to avoid being stranded by coastal storms.

Evidence
Theme Methods (location, study design, sample size) and Outcomes GRADE Physical Health [59] Methods: This research has established a foundational understanding of vulnerability and adaptation, based on interviews with community members and stakeholders to identify and describe climatic hazards and adaptive methods.  leave their community due to climatic and environmental changes [77]. Another review study identified 120 original studies published between 2001 and 2020. Most studies were quantitative (n = 67), cross-sectional (n = 42), conducted in high-income countries (n = 87), and concerned with the first of the WHO global research priorities-assessing the mental health risks associated with climate change (n = 101) [84]. Throughout the literature, some studies focused on the health outcomes of climate change in Indigenous communities. For example, one study found a gap in the published material when it came to climate change and Indigenous Peoples' health reporting. While some systematic reviews reported on vulnerability assessments of Indigenous Peoples [92], other research studies stated that climate change is causing and exacerbating Inuit environmental dispossession, but these findings yet did not mention Atlantic Canadian Indigenous groups [71]. When it comes to migration and place attachment, the findings of one study reported that climate change is having a detrimental influence on feelings of place attachment by interrupting hunting, fishing, foraging, trapping, and traveling, as well as modifying local landscapes-changes that have an impact on physical, mental, and emotional health and well-being [93].
Other than Atlantic populations, the reported research on the mental health effects of climate change was concentrated on Northern Canada with Indigenous engagement [76,89,[94][95][96]. One systematic review reported major gaps in research on the mental health of Indigenous Peoples in Canada, both demographically and geographically, with a specific mention of Métis and Indigenous Peoples living in cities or off-reserve are particularly being underrepresented; this is a big gap that must be bridged [96]. Climate change is anticipated to be a major mental health concern for Indigenous Peoples, and efforts to address it through research, legislation, and mental health programs should be prioritized [95].

Physical health repercussions
Global understanding of the human health consequences of climate change for Indigenous Peoples is insufficient. In contrast to the global framing of climate change discourse for Indigenous Peoples, there is a growing body of research studying climate change susceptibility and adaptation at the local to regional level [97], including a number of studies focusing on health and climate change [22,24,86,98]. Trends show a rising interest in physical health issues related to climate change, as well as a greater emphasis on the north, with an emphasis on food security and indirect health repercussions [81,91,99]. Numerous articles reported on food security and stated that climate change's effects on the Canadian food system influence human health via complex networks [100]. Water security was also mentioned in the literature as a health repercussion of environmental hazards. One research investigated the environmental and health impacts of climate change, reporting changes in the environment and food security [70]. Graphs, stemming from the compilation, indicated what are perceived as the growing problems linked to climate change. In order to take a positive, forward thinking, inclusive action, at the local level, the research suggested that science should value and team up with traditional knowledge [70]. Some studies have argued that Northern Indigenous Peoples have enhanced sensitivity to the effects of climate change, which has a particular impact on this group's culture, health, and food security [101]. Indigenous Peoples have also been recognized as a highly vulnerable group in the global climate change debate due to their residence in fast changing regions and the disproportionate burden of disease and mortality experienced by many communities [94,102,103]. Methodologically, some research in the literature noted problems and limitations with data collection and analysis of the studies that were included. The duration and season of data collection also introduced bias into the study design, for example, by excluding individuals who may be engaged in land-based activities (e.g. harvesting during specified seasons) or would limit the experience to specific seasons that cannot be transferred to other time frames. More longitudinal studies, community-based monitoring, and focused adaptation research, all of which have the potential to help us learn more about climate health in Indigenous populations in Atlantic Canada, are all needed. These methods lay a solid platform for forging meaningful connections with communities, knowledge co-production, and adaption empowerment, all of which are important aspects of community-based participatory research [59]. Other reported physical health impacts included the increasing incidence and range of infectious diseases, and heat-related illnesses [104,105]. Some literature research was undertaken in order to adequately capture the scope of climate change, food security, and human health nexus, as well as the intricacies of the relationship [81]. One study highlighted that compared to non-Indigenous populations, Indigenous Peoples have lower life expectancies, higher mortality and morbidity rates, higher infant mortality rates, lower nutritional intake coupled with greater food insecurity, and higher incidences and prevalence of infectious, non-infectious, and chronic diseases [95]. One research used a case study design and a participatory and collaborative approach with the community of Nain in northern Labrador, Canada [71]. Focus groups (n = 2), interviews (n = 22), and participant observations were conducted in 2010-11 [71] and reported that negative physical health impacts were reported on less frequently than positive health benefits of sea ice use, which were predominantly related to mental/emotional, spiritual, social, and cultural health.
It goes without saying that a more conceptual framework is needed that fully captures these networks and is urgently needed so that Canadians and their communities may prepare for future repercussions [81,100]. Assessments that look into and map formal and informal mental health interventions can give decision-makers and communities a clear picture of all the resources available, as well as those that are needed, to address climate change-related distress, improve affirmative mental health, and support psychosocial resilience [101,106]. Community visits and workshops were used in one study to educate northerners (Canada) about the effects of climate change on their health, as well as strategies for developing research proposals and budgets to meet program requirements [107]. Involving Indigenous communities in climate change response, using both qualitative and quantitative methods to capture indirect effects on physical and mental health, and understanding the priorities and existing adaptation strategies that could incorporate Indigenous cultures and knowledge should be highlighted in future research [108].

'Two-Eyed Seeing' approach for climate change and human health
The new effort includes videos and tools to help Indigenous communities deal with climate change. To address key concerns like environmental conservation, 'Two-Eyed Seeing' combines both Western tradition and Indigenous knowledge systems [116][117][118]. Bridging various knowledge systems necessitates the use of methodology from the natural and social sciences, as well as regular consideration of the value systems of all knowledge holders, in a process that is iterative and feedback-driven [119]. 'Learning to see from one eye with the strengths of Indigenous knowledge … and learning to use both these eyes together, for the benefit of all' says the Mi'kmaq principle of 'Etuaptmumk' or 'Two-Eyed Seeing' which captures the concept of bringing different knowledge systems together to increase our collective breadth and depth of understanding [116,120]. Utilizing Indigenous knowledge as a lens and adding an additional Western lens results in a more accurate view.
Indigenous Peoples have had a deep relationship with nature from the beginning of time. Dr Albert Marshall, a Mi'kmaq Elder who advocated the concept of 'Two-Eyed Seeing' , reminds us that it is through our relationship with the land that we can maintain kinship to live in harmony [121]. This is a connection that goes beyond definition and is all-encompassing. The Mi'kmaq, for example, are stewards of their environment in Mi'kma'ki, their ancestral homeland (Atlantic Canada). This guardianship in social and natural sciences, with the same interconnection, can be used to share knowledge or integrate scientific data with Indigenous perspectives.
Indigenous and scientific knowledge have a lot of promise in terms of health and climate change interactions, but there are still some issues [117,120]. As the use of Indigenous and scientific knowledge becomes more widely encouraged and enforced, there is a risk of implementing approaches that generate power imbalances or only contain Indigenous information on the surface [120]. From project design to data interpretation and project evaluation, meaningful involvement with knowledge holders is required to ethically bridge knowledge systems in specific regions such as Atlantic Canada.
There is insufficient information to investigate the relationships between Indigenous climate-related narratives, documented temperature variations, and climate change effect studies from the scientific literature [23]. Proposing frameworks to improve the synthesis of Indigenous narratives of observed climate change with global assessments is crucial, in order to contribute to the thoughtful and respectful integration of Indigenous knowledge with scientific data and analysis, so that science can benefit from this rich body of knowledge [28].
In this review, we wanted to mention a bit about the Two-Eyed Seeing approach, which can enhance environmental assessment and planning by providing a more accurate and coherent narrative of long-term social-ecological change. To see with one eye the best of Indigenous ways of knowing and with the other eye the best of the Western ways of knowing, that will successfully incorporate Indigenous knowledges and western science. Given the scarcity of data on such a significant population and in such an important scientific discipline, future studies in climate change and health sciences should adopt a 'Two-Eyed Seeing' way to collect quantitative and qualitative data, while generating scientific reports, reviews, and research publications.

Discussions and conclusions
The links between mental health and climate change in Indigenous communities around the world are clear to varying degrees, but due to a lack of data or reporting evidence, it remains a highly challenging topic [122,123]. Indigenous Peoples have a strong bond with the land and unique perspectives on how it is changing. Climate change has impacted the physical, mental, and emotional health of Indigenous Peoples in Atlantic Canada, according to this review. Studies in Canada and Atlantic Canada have documented the environmental and health implications of climate change. Yet, even though Atlantic Canada is particularly vulnerable to climate change's environmental and health repercussions, Indigenous voices in the region are still unheard of. The Indigenous communities' reported climate change environmental consequences were moderate in this systematic investigation, concentrating primarily on climate change environmental concerns (freshwater, aquaculture, and coastal concerns) and mental-physical health [86]. The review showed that climate change enhanced multiple processes of vulnerability specific to Indigenous Peoples, as well as providing more indirect and intangible mental health evidence [124]. Indigenous perspectives of the world are holistic in nature and that the whole is considered to be alive with Spirit that requires respect and reverence, because all life has a place in the Sacred Hoop of Life, which many call the Medicine Wheel [125]. The Medicine Wheel is a teaching tool used by many North American Indigenous cultures in Knowledge Translation/transmission [126]. Applying this tool allows for a comprehensive examination of the multiple impacts of climate change on Indigenous lives [127].
Some of the reported data findings suggest that the impact of climate change on the mental health of Indigenous communities may be beyond rates of incidence and prevalence of mental illness [76]. Rather, with various indirect impacts that have the potential to be extremely detrimental to the socio-cultural wellbeing of Indigenous communities. Climate change has both direct and indirect effects, and these often-intangible losses disrupt core drivers of psychological wellness and health in Indigenous communities, rendering them more vulnerable to mental health repercussions linked to climate change [108]. Underpinning these mental health impacts is a desire to adapt and respond to climate change amongst Indigenous communities. Hence, Indigenous Peoples' perceptions of and responses to these climate-related mental health consequences should not be neglected. To truly comprehend the impact of climate change on First Nations, government stakeholders, policymakers, and researchers must first comprehend the connection that Indigenous Peoples have to their environment and understand how they interact with and protect their territory. This could be the key to global issues resulting from climate change.
The recommendations from the articles stated above remain the same: there is an urgent need for a systematic collection of high-quality baseline empirical data in Indigenous communities to help researchers better understand the local linkages between climate events and human health. More engagement and knowledge of essential goals, as well as adaptation approaches adapted to distinct Indigenous Peoples, are required. Most of the studies focused on Indigenous knowledge and experience (from outside of Canada), but owing to inclusion rules, they were excluded from this analysis. Studies in Canada and Atlantic Canada have documented the environmental and health implications of climate change. Future investigations should focus on this region and its Indigenous Peoples, exploring specific mental and physical health factors, due to the intensified effects of climate change.
To conclude, even though Atlantic Canada is particularly vulnerable to climate change's environmental and health repercussions, Indigenous voices in the region are still unheard of. This review confirms the lack of and importance of traditional knowledge, cultural identity, social connections, and kinship as key adaptative and coping strategies towards climate change's environmental and health impacts. More research and funding from all levels of government are required for a better understanding of climate-health linkages among Indigenous groups in this region. Future investigations should focus on this region and its Indigenous Peoples, exploring specific mental and physical health factors, due to the intensified effects of climate change. We call for more research on this topic in the region, considering Indigenous Peoples' high cultural diversity as well as the environmental and health challenges posed by climate change in this region, which should be a priority for the Canadian government as well as regional and global research funding agencies, filling the research gap identified in Atlantic Canada.

Data availability statement
The data that support the findings of this study are available upon reasonable request from the authors.

Author contributions
Conceptualization, X W; literature analysis, P K; supervision, X W; writing-original draft, P K; writing-review and editing and methodology, P K; M A; and P J A; Indigenous knowledge support, counseling, and investigation, P J A and M A. All authors have read and agreed to the published version of the manuscript.