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Published in final edited form as: Nurs Outlook. 2024 Mar 4;72(3):102150. doi: 10.1016/j.outlook.2024.102150

Application of the socioecological model to mitigate risks of heat illness

Jean M Bernhardt a,*, Azita Amiri b
PMCID: PMC11389656  NIHMSID: NIHMS2007173  PMID: 38442464

Abstract

Background:

The socio-ecological model (SEM) is a widely used framework that can be applied to heat-related illness (HRI) in the context of multiple influencing factors that exist in society. Leaders and policymakers must intervene to mitigate the deleterious effects of climate change on those at risk.

Purpose:

The purpose is to introduce the SEM as a framework to address the complex factors contributing to the impact of excess heat.

Methods:

Conceived through the SEM, the compounding and cumulative impact of excess heat resulting in HRI is operationalized.

Discussion:

The SEM provides a structure for understanding the complex nature of climate change and HRI and proposed interventions. The prevention of HRI is dependent on actions, related to practice, education, research, and advocacy across multiple levels of the SEM. The SEM has the potential to target HRI at all levels of society to reduce the harm of excess heat.

Keywords: Socioecological model, Climate change, Policy, Theory application, Heat-related illnesses

Introduction

Climate change and its impact on health outcomes for people worldwide challenge our understanding of weather patterns, climate variability, and their contributing influences on health. Excess heat presents a major health risk associated with climate change (Ebi et al., 2021). As temperatures rise due to global warming, heatwaves have become more frequent, intense, and prolonged, increasing the risk of heat-related illness (HRI) and deaths (The Lancet, 2021).1 Based on a new study, during last year’s northern hemisphere summer, the hottest on record, more than 61,000 people died from heat-related causes in 35 European countries (Ballester et al., 2023). In 2021, 1,600 deaths occurred in the United States from heat exposure (Centers for Disease Control & Prevention (CDC), 2023). However, this statistic is thought to be under-reported because HRI may not be diagnosed, and where heat exposure is a contributing factor, only an additional 300 deaths are accounted for annually (Vaidyanathan et al., 2020). The elderly, children, pregnant women, those engaged in exertional activities outdoors, like agricultural workers, and people with preexisting medical conditions are particularly vulnerable to HRI (Arsad et al., 2022; Faurie et al., 2022).

Climate change leads to extreme weather events, including low precipitation ones, like heat waves, droughts, and wildfires, and high precipitation ones like excess rainfall, hurricanes, floods, and landslides. There are a few strategic frameworks addressing health and climate in general such as Climate Change and Health: A Framework for Action (Center for Climate Change and Health, 2020), Conceptual Framework for the Relationship of Climate Change to Human Health (USGCRP, 2018), and CDC (2022) communication, policy, and partnership strategic plan, but an overarching framework to explain the excess heat phenomena in relation to human harms is absent. None specifically provide a lens into the multiple levels of society where individuals interact.

Moreover, climate justice frameworks, such as Just Transition Framework from the Climate Justice Alliance (n.d.), focus on the burden on frontline groups, those who experience the immediate effects of extreme weather events and fenceline groups, those who live next but do not contribute to fossil fuel emission production (Khan et al., 2020). Others, like the Planetary Health Education Framework from the Planetary Health Alliance (n.d.), seek to educate people about broad environmental changes caused by the intersection of nature, humans, and health. Furthermore, conceptual or theoretical frameworks to explain discretely defined influences, like urban heat islands (UHI) (Karimi et al., 2018), the pathophysiology related to inflammation in chronic conditions (Hansson et al., 2020), the biological response to heat stress in specific populations, like farmworkers (Mac & McCauley, 2017), as well as models to mitigate the results of excess heat (Almuzaini et al., 2022) exist; however, a broader understanding of the conditions that create the risk factors for HRI are not adequately explained.

Frameworks work to guide methodological decisions and clarification of essential findings. The aim of a theoretical framework is to illustrate the scientist’s understanding of the main concepts using an underpinning theory, the state of assumptions and orientations of the project under study, relationships among concepts, and to identify the areas that need more research (Luft et al., 2022). Nurses can benefit from theoretical frameworks. First, they provide a structure and foundation for understanding the complex nature of healthcare and therefore HRI. Next, they help identify gaps in knowledge and provide a guide to fill those gaps. Additionally, theoretical frameworks can inform decisions and judgments based on evidence-based research. They can also help nurses communicate more effectively with each other and patients/clients through a common language and understanding of healthcare concepts. Lastly, theoretical frameworks can aid in developing new research questions and designing effective interventions to improve health outcomes. Overall, theoretical frameworks are a valuable tool to enhance knowledge and improve the quality of care provided to patients/clients, families, and communities. The purpose of this article is to explain the relationships central to climate change and their impact on HRI through the application of the socio-ecological model (SEM).2 As such, this manuscript does not involve any human subjects and was not subject to an internal review board approval.

Background

The deleterious impacts of climate change related to increasing ambient temperatures are well-documented (Romanello, 2022; Vicedo-Cabrera et al., 2021; World Health Organization, 2021). The world’s temperature is increasing because of carbon emissions from the burning of fossil fuels known as the greenhouse effect. The greenhouse effect has increased the average global temperature (Ahima, 2020), and slight changes in temperature have caused weather imbalances, including more frequent heat waves (Shafiei Shiva et al., 2019). Despite findings from the Lancet Countdown on Health and Climate Change’s earliest edition in 2016, the impact of global warming has remained unchecked and the social consequences of climate change, specifically human well-being, have resulted in negative health effects.

Thermoregulation is the ability of the body to regulate its core temperature by moving heat in and out while maintaining a core body temperature of approximately 37C. Core body temperature is controlled by the hypothalamus. The hypothalamus alerts thermo-receptors to store or release heat centrally or peripherally. Heat production from exertion plus heat gain from ambient temperatures above the body’s heat loss results in an elevated core body temperature (Vecellio et al., 2023). As body temperature rises above 38C, humans’ health and well-being are impacted if cooling does not occur. Core body temperatures above 40C are commonly defined as heat stroke worldwide (Bouchama & Knochel, 2002).

Sweating is the process by which the brain triggers the body’s ability to cool. Sweat glands draw water from the blood stream to make sweat which evaporates to cool the body. HRI is a range of physical symptoms that present when thermoregulation becomes ineffective resulting in hyperthermia. Prolonged sweating can deplete the body of water and salt leading to dehydration (CDC, n.d.). Symptoms begin with thirst and dizziness, and then as dehydration worsens, heavy sweating, muscle cramps, and syncope present as heat exhaustion. Heat exhaustion can quickly progress to heat stroke, which is the absence of sweating, changes in heart rate, and altered mental status (Westwood et al., 2021). Heat stroke is a medical emergency and can result in end organ damage or death if not rapidly recognized and treated.

Humans can acclimatize to excess heat by progressively increasing their exposure to heat over time. Heat acclimatization is a protective physiological response of the body to improve its heat tolerance by adapting to elevated temperatures. Progressive tolerance to heat occurs when the body dissipates heat through increased cardiac output, sweating and the evaporation of sweat without loss of electrolytes (Chapman et al., 2020). Acclimatization occurs over 3 to 14 days and any time away from the higher temperatures requires time to reacclimate (Ashley et al., 2015). The lack of acclimatization in hot temperatures leads to dehydration, fatigue, heat exhaustion, and potentially, heat stroke (Heutel et al., 2021; Rublee et al., 2021). Currently, the linking of single heat events across the United States and the world to climate change has highlighted the progressive shortening of time for acclimatization (Shafiei Shiva et al., 2019).

Increasing ambient heat places healthy individuals at risk for negative health outcomes when acclimatization and air cooling options are not available. Young girls have less body surface area for heat dissipation and tend to sweat from their extremities whereas boys sweat more from their chests and backs (Arlegui et al., 2021). Older people by virtue of normal aging processes have a decreased ability to dissipate heat due to a reduced sweat rate resulting from reduced functionality of sweat glands (Millyard et al., 2020). Those who work outdoors in extremely elevated temperatures for prolonged periods of time without adequate time to acclimate or the availability of cooling strategies, like shade, water, rest breaks, cooling vests, ice packs, or water dousing are at risk (Karthick et al., 2023; Morris & Jay, 2016). Yet young athletes subjected to repeated exercise in hot temperature environments demonstrated the ability to decrease heart rates and increase sweat rate thereby increasing heat dissipation (Kerr et al., 2019). While heat exposure is necessary for acclimatization, theoretical and experimental models have demonstrated that there is a limit to the human body’s ability to thermoregulate (Vecellio et al., 2023). The Pennsylvania State University Human Environmental Age Thresholds Project modeled age associated thermoregulatory function in high humidity temperatures and found that humans may not be able to adapt as well as previously thought (Wolf et al., 2023). They suggested that the previously accepted threshold of 35C may need to be lowered to 30C for populations, such as older people, to acclimatize.

Pregnant people, those with underlying health conditions, or living alone are vulnerable populations at risk for negative health outcomes because of altered cardiac function or impaired skin function which inhibits thermoregulation (Samuels et al., 2022). Although pregnant people can physiologically thermoregulate, heat exposure increases their risk of dehydration which can lead to complications of pregnancy, like low amniotic fluid, and risk to the fetus, such as low birth weight and stillbirth (Chersich et al., 2020). Individuals who suffer from obesity are prone to greater thermoregulatory strain prior to acclimatization (Faulkner et al., 2015) which may be associated with an inflammatory response (Hoekstra et al., 2018). People with diabetes and conditions associated with hyperglycemia have the potential for greater negative health outcomes because they have sudomotor dysfunction thereby producing less sweat and reduced skin blood flow which inhibits heat dissipation (Chahal et al., 2017). Feelings of social isolation and infrequent social contact are significant predictors of fatal impacts of excess heat (Paravantis, 2022).

Adverse health outcomes associated with excess ambient heat have been linked to socioeconomic vulnerability (Puley, 2022). Low-income and minority groups are more vulnerable to heat when they live in urban areas where temperatures are chronically higher than suburban and rural areas due to an effect known as UHI (Hess, 2023). UHI exist when densely spaced, heat-absorbing, impervious buildings attract more heat during the day than they can release at night as compared to natural soil and vegetation (Peng et al., 2012). Dense neighborhoods without open spaces have higher ambient temperatures (Phelan et al., 2015). Thereby, people in low-income and minority groups who live in warmer neighborhoods may be more vulnerable to HRI because they have fewer resources to cope with excess heat. While rural areas have similar heat stress indices during daytime hours and more access to outdoor space and water sources, there is conflicting evidence on their rate of hospitalizations during heat waves (Conaty et al., 2023; Jagai et al., 2017) and if the integrity of roads, and greater distances to healthcare services delay care for HRI (Seong et al., 2023; Yeargin et al., 2020).

HRI has been extensively studied in relation to occupational exposures. Working populations exposed to excess heat or point heat sources may experience more economic and social disadvantages than those not working in excess heat (Marsh et al., 2015). The incidence of occupational exposure and traumatic injuries increases for every 1C that the humidity index rises (Spector et al., 2019). Mutic et al. (2018) found that female gender, Hispanic farmworkers in Florida were three times more likely to experience three or more symptoms associated with ineffective thermoregulation and HRI, including heavy sweating, headaches, dizziness, and muscle cramps. HRI in child agricultural farmworkers as young as 10 years old who can be legally hired is common (Arnold et al., 2020) and related to higher core temperatures and decreased ability to sweat. Despite recent debates about the pathophysiology of thermoregulation in children (Smith, 2019), children exposed to excess heat are at risk of HRI.

HRI resulting from exposure to excess heat in the context of climate change presents a complex intersection of physical, environmental, and social processes. HRI is only a small portion of the health impacts from excess heat. The most severe forms of HRI, heat exhaustion and heat stroke are correlated with heat waves (Bai et al., 2014; Dematte et al., 1998).

A theoretical framework that explains the intersectionality and compounding impacts of these processes is necessary to improve our understanding of how interventions to address climate change and HRI can synergistically mitigate and prevent negative health outcomes. Socio-ecological theory provides a lens to explore the relationships between climate change and HRI.

Theoretical Framework

The SEM seeks to explain human development and evolved into a theory in the 1970s (Bronfenbrenner, 1986). A group of five nesting circles demonstrates the societal influences on the health of individuals. At the center of the nest is the individual, who is immediately surrounded by the mesosystem representative of the individual’s social network. The mesosystem sits in the exosystem made up of the community where the individual attends school and works. The macrosystem which includes cultural norms, and the physical environment engulfs the exosystem. The largest circle, the chronosystem represents the greatest influence over time of public policy.

The SEM is a widely used framework that envisions health in the context of multiple influencing factors that exist in society. The SEM purports that all surrounding levels affect the individual (Figure 1). An individual’s health is influenced by those in their social networks, their school and work, the physical space where they live, and the public policies related to how and what decisions impact the other levels. Using a systematic approach to apply the evidence related to HRI has the potential to improve interventions and promote best practices.

Figure 1.

Figure 1.

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Socio-Ecological Model: A Framework for Heat-Related Illness.

Conceived through the SEM framework, the impact of excess heat resulting in HRI to an individual is a compounding and cumulative one. At the chronosystem level, public policies addressing the reasons for climate change shape the increasing frequency of heat waves and rising ambient temperatures. As a result of public policies, the macrosystem encompasses the community or environment where cultural norms and the physical space prevent or potentiates the effects of excess heat. The exosystem includes organizations in the community which contains schools and work settings that mitigate or exacerbate the risk of excess heat. The mesosystem or the interpersonal level contains social support systems, including healthcare providers and the conditions that affect one’s quality of life, commonly referred to as social determinants of health, including education level, income disparities, poverty, and housing security. The individual then lives with existing health problems and comorbidities that place them at greater risk. Table 1 shows how the SEM levels are applied to the presence of excess heat from climate change.

Table 1.

Socio-Ecological Level and Application to Excess Heat

SEM level Definition Example of application to HRI
Intrapersonal (individual) Existing physical & cognitive abilities of the individual Ability to recognize increasing heat, increased sensation of thirst, moving to shade, acclimatization
Interpersonal (mesosystem) Interactions within one’s social networks & their social determinants of health Those living alone or are dependent on the care of others may not be able to independently mitigate exposure to elevated temperatures
Those working in low wage occupations may be exposed to excess heat
Organizational (exosystem) Groups that support the individual, like school or work Organizations support efforts to mitigate heat exposure, like schools provide air conditioning; work sites provide water & share breaks
Community (macrosystem) Environment that represents the values & norms where one lives, works, & plays Creating housing requires removal of trees and pouring concrete which contributes to an UHI
Public Policy (chronosystem) National, regional, and state policies supporting values & norms at all levels The Clean Air Act; funding to support the development of alternatives to fossil fuel emissions.
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Intrapersonal (individual)

The intrapersonal level of the SEM considers the physical and cognitive abilities of the individual as well as their prior experiences with HRI. Physical characteristics include age, sex, general health status, medical conditions, medications, and experience in the presence of excess heat. Cognitive factors include the ability to recognize the presence of increasing ambient heat, such as increased sensation of thirst, and engaging in cooling activities, like moving indoors. The individual’s social network highly influences their health and safety at the intrapersonal level. Those with medical conditions and who take medications that potentiate dehydration are most at risk. This level is strongly influenced by the risk determination of the individual to all the other levels of the SEM. Therefore, individuals should be knowledgeable about their own risks and the potential for adverse health outcomes in the presence of excess heat.

Interpersonal (mesosystem)

The interpersonal level includes the social system and network of others that are involved with the individual. Individuals who are isolated or alone are more at risk for HRI than those with others who are involved and can check on them (Orlando et al., 2021). Consequently, those with compromised health and who cannot respond to increasing ambient heat require immediate attention. An individual’s socioeconomic status, including education level, citizenship status, and income needs, may constrain their options to avoid excess heat, like the availability of low-wage agricultural farms or kitchen work where excess heat is characteristic.

Organizational (exosystem)

The organizational level incorporates groups that have come together to provide an established function, like schools and work settings. These structures influence how individuals mitigate the risks of excess heat. Schools may or may not have air conditioning available. Outdoor work settings may require wearing heavy layers of clothing or lack adequate water breaks. Thus, how organizations are designed determines the resources they have available to lessen the severity of increasing ambient temperature, like access to shade and cooling sites.

Community (macrosystem)

The community or environmental level comprises the values and norms affiliated with recognizing that rising temperatures impact the physical space where we live, work, and play. For example, deforestation to construct buildings which eliminates green space and abolishes tree canopies demonstrates conflicting needs with a built environment. The construction of greater masses of impervious spaces increases ambient temperatures which creates an environmental hazard and unsafe situation for those most vulnerable to excess heat. Hence, how the physical environment exists reflects our beliefs in the need to prevent or not, the effects of excess heat.

Public policies (chronosystem)

The public policy level covers all the legislation and guidelines for best practices that address climate change adaptation. Ideally, policies and programs reduce the risk of excess heat and HRI. In an ideal world, policies address each level of the SEM. National, regional, and state policies should address climate change adaptation strategies and prevent the deleterious health effects of excess heat. Climate adaptation strategies involve legislative and economic policies that support the expansion of hybrid and electric-powered vehicles thereby preventing the fossil fuel emissions which lead to increasing ambient temperatures. Past policies, like limiting funding for public transportation thereby supporting great reliance on automobiles have supported the production of fossil fuel emissions,

Implications for Practice

Complex interactive interventions can address the extraordinary threats to human health that climate change has created. As the outer and most encompassing level of the SEM, it would make sense that the influence of policies on all other levels would change an individual’s risk of HRI. However, shared values of engagement at the community level and compliance at the organizational level must be present.

Clinical Practice

The negative outcomes of climate change can be mitigated by applying the SEM to practice. Specifically, it can inform measures to counteract climate change through understanding the interconnectedness of different systems, such as the natural environment, social systems, economic systems, community structure, and individual risk factors. Additionally, it could shape policies or interventions that can eliminate HRI at the individual and system levels. Furthermore, this framework has the potential to focus on the psychological impact of climate change and excess heat on individuals and communities. The application of the SEM has the potential to strengthen social support networks or promote community resilience.

Nurses who apply knowledge about HRI to the care of their patients/clients engage in diverse ways at the level of individual (intrapersonal) and interpersonal (mesosystem). They may screen patients/clients for risk factors when a heat wave is forecasted using the Heat-Related Illness Screening Tool (HIST) (Bernhardt et al., 2023) or implement the A CLIMATE tool (Nicholas et al., 2021) to identify climate-related change health consequences in emergency rooms. Patients/clients living in the community with diabetes may be advised to increase their hydration and spend time in a cooling station. Nurses in school settings may recommend that student-athletes exercise in the early mornings or evenings when ambient temperatures are lowest. Existing interventions must be consistently offered to all individuals, families, and communities at risk.

Education

Nurses can use this theoretical framework to develop educational strategies that promote environmental awareness, sustainable behavior, and social responsibility. Academic institutions represent the organizational (exosystem). Curriculums should include content about climate change and HRI through didactic, clinical, and simulation forums. The MGH Institute of Health Professions School of Nursing in Boston, MA has integrated climate change science into its courses at the baccalaureate, masters, and doctoral levels (Nicholas et al., 2020). To adequately educate students about climate change and HRI, faculty need to possess current knowledge themselves. Resources, such as the Alliance for Nurses for Healthy Environments, the MGH Institute of Health Professions Center for Climate Change, Climate Justice, and Health, and the CDC, are available to educators to learn about climate change, HRI, and SEM.

Research

Doctoral-prepared nurses are encouraged to design and evaluate solutions to problems within and across levels of the SEM. Evidence-based practice solutions need to be prioritized and disseminated to reduce the harms of HRI. The SEM has the potential to contribute to a growing body of evidence about effective interventions that can be shared broadly to reduce harm to individuals (intrapersonal and mesosystem). As the body of research grows, educators can integrate the SEM as a framework to address the deleterious effects of climate change into health professional curriculums (exosystem) while protecting the most vulnerable populations.

Advocacy

Nurses advocate for their patients/clients at local, regional, and national levels. Global organizations like the Climate Action Network strive to shape public policy and take legal action that supports climate justice. Nurses serve on boards of community groups advocating for improved housing and housing locations that include green spaces and tree cover as part of the organizational (macrosystem) and public policy (chronosystem) levels. At the outermost level of the SEM, public policies (chronosystem), nurses are well-positioned to advocate for regulatory and legislative structural changes, such as the availability of cooling stations and water breaks with the United Farm Worker Foundation and applying scientific evidence to find solutions to minimize fossil fuel emissions through the Environmental Defense Fund.

A Case Study

The nurse at an urban community health center visits the local ball field to screen and educate residents watching a youth game in anticipation of an incoming heat wave. Most live in the 50-year 800-unit public housing complex adjacent to the ball field that is in various stages of demolition and renovation. As the nurse approaches, she notices that the public water bubbler is still covered from the COVID pandemic. The nurse begins by offering materials from the CDC on how to prevent HRI. As residents express interest, the nurse offers to screen them to determine their risk of HRI with the HIST. As more residents are screened, the nurse realizes that most do not have air conditioning in their units and other than to come to the ball field, they feel unsafe opening their windows or going outside. As the nurse scans the area, she does not see any trees. The nurse identifies that many have multiple chronic illnesses and is aware that they come to the community health center for their healthcare. Many are unemployed and the nurse knows that to be eligible to live in this complex, household income must be 200% below the poverty level. Even though, it is families at the ball field, the nurse knows that older people over 65 years old live in the complex, too. Table 2 highlights nursing interventions at each level of the SEM. Interventions at each level can be conducted independently. However, without interventions at the public policy level, air cooling, the primary intervention for excess heat will not be attained. Environmental responses at the community level along with the involvement of organizations must align to prevent or mitigate HRI in vulnerable individuals, families, and communities.

Table 2.

Nursing Interventions to Prevent or Mitigate HRI by SEM Level

SEM level Definition Nursing interventions
Intrapersonal (individual) Existing physical & cognitive abilities of the individual The nurse screens for risk of HRI. The nurse advises residents to bring a container with water to the ball field.
Interpersonal (mesosystem) Interactions within one’s social networks & their social determinants of health The nurse identifies that the residents are a low-income population with limited health literacy. The nurse asks residents to check on their older neighbors who are living alone.
Organizational (exosystem) Groups that support the individual, like school or work The nurse commits to coming back with times and locations of local cooling stations. The nurse reminds residents that they can come to the community health center for air cooling during the day.
Community (macrosystem) Environment that represents the values & norms where one lives, works, & plays The nurse advises those who have air conditioning not to go out when the heat wave hits. The nurse suggests green spaces in locations where residents without air conditioning feel safe to seek ventilation and shade.
The nurse contacts the developer of the complex to learn more about plans for air cooling in the new buildings and green spaces and tree canopy.
Public Policy (chronosystem) National, regional, and state policies supporting values & norms at all levels The nurse investigates requirements for air conditioning in public housing complexes and learns there is no federal requirement. However, states can use healthcare funds for air conditioners when they are considered medically necessary. The nurse contacts the state Medicaid office to find out where referrals can be made.
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Application of theoretical frameworks to real-world problems provides the opportunity to broaden one’s lens of possible causal and contributing factors leading to innovative solutions. The SEM is inclusive of the environmental and social influences on individuals, families, and communities, specifically the impacts of social determinants of health and how they are probable, seed, multiply, and continue. Simultaneously, it supports a strategy to combat where negative influences exist. Possible barriers to applying the SEM to HRI are beliefs that climate change is not a real problem or lack of sufficient evidence that specific populations are at risk for HRI. However, the SEM provides a framework to evaluate as well as address assumptions, arguments, and phenomena related to excess heat and its harm to humans.

Conclusion

The effects of climate change will not retract. The SEM provides a framework to envision simultaneous and integrated interventions to prevent HRI. The prevention of HRI is dependent on actions across multiple levels of the SEM. A theory-driven approach using the SEM recognizes that each level affects outcomes directly and indirectly. Climate change has potentiated the presence of HRI through complex factors that exist in society. Strategies to address HRI must also involve the alleviation of climate change. The SEM can enhance the practice of nurses and potentially improve outcomes for patients/clients, families, and communities. The SEM has the potential to target HRI directly by testing solutions at each level to reduce the harm of excess heat on individuals.

Acknowledgments

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors acknowledge support from the National Institutes of Health/National Institute of Environmental Health Sciences Environmental Health Research Institute for Nurse and Clinician Scientists (EHRI-NCS) (R25ES033452, PI: Castner J).

Footnotes

Declaration of Competing Interest

None.

CRediT authorship contribution statement

The authors confirm responsibility for the following: Bernhardt-conceptualization and design, methodology, visualization, writing-original draft preparation, writing-review & editing, Amiri-writing-review & editing.

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