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İklim Değişikliğinin Anne ve Yenidoğan Sağlığı Üzerine Etkisi

Yıl 2023, Cilt: 16 Sayı: 1, 104 - 112, 15.01.2023
https://doi.org/10.46483/deuhfed.1008043

Öz

Özellikle son yıllarda üzerinde durulan iklim değişikliği; on yıllardır süren sıcaklık, yağış, rüzgâr gibi hava olaylarındaki değişiklik olarak tanımlanmaktadır. İklim değişikliği ile birlikte, temiz suya erişim, hava kalitesi, hava sıcaklıklarında değişim, güvenli barınma ve gıda güvenliği gibi sağlığın belirleyicileri olumsuz etkilenerek insan sağlığı etkilenmektedir. Bu durumdan etkilenen risk grubunda bulunan bireyler, özellikle gebeler ve yenidoğanlar, savunmasız ve duyarlı alt grupları oluşturmaktadırlar. İklim değişikliği ve sağlığa etkilerini konu alan çalışmaların özellikle son yıllarda yürütülmüş olduğu dikkati çekmektedir. Bu derlemede iklim değişikliğinin anne ve yenidoğan sağlığı üzerine etkilerinin neler olduğuna dikkat çekilmek istenmiştir. İncelenen araştırmalardan yüksek derece sıcaklığa maruz kalma ve hava kirliliği ile gestasyonel diyabet, hipertansiyon, erken doğum, erken membran rüptürü, düşük doğum ağırlığı, ölü doğum, yenidoğan cinsiyeti ve konjenital anomaliler arasında ilişki olduğu saptanmıştır. İklim değişikliğinin sağlık üzerine olumsuz etkilerini azaltmada hemşirelere önemli sorumluluklar düşmektedir. Toplumun ve bireyin dayanıklılık kapasitesini arttırma, başa çıkma stratejilerini ve ileriye dönük davranışlarını geliştirme, sosyal destek ve yeşil çevre için politikalar geliştirmeye yönelik eğitici, savunucu, değişim ajanı, liderlik, bakım verici ve denetleyici gibi var olan rollerini hemşireler etkili bir biçimde kullanmalıdır.

Kaynakça

  • Agay-Shay K, Friger M, Linn S, Peled A, Amitai Y, Peretz C. Ambient temperature and congenital heart defects. Human Reproduction 2013; 28(8): 2289–2297.
  • Altunok A, Altunok E. AB iklim değişikliği politikaları. Denetişim 2016; (12): 45-55.
  • Arroyo V, Linares C, Díaz J. Premature births in Spain: Measuring the impact of air pollution using time series analyses. Science of the Total Environment 2019;660: 105–114.
  • Asamoah B, Kjellstrom T, Östergren PO. Is ambient heat exposure levels associated with miscarriage or stillbirths in hot regions? A cross-sectional study using survey data from the Ghana Maternal Health Survey 2007. International Journal of Biometeorology 2018; 62(3):319–330.
  • Avilés LA, Alvelo-Maldonado L, Padró-Mojica I, Seguinot J, Jorge J. C. Risk factors, prevalence trend, and clustering of hypospadias cases in Puerto Rico.? The Journal of Pediatric Urology 2014; 10(6):1076–1082.
  • Barna S, Goodman B, Mortimer F. The health effects of climate change: What does a nurse need to know? Nurse Education Today 2012; 32(7): 765–771.
  • Bekkar B, Pacheco S, Basu R, De Nicola N. Association of air pollution and heat exposure with preterm birth, low birth weight, and stillbirth in the us: a systematic review. JAMA 2020; 3(6): e208243.
  • Booth GL, Luo J, Park AL, Feig DS, Moineddin R, Ray JG. Influence of environmental temperature on risk of gestational diabetes. Canadian Medical Association Journal 2017; 189(19): E682–E689.
  • Brantsæter AL, Torjusen H, Meltzer HM, Papadopoulou E, Hoppin JA, Alexander J, et al. Organic food consumption during pregnancy and hypospadias and cryptorchidism at birth: the Norwegian mother and child cohort study (moba). Environmental Health Perspectives 2016;124(3): 357–364.
  • Canadian Nursing Association. The role of nurses in addressing climate change. (2008). Ottawa, Ontario, Canada 1-24.
  • Catalano R, Bruckner T, Smith KR. Ambient temperature predicts sex ratios and male longevity. Proceedings of the National Academy of Sciences of the United States of America 2008; 105:2244-7
  • Chersich MF, Pham MD, Areal A, Haghighi MM, Manyuchi A, Swift CP, et al. Associations between high temperatures in pregnancy and risk of preterm birth, low birth weight, and stillbirths: systematic review and meta-analysis. BMJ Clinical Research 2020; 371: m3811.
  • Costello A, Montgomery H, Watts N. Climate change: The challenge for healthcare professionals. British Medical Journal 2013;347: 6060
  • Dadvand P, Basagaña X, Sartini C, Figueras F, Vrijheid M, de Nazelle A, et al. Climate extremes and the length of gestation. Environmental Health Perspective 2011;119(10): 1449–1453.
  • Elongi JP, Tandu B, Spitz B, Vendonck F. Influence of the seasonal variation on the prevalence of preeclampsia in Kinshasa. Gynecologie Obstetrique Fertilite 2011; 39(3):132-135.
  • European Commission. Climate negotiations.15 Ağustos 2020 tarihinde, https://ec.europa.eu/clima/eu-action/international-action-climate-change/climate-negotiations_en adresinden erişildi.
  • Ha S, Liu D, Zhu Y, Sherman S, Mendola P. Acute associations between outdoor temperature and premature rupture of membranes. Epidemiology 2018; 29(2): 175–182.
  • Helle S, Helama S, Lertola K. Evolutionary ecology of human birth sex ratio under the compound influence of climate change, famine, economic crises and wars. Journal of Animal Ecology 2009; 78: 1226–1233
  • Janani F, Changaee F. Seasonal variation in the prevalence of preeclampsia. Family Medicine & Primary Care Review 2017;6(4):766–769.
  • Kilinc MF, Cakmak S, Demir DO, Doluoglu OG, Yildiz Y, Horasanli K, et al. Does maternal exposure during pregnancy to higher ambient temperature increase the risk of hypospadias? The Journal of Pediatric Urology 2016;12(6):407.
  • Konkel L. Taking the heat: potential fetal health effects of hot temperatures. Environmental Health Perspectives 2019;127(10):102002.
  • Kumar V, Abbas AK, Aster JC. (2015). Environmental and nutritional diseases. Robbins and Cotran Pathologic Basis of Disease içinde (ss. 403-450). 9th ed. Elseiver.
  • Leffers J, Levy RM. Nicholas PK. Sweeney CF. Mandate for the nursing profession to address climate change through nursing education. Journal of Nursing Scholarship 2017; 49(6):679-687.
  • MacVicar S, BerrangFord L, Harper S, Huang Y, Namanya Bambaiha D, Yang S. Whether weather matters: Evidence of association between in utero meteorological exposures and foetal growth among Indigenous and nonIndigenous mothers in rural Uganda. PLoS One. 2017;12: e0179010
  • Malley CS, Kuylenstierna JC, Vallack HW, Henze DK, Blencowe H, Ashmore MR. Preterm birth associated with maternal fine particulate matter exposure: a global, regional and national assessment. Environment International 2017; 101:173–182
  • Mandakh Y, Rittner R, Flanagan E, Oudin A, Isaxon C, Familari M, et al. Maternal exposure to ambient air pollution and risk of preeclampsia: a populationbased cohort study in Scania, Sweden. International Journal of Environmental Research and Public Health 2020;17(5): 1744.
  • Molina O, Saldarriaga V. The perils of climate change: In utero exposure to temperature variability and birth outcomes in the Andean region. Economics and Human Biology 2017; 24:111124
  • Oyeyipo IP, van der Linde M, du Plessis SS. Environmental Exposure of Sperm Sex-Chromosomes: A Gender Selection Technique. Toxicological Research 2017;33(4): 315–323.
  • Patel SS, Burns TL. Nongenetic risk factors and congenital heart defects. Pediatric Cardiology 2013; 34(7):1535–1555.
  • Peterka M, Likovsky Z, Panczak A, Peterkova R. Long-term significant seasonal differences in the numbers of new-borns with an orofacial cleft in the Czech Republic – a retrospective study. BMC Pregnancy Childbirth 2018; 18 (1): 348.
  • Robledo CA, Mendola P, Yeung E, Männistö T, Sundaram R, Liu D, et al. Preconception and early pregnancy air pollution exposures and risk of gestational diabetes mellitus. Environmental Research 2015;137: 316–322.
  • Sales F, Peralta OA, Narbona E, McCoard S, De los Reyes M, González-Bulnes A, et al. Hypoxia and oxidative stress are associated with reduced fetal growth in twin and undernourished sheep pregnancies. Animals 2018; 8(11):217.
  • Schifano P, Asta F, Dadvand P, Davoli M, Basagana X, Michelozzi P. Heat and air pollution exposure as triggers of delivery: A survival analysis of population-based pregnancy cohorts in Rome and Barcelona. Environment International 2016; 88: 153–159.
  • Schneuer FJ, Holland AJ, Pereira G, Bower C, Nassar N. Prevalence, repairs and complications of hypospadias: an Australian populationbased study. Archives of Disease in Childhood 2015;100(11):1038–1043.
  • Son JY, Lee JT, Lane KJ, Bell ML. Impacts of high temperature on adverse birth outcomes in Seoul, Korea: Disparities by individual- and communitylevel characteristics. Environmental Research 2019; 168: 460–466.
  • Spinoit AF. Hypospadias increased prevalence in surveillance systems for birth defects is observed: Next to climate change are we going towards a human fertility alteration? European Urology 2019; 76(4): 491–492.
  • Stingone JA, Luben TJ, Sheridan SC, Langlois PH, Shaw GM, Reefhuis J, et al. Associations between fine particulate matter, extreme heat events, and congenital heart defects. Environmental Epidemiology 2019; 3(6): e071.
  • T.C. Sağlık Bakanlığı İklim değişikliği. 15 Ağustos 2020 tarihinde, https://hsgm. saglik.gov.tr/tr/cevresagligi-ced/ced-birimi/iklide%C4%9Fi%C5%9Fikli%C4%9Fi.html adresinden erişildi.
  • Van Zutphen AR, Lin S, Fletcher BA, Hwang SA. A population-based case-control study of extreme summer temperature and birth defects. Environmental Health Perspectives 2012;120(10):1443–1449.
  • Verburg PE, Tucker G, Scheil W, Erwich JJ, Dekker GA, Roberts CT. Seasonality of gestational diabetes mellitus: a South Australian population study. BMJ Open Diabetes Research & Care 2016; 4(1): e000286.
  • Wang Q, Zhang H, Liang Q, Knibbs LD, Ren M, Li C, et al. Effects of prenatal exposure to air pollution on preeclampsia in Shenzhen, China. Environmental Pollution 2018; 237:18–27.
  • World Health Organisation (2020). Preterm birth. 7 Ağustos 2020 tarihinde,https://www.who.int/newsroom/ fact-sheets/detail/preterm-birth adresinden erişildi.
  • World Health Organization. Global strategy on human resources for health: Workforce 2. (2016). 7 Ağustos 2020 tarihinde http:// apps.who.int/iris/bitstream/10665/250368/1/978924 1511131-eng. pdf?ua=1. adresinden erişildi.
  • World Health Organization. Quantitative risk assessment of the effects of climate change on selected causes of death, 2030s and 2050s (2014). Geneva, Switzerland: 10 Temmuz 2020 tarihinde http://www.who.int/globalchange/publications/quantitative-riskassessment/en/ adresinden erişildi.
  • World Meteorological Organization. Summary for policymakers. In: global warming of 1.5°C. Geneva: World Meteorological Organization 2018;32.
  • Xie E, Howard C, Buchman S, Miller FA. Acting on climate change for a healthier future: Critical role for primary care in Canada. Canadian Family Physician 2021; 67(10):725-730.
  • Zhang J, Chen G, Liang S, Liu J, Zhang J, Shen H, et al. PM2.5 exposure exaggerates the risk of adverse birth outcomes in pregnant women with pre-existing hyperlipidemia: Modulation role of adipokines and lipidome. Science of the Total Environment 2021:787
  • Zhang JJ, Wei Y, Fang Z. Ozone pollution: a major health hazard worldwide. Frontiers in Immunology 2019;10: 2518.

The Effect of Climate Change on Maternal and Newborn Health

Yıl 2023, Cilt: 16 Sayı: 1, 104 - 112, 15.01.2023
https://doi.org/10.46483/deuhfed.1008043

Öz

Climate change, which has been emphasized in recent years; is defined as the change in weather events such as temperature, precipitation, wind over decades. With climate change, determinants of health such as access to clean water, temperature, air quality, safe housing and food security are negatively affected, and human health is affected. Individuals in the risk group affected by this situation, especially pregnant women and newborns, constitute vulnerable and sensitive subgroups. It is noteworthy that studies on climate change and its effects on health have been carried out especially in recent years. This review, it is aimed to draw attention to the effects of climate change on maternal and newborn health. Among the studies examined, it was determined that there is a relationship between exposure to high temperatures and air pollution and gestational diabetes, hypertension, preterm birth, premature rupture of membranes, low birth weight, stillbirth and newborn sex and congenital anomalies. Nurses have important responsibilities in reducing the negative effects of climate change on health. Nurses should effectively use their roles such as educator, advocate, change agent, leadership, caring and supervisor to increase the resilience capacity of the society and the individual, to develop coping strategies and forward-looking behaviors, to develop policies for social support and green environment.

Kaynakça

  • Agay-Shay K, Friger M, Linn S, Peled A, Amitai Y, Peretz C. Ambient temperature and congenital heart defects. Human Reproduction 2013; 28(8): 2289–2297.
  • Altunok A, Altunok E. AB iklim değişikliği politikaları. Denetişim 2016; (12): 45-55.
  • Arroyo V, Linares C, Díaz J. Premature births in Spain: Measuring the impact of air pollution using time series analyses. Science of the Total Environment 2019;660: 105–114.
  • Asamoah B, Kjellstrom T, Östergren PO. Is ambient heat exposure levels associated with miscarriage or stillbirths in hot regions? A cross-sectional study using survey data from the Ghana Maternal Health Survey 2007. International Journal of Biometeorology 2018; 62(3):319–330.
  • Avilés LA, Alvelo-Maldonado L, Padró-Mojica I, Seguinot J, Jorge J. C. Risk factors, prevalence trend, and clustering of hypospadias cases in Puerto Rico.? The Journal of Pediatric Urology 2014; 10(6):1076–1082.
  • Barna S, Goodman B, Mortimer F. The health effects of climate change: What does a nurse need to know? Nurse Education Today 2012; 32(7): 765–771.
  • Bekkar B, Pacheco S, Basu R, De Nicola N. Association of air pollution and heat exposure with preterm birth, low birth weight, and stillbirth in the us: a systematic review. JAMA 2020; 3(6): e208243.
  • Booth GL, Luo J, Park AL, Feig DS, Moineddin R, Ray JG. Influence of environmental temperature on risk of gestational diabetes. Canadian Medical Association Journal 2017; 189(19): E682–E689.
  • Brantsæter AL, Torjusen H, Meltzer HM, Papadopoulou E, Hoppin JA, Alexander J, et al. Organic food consumption during pregnancy and hypospadias and cryptorchidism at birth: the Norwegian mother and child cohort study (moba). Environmental Health Perspectives 2016;124(3): 357–364.
  • Canadian Nursing Association. The role of nurses in addressing climate change. (2008). Ottawa, Ontario, Canada 1-24.
  • Catalano R, Bruckner T, Smith KR. Ambient temperature predicts sex ratios and male longevity. Proceedings of the National Academy of Sciences of the United States of America 2008; 105:2244-7
  • Chersich MF, Pham MD, Areal A, Haghighi MM, Manyuchi A, Swift CP, et al. Associations between high temperatures in pregnancy and risk of preterm birth, low birth weight, and stillbirths: systematic review and meta-analysis. BMJ Clinical Research 2020; 371: m3811.
  • Costello A, Montgomery H, Watts N. Climate change: The challenge for healthcare professionals. British Medical Journal 2013;347: 6060
  • Dadvand P, Basagaña X, Sartini C, Figueras F, Vrijheid M, de Nazelle A, et al. Climate extremes and the length of gestation. Environmental Health Perspective 2011;119(10): 1449–1453.
  • Elongi JP, Tandu B, Spitz B, Vendonck F. Influence of the seasonal variation on the prevalence of preeclampsia in Kinshasa. Gynecologie Obstetrique Fertilite 2011; 39(3):132-135.
  • European Commission. Climate negotiations.15 Ağustos 2020 tarihinde, https://ec.europa.eu/clima/eu-action/international-action-climate-change/climate-negotiations_en adresinden erişildi.
  • Ha S, Liu D, Zhu Y, Sherman S, Mendola P. Acute associations between outdoor temperature and premature rupture of membranes. Epidemiology 2018; 29(2): 175–182.
  • Helle S, Helama S, Lertola K. Evolutionary ecology of human birth sex ratio under the compound influence of climate change, famine, economic crises and wars. Journal of Animal Ecology 2009; 78: 1226–1233
  • Janani F, Changaee F. Seasonal variation in the prevalence of preeclampsia. Family Medicine & Primary Care Review 2017;6(4):766–769.
  • Kilinc MF, Cakmak S, Demir DO, Doluoglu OG, Yildiz Y, Horasanli K, et al. Does maternal exposure during pregnancy to higher ambient temperature increase the risk of hypospadias? The Journal of Pediatric Urology 2016;12(6):407.
  • Konkel L. Taking the heat: potential fetal health effects of hot temperatures. Environmental Health Perspectives 2019;127(10):102002.
  • Kumar V, Abbas AK, Aster JC. (2015). Environmental and nutritional diseases. Robbins and Cotran Pathologic Basis of Disease içinde (ss. 403-450). 9th ed. Elseiver.
  • Leffers J, Levy RM. Nicholas PK. Sweeney CF. Mandate for the nursing profession to address climate change through nursing education. Journal of Nursing Scholarship 2017; 49(6):679-687.
  • MacVicar S, BerrangFord L, Harper S, Huang Y, Namanya Bambaiha D, Yang S. Whether weather matters: Evidence of association between in utero meteorological exposures and foetal growth among Indigenous and nonIndigenous mothers in rural Uganda. PLoS One. 2017;12: e0179010
  • Malley CS, Kuylenstierna JC, Vallack HW, Henze DK, Blencowe H, Ashmore MR. Preterm birth associated with maternal fine particulate matter exposure: a global, regional and national assessment. Environment International 2017; 101:173–182
  • Mandakh Y, Rittner R, Flanagan E, Oudin A, Isaxon C, Familari M, et al. Maternal exposure to ambient air pollution and risk of preeclampsia: a populationbased cohort study in Scania, Sweden. International Journal of Environmental Research and Public Health 2020;17(5): 1744.
  • Molina O, Saldarriaga V. The perils of climate change: In utero exposure to temperature variability and birth outcomes in the Andean region. Economics and Human Biology 2017; 24:111124
  • Oyeyipo IP, van der Linde M, du Plessis SS. Environmental Exposure of Sperm Sex-Chromosomes: A Gender Selection Technique. Toxicological Research 2017;33(4): 315–323.
  • Patel SS, Burns TL. Nongenetic risk factors and congenital heart defects. Pediatric Cardiology 2013; 34(7):1535–1555.
  • Peterka M, Likovsky Z, Panczak A, Peterkova R. Long-term significant seasonal differences in the numbers of new-borns with an orofacial cleft in the Czech Republic – a retrospective study. BMC Pregnancy Childbirth 2018; 18 (1): 348.
  • Robledo CA, Mendola P, Yeung E, Männistö T, Sundaram R, Liu D, et al. Preconception and early pregnancy air pollution exposures and risk of gestational diabetes mellitus. Environmental Research 2015;137: 316–322.
  • Sales F, Peralta OA, Narbona E, McCoard S, De los Reyes M, González-Bulnes A, et al. Hypoxia and oxidative stress are associated with reduced fetal growth in twin and undernourished sheep pregnancies. Animals 2018; 8(11):217.
  • Schifano P, Asta F, Dadvand P, Davoli M, Basagana X, Michelozzi P. Heat and air pollution exposure as triggers of delivery: A survival analysis of population-based pregnancy cohorts in Rome and Barcelona. Environment International 2016; 88: 153–159.
  • Schneuer FJ, Holland AJ, Pereira G, Bower C, Nassar N. Prevalence, repairs and complications of hypospadias: an Australian populationbased study. Archives of Disease in Childhood 2015;100(11):1038–1043.
  • Son JY, Lee JT, Lane KJ, Bell ML. Impacts of high temperature on adverse birth outcomes in Seoul, Korea: Disparities by individual- and communitylevel characteristics. Environmental Research 2019; 168: 460–466.
  • Spinoit AF. Hypospadias increased prevalence in surveillance systems for birth defects is observed: Next to climate change are we going towards a human fertility alteration? European Urology 2019; 76(4): 491–492.
  • Stingone JA, Luben TJ, Sheridan SC, Langlois PH, Shaw GM, Reefhuis J, et al. Associations between fine particulate matter, extreme heat events, and congenital heart defects. Environmental Epidemiology 2019; 3(6): e071.
  • T.C. Sağlık Bakanlığı İklim değişikliği. 15 Ağustos 2020 tarihinde, https://hsgm. saglik.gov.tr/tr/cevresagligi-ced/ced-birimi/iklide%C4%9Fi%C5%9Fikli%C4%9Fi.html adresinden erişildi.
  • Van Zutphen AR, Lin S, Fletcher BA, Hwang SA. A population-based case-control study of extreme summer temperature and birth defects. Environmental Health Perspectives 2012;120(10):1443–1449.
  • Verburg PE, Tucker G, Scheil W, Erwich JJ, Dekker GA, Roberts CT. Seasonality of gestational diabetes mellitus: a South Australian population study. BMJ Open Diabetes Research & Care 2016; 4(1): e000286.
  • Wang Q, Zhang H, Liang Q, Knibbs LD, Ren M, Li C, et al. Effects of prenatal exposure to air pollution on preeclampsia in Shenzhen, China. Environmental Pollution 2018; 237:18–27.
  • World Health Organisation (2020). Preterm birth. 7 Ağustos 2020 tarihinde,https://www.who.int/newsroom/ fact-sheets/detail/preterm-birth adresinden erişildi.
  • World Health Organization. Global strategy on human resources for health: Workforce 2. (2016). 7 Ağustos 2020 tarihinde http:// apps.who.int/iris/bitstream/10665/250368/1/978924 1511131-eng. pdf?ua=1. adresinden erişildi.
  • World Health Organization. Quantitative risk assessment of the effects of climate change on selected causes of death, 2030s and 2050s (2014). Geneva, Switzerland: 10 Temmuz 2020 tarihinde http://www.who.int/globalchange/publications/quantitative-riskassessment/en/ adresinden erişildi.
  • World Meteorological Organization. Summary for policymakers. In: global warming of 1.5°C. Geneva: World Meteorological Organization 2018;32.
  • Xie E, Howard C, Buchman S, Miller FA. Acting on climate change for a healthier future: Critical role for primary care in Canada. Canadian Family Physician 2021; 67(10):725-730.
  • Zhang J, Chen G, Liang S, Liu J, Zhang J, Shen H, et al. PM2.5 exposure exaggerates the risk of adverse birth outcomes in pregnant women with pre-existing hyperlipidemia: Modulation role of adipokines and lipidome. Science of the Total Environment 2021:787
  • Zhang JJ, Wei Y, Fang Z. Ozone pollution: a major health hazard worldwide. Frontiers in Immunology 2019;10: 2518.
Toplam 48 adet kaynakça vardır.

Ayrıntılar

Birincil Dil Türkçe
Konular Hemşirelik
Bölüm Derleme
Yazarlar

Renginar Öztürk Dönmez 0000-0002-0969-6943

Şeyma Kurt 0000-0003-2686-8572

Yayımlanma Tarihi 15 Ocak 2023
Yayımlandığı Sayı Yıl 2023 Cilt: 16 Sayı: 1

Kaynak Göster

APA Öztürk Dönmez, R., & Kurt, Ş. (2023). İklim Değişikliğinin Anne ve Yenidoğan Sağlığı Üzerine Etkisi. Dokuz Eylül Üniversitesi Hemşirelik Fakültesi Elektronik Dergisi, 16(1), 104-112. https://doi.org/10.46483/deuhfed.1008043

Dokuz Eylül Üniversitesi Hemşirelik Fakültesi Elektronik Dergisi ULAKBİM Türk Tıp Dizini, Türk Medline, Türkiye Atıf Dizini, Şubat 2021 tarihinden beri EBSCO Host ve 26 Ekim 2021 tarihinden itibaren DOAJ ve 18 Ocak 2022 tarihinden beri Index Copernicus tarafından indekslenmektedir.

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