N = 1961; 12–17 years old; 2007–2008) in the Balearic Islands, Spain. The study analyzed the relationships between body weight status, body image, and self-weight concern, and actual attempts to lose weight by restrained eating and/or increased exercising. In terms of regulatory focus theory (RFT), we considered that efforts to lose or to maintain weight (successful or failed) would be motivated either by a “promotion focus” (to show an attractive body), or a “prevention focus” , or both. Results showed that 41% of overweight boys and 25% of obese boys stated that they had never made any attempt to lose weight, and 13 and 4% in females. Around half of overweight boys and around a quarter of obese boys stated that they were “Not at all” concerned about weight gain, and girls’ percentages decreased to 13 and 11%, respectively. By contrast, 57% of normal weight girls monitored their weight and stated that they had tried to become slim at least once. Weight self-regulation in females attempted to combine diet and exercise, while boys relied almost exclusively on exercise. Apparent lack of consciousness of body weight status among overweight boys, and more important, subsequent absence of behaviors to reduce their weight clearly challenges efforts to prevent obesity. We argue that several causes may be involved in this outcome, including unconscious, emotional (self-defense), and cognitive (dissonance) mechanisms driven by perceived social stigmatization of obesity. The active participation of social values of male and female body image (strong vs. pretty), and the existence of social habituation to overweight are suggested. A better knowledge of psychosocial mechanisms underlying adolescent weight self-control may improve obesity epidemics.Adolescents’ self-control weight behaviors were assessed ( Results from US National Health and Nutrition Examination Surveys (NHANES) pointed out that the obesity prevalence remained stable over past 10 years , 3, mainThe increased prevalence in adolescent overweight contrasts paradoxically with the prevailing social appreciation of thinness –6, whichLongitudinal surveys and psychiatric studies have long warned that adolescents’ weight self-regulation practices promoted by thinness goals sometimes fuel unhealthy habits such as smoking, alcohol and drug use, purges, or vomits, or even result in anorexia and bulimia disorders .Comprehensible alarm resulting from these potential hazards has tended to obscure the positive role that body weight self-regulation processes, motivated by concern with body image, may represent by promoting a more balanced food intake and regular physical activity during adolescence. In our view, the relationship between ideal body image and weight self-regulation process can be connected through Higgins’ , 12 reguIn this theoretical framework, we consider that adolescents’ weight self-regulation efforts either by losing excessive weight, or by maintaining it in reasonable magnitudes, would involve a motivational “promotion focus”  as well as a “prevention focus” .However, as any human motivated behavior, weight-control may turn into a serious mental illness . AnorexiUntil now, many cross-sectional surveys have assessed the relationship between losing weight behaviors and body image attitudes. These studies have pointed out the common inclination of the obese and overweight population to underestimate their weight –23. On tWith reference to measured body fat, half of the girls with above-average values also considered themselves to be normal weight , and 4% In agreement with these unexpected findings within a context of obesity rejection, one longitudinal study found a dip in interest among teenagers in controlling their weight . MoreoveIncongruences between self-regulatory theoretical predictions and empirical findings demand a better understanding of self-weight goals among adolescents. The aim of this study was to assess the relationship between body mass status, body image perception, self-weight concern, and the personal motivation to actually engage in healthy weight control behaviors through cutting down food intake and/or regular exercise in a representative sample of adolescents living in a Mediterranean area. Body image satisfaction according to weight status, age, and gender was also assessed.The study is part of a broader population-based cross-sectional survey carried out on Balearic Islands’ 12- to 17-year-old adolescents between 2007 and 2008. The sample was selected by means of a multiple-step, simple random sampling, taking into account, first, the location, with towns from all over the Balearic Islands being represented , and then by random selection of schools within each town. Sample size was stratified by age and gender.To calculate a representative number of adolescents, a variable BMI was selected with the greatest variance for this age group, based on data from the literature at the time of the study . SamplinThe sample was oversized to prevent loss of information and was needed to do the fieldwork in complete classrooms. In each school, classrooms were randomly selected from among those of the same grade, or level, and all the adolescents in one classroom were asked to participate in the survey. A letter informing the nature and purpose of the study was sent to parents or legal guardians. After receiving their written consent, the adolescents were then considered for inclusion in the study. All responses to questionnaires were filled in by the adolescents. Once the field study had been completed, the adolescents who did not fulfill the inclusion criteria were excluded. Finally, the sample was adjusted by a weighting factor in order to balance the sample according to the distribution of the Balearic Islands’ population and to guarantee that each of the groups, already defined by the previously mentioned factors (age and gender), were representative. The final number of subjects included in the study, 1961 adolescents , were a representative sample of the Balearic Islands’ adolescent population. Reasons for not taking part were: (a) the subject declined to be interviewed, and (b) the parents did not authorize the interview.The study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving human subjects were approved by the Balearic Islands’ Ethics Committee  under number IB-530/05-PI. Written informed consent was obtained from all subjects and also from the next of kin, careers, or guardians on the behalf of the minors involved in the study.2), and study participants were specifically categorized by age and gender using the BMI cut-offs developed and proposed by the International Obesity Task Force (IOTF) , with the subject’s head placed in the Frankfurt plane. Body weight was determined to the nearest 100 g using a digital scale . The subjects were weighed barefoot, wearing light underwear, as previously described . BMI wase (IOTF)  and Colee (IOTF) , 36: norThe subjects were asked to estimate their current height and weight prior to measurement. Estimates within ±2 kg of real weight were classified as correct, <2 kg under real weight were considered as an underestimate, and >2 kg than real weight were considered as an overestimate.Subjects had to choose the most similar silhouette to their image , and the silhouette they would like to have from other similar series  using Stunkard’s Figure Rating Scale Figure , which iThe subjects were given multiple choice answers to the question, “Would you say that to gain weight is something that worries you? Not at all – Somewhat – A lot,” followed by the question and multiple choice answers, “I consider myself obese: Yes – No.”The subjects responded to the question, “Have you ever tried to control your weight? (Yes – Never)” followed by the question, “If you answered yes, have you done so by: dieting (Yes – No); regular sport practice (Yes – No).”2. The level of significance for acceptance was P < 0.05.Analyses were performed with the Statistical Package for the Social Sciences, version 21.0 . Significant differences in prevalence were calculated by means of χAs shown in Table Figure Table The difference between the real and ideal silhouette selected by each subject is shown in the body image satisfaction columns, which reveal that nearly half of the teenagers would like to be thinner. However, 25.7% of boys would like to have a larger silhouette.The percentages of satisfied boys and girls were similar among subjects of normal weight, but girls still wished to be thinner and boys to be larger. Acceptance of being overweight was significantly higher amongst boys.The Weight gain concern columns in Table Table Among the Balearic Islands’ adolescents, the prevalence of overweight is higher and the prevalence of obesity is lower than in the Spanish adolescent population . Our stuOur data confirm that girls have a more accurate knowledge of their weight than boys (probably by checking it frequently at home); they desire a thinner ideal body image; are much more concerned about weight gain and; as in adults , they maAccording to RFT, the personal motivation to weight self-control may be triggered by the wish to be attractive and/or to avoid to be rejected, being last case more influential, as an individual perceives himself/herself more deviant from social body standard.However, it is a well-known psychological principle that losing weight is an objective hard to attain, as our adolescents’ figures actually reveal. Clearly, changing comforting habits requires difficult psychological skills, which include an ability to tolerate uncomfortable internal reactions due to hunger or fatigue and a reduction of pleasure, as well as and a behavioral commitment to clearly defined values . TherefoThis failure may result in frustration and anger , a decreHowever, in a social context where the stigma of obesity is a long way of being relaxed , the higLooking for alternative explanations, one may conjecture that the obese stigmatization actually threatens the self-esteem, particularly of the most weighted individuals, thus setting up subconscious ego self-defense denial mechanisms to protect self-esteem –55. HighMoreover, social stigma may also pose a cognitive dissonance conflict to overweighed population. Thus, biased body image perception and weight underestimations might be a reflection of a compromise between the social “ought” to body self-image and the perceived body self-image. In other words, self-indulgent weight judgments would be attempts to restore cognitive consonance by claiming “I’m not so fat!” This would explain why half of overweight and obese boys underestimated their weight.However, our data reveal that most overweight and obese girls do not seem to be affected by the same emotional and cognitive processes. Therefore, beyond the superior worth given to thinness among girls, other psychological parameters are needed to explain the high percentage of boys not concerned about weight gain, or even willing to gain it (65.9 and 25% respectively). Because in male population, masculinity is frequently correlated with a big body, many boys may have considered that to look “manly,” one should better be “well built” than “slim.” This aim at looking “strong” parallels the girls’ concern at looking “pretty.” Thus, in the case of males, being overweight is not always associated to a negative social value, but rather to a positive one if associated to strength. Accordingly, to be a very thin boy may trigger more negative social consequences that to be moderately overweight . Indeed, a silhouette that represents a slightly overweight boy could be interpreted as a silhouette representing a muscular boy . This could also explain the discrepancy between the ideal silhouettes chosen by boys and girls.In conclusion, “the lesser of two evils principle” is somewhat pertinent in this context: when confronted to the choice “being a bit overweight” vs. being a “bit too thin,” perhaps, most boys would choose the first option.Complementarily, our results could indicate the emergence of a process of social habituation to people exhibiting signs of overweight, a phenomenon comparable to the familiarity with shaved heads, which made it acceptable to be bald. In this direction, Rand and Resnick  not onlyBeyond the influence of body image attitudes on weight self-control, it has recently been suggested that personality factors, such as impulsivity and reward/punishment sensitivity, may also play a role in the observed gender motivational and behavioral differences in weight self-monitoring and control . The perNowadays, when public efforts to prevent overweight are multiplying –62, and Moreover, messages must face the fact that many overweight and obese boys do not actually feel the necessity to lose weight, rather to attribute their physical status to laziness, lack of will-power, or other common negative social stereotypes of overweight people .So, in tAnother practical finding of our study is the important gender difference we observe in behaviors to achieve a healthy weight. In fact, girls typically used diet and exercise to lose weight, and boys used only exercise. The different competing body image motivations between boys and girls  probably boosts the males’ link between sport and muscles and the females’ one between diet and slenderness, thus explaining the girls’ increased confidence in diet and the boys in exercise. Moreover, boys are perhaps more reluctant to go hungry, and girls have a greater fear of having their figures criticized. Therefore, interventions to prevent obesity should suitably accommodate and highlight the benefits of diet among boys, and physical activity among girls.Afterward, interventions should focus on the advantages of maintaining a reasonable weight by healthy eating and exercise habits by means of presenting well described, attractive strategies to achieve that goal.JT, MB, AP, and JP conceived, designed, devised and supervised the study. MB, JP, and JT collected and supervised the samples. MB, AP, and JT analyzed the data and JP, MB, and JT wrote the manuscript. AP and JT obtained funding. All authors read and approved the final manuscript. The study sponsor had no role in study design.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


We show an electrical method to break open living cells amongst a population of different cell types, where cell selection is based upon their shape. We implement the technique on an optoelectronic platform, where light, focused onto a semiconductor surface from a video projector creates a reconfigurable pattern of electrodes. One can choose the area of cells to be lysed in real-time, from single cells to large areas, simply by redrawing the projected pattern. We show that the method, based on the “electrical shadow” that the cell casts, allows the detection of rare cell types in blood (including sleeping sickness parasites), and has the potential to enable single cell studies for advanced molecular diagnostics, as well as wider applications in analytical chemistry. The selective lysis of cells, either to enrich samples for diagnostic assays or to target drug delivery and enhance therapy, is of considerable interest. As a consequence, a variety of techniques that result in the lysis of the cell membrane have been described, including the use of chemicals,Here, we describe a method Figure  that ena16To understand this process, we consider a normal healthy cell with a resting potential that depends upon the relative concentrations of cations across the membrane. Upon exposure to an electric field, this potential increases as a result of charge accumulation at the membrane.However, in contrast to these methods, where larger cells always lyse preferentially to smaller cells, we have developed a method that enables shape-selectivity in such a way that cells with a different geometry will preferentially lyse from within a mixture of cell types Figure . To achiWe also demonstrate that this technique can be implemented in a low-cost optoelectronic platform Figure , where eWe apply this optoelectronic technique to large-scale, electrically induced, shape-selective lysis of cells, demonstrated by selective lysis of red blood cells (RBCs) over white blood cells (WBCs) and of RBCs over trypanosomes (blood-borne parasites). This technique has the potential to facilitate downstream analysis of rare cells out of a complex population. This has significant implications for cancer diagnostics, in particular for leukemia, where the genomic and proteomic information of specific lymphocytes carries diagnostic information, while the molecular profiles of circulating tumor cells has been linked to prognosis24Figure To optimize the efficiency of the method, we modelled the system (COMSOL Multiphysics 3.5), where cells were represented by a single-shelled model with a 7 nm membrane, using a 2D geometric cross section through the cells and electrodes Figure . The valFigure The model also shows that the shape of the electrical shadow correlates to the geometry of the cell. The relatively wide and flat biconcave RBCs cause a greater deflection of the field lines around them. This leads to a concentration of these field lines at their edges and underneath them, resulting in large electrical fields in these locations. The spherical WBCs also increase the strength of the electric field around them, but dramatically less so than the RBCs, thus providing a handle to lyse cells specifically depending on their shape.Furthermore, we used the model to investigate whether this same phenomenon could be observed with a good electrical conductor, such as gold or platinum, traditionally used as an electrode in cell lysis experiments. Metals, as good electrical conductors, will have a constant potential across their surface, and, as expected, this reduces the ability of the cell to change the electrical fields around it Figure . This co−1 to those of PBS at approximately 1400 mS m−1. However results in Figure −1, for which lysis efficiency is above 75 % across a wide range of frequencies.These events occur in media with a range of conductivities from 25 mS m−1 buffer conductivity and a frequency of 20 kHz, we demonstrated a circa twenty-fold enrichment of WBC with respect to RBCs . In one example, using optimized conditions of 100 mS ms Figure . At the s Figure , there wWhile the observation of the lysis of a few cells under high magnification is important to understand this new technique, one benefit will come from the lysis of a large number of cells of one type while leaving another intact. Here we show shape-selective lysis of RBCs over trypanosomes . In the future, the method may be useful in detecting other rare cell types in blood, including metastasing cancer cells.In conclusion, we have shown a method whereby the shape, not size, of the cell determines the electrical conditions that result in lysis. We demonstrated that the technique can be performed over large areas, which could be several mm


Famed microbiologist René J. Dubos (1901–1982) was an early pioneer in the developmental origins of health and disease (DOHaD) construct. In the 1960s, he conducted groundbreaking research concerning the ways in which early-life experience with nutrition, microbiota, stress, and other environmental variables could influence later-life health outcomes. He recognized the co-evolutionary relationship between microbiota and the human host. Almost 2 decades before the hygiene hypothesis, he suggested that children in developed nations were becoming too sanitized  and that scientists should determine whether the childhood environment should be “dirtied up in a controlled manner.” He also argued that oft-celebrated growth chart increases via changes in the global food supply and dietary patterns should not be equated to quality of life and mental health. Here in the second part of our review, we reflect the words of Dubos off contemporary research findings in the areas of diet, the gut-brain-axis (microbiota and anxiety and depression) and microbial ecology. Finally, we argue, as Dubos did 40 years ago, that researchers should more closely examine the relevancy of silo-sequestered, reductionist findings in the larger picture of human quality of life. In the context of global climate change and the epidemiological transition, an allergy epidemic and psychosocial stress, our review suggests that discussions of natural environments, urbanization, biodiversity, microbiota, nutrition, and mental health, are often one in the same. But it can be surmised that the consumption of new kinds of food will bring in its train new types of medical problems. Nutritional disease can arise not only from qualitative or quantitative deficiencies, but also from toxic effects, which are often slow in manifesting themselves…scientific knowledge is not yet sufficient to replace the biological wisdom derived from the countless centuries during which mankind has engaged in the empirical trial of foodstuffs”  suggested that overzealous sanitary efforts, a “circa early 1970s. This was the dawning of the era of the sanitizing-product industry .low exposure to bacteria via food or the environment in general. All this results in an ‘abnormally’ stable microflora” in Westernized nations …But sanitary practices and other aspects of the ways of life may also play an important part by affecting the indigenous microbiota…histological differences observed in the intestinal mucosa depending upon the socioeconomical status may be relevant to the problem, since they probably reflect the intensity of the inflammatory response to the so-called ‘normal’ flora.” [“ flora.” .Concerning his own groundbreaking studies on the microbiota of the total environment and what it might mean to human well-being, Dubos referred to himself as simply walking in Metchnikoff’s footsteps . Within Fast-forward and studies using germ- and pathogen-free mice have shown definitively that microbes can influence brain and behavior ,169. In These studies show us that microbes matter; however, there are massive limitations when using rodent studies as a means to provide translation in general  and espeThis sometimes inconvenient yet perspective-providing fact can, at times, be easily overlooked. While many future promissory notes are now being signed off with the signature of “microbiome,” Dubos warned about select overselling of similar technological advances in his time. He referred to their promotion at scientific meetings as a combination of “intellectual dishonesty” and “intellectual escapism” when they ignore glaring holistic environmental variables that are not nearly as press-release-worthy . In the Notwithstanding translation difficulties, the emerging rodent studies have provided some undeniably valuable clues to possible mechanistic pathways between microbes and brain function. Collectively, the experimental studies indicate that beneficial microbes might influence neurocognitive function, behavior, and perceived stress by various pathways: direct communication to the central nervous system (most likely via the vagus nerve), controlling the intestinal barrier (and limiting systemic low-grade inflammation), improvement of nutritional status , reducing systemic oxidative stress, regulation of glucose control, and limitation of uremic toxin production -183. UndIn the clinical setting, several studies have shown that oral probiotics, or fermented foods/beverages inclusive of beneficial bacteria, may provide value in end points such as depression, anger, anxiety, and daily mood -189. PerWhile intestinal microbiota and dietary interactions have received considerable international attention, it is worth noting that lactic acid bacteria, bifidobacteria, and numerous other potentially beneficial microbes are found throughout natural environments. For example, lactic acid bacteria make up a significant portion of the phyllosphere  even under extreme conditions. Moreover, bifidobacteria are found in the rhizosphere  of some of the harshest environments on the planet Earth ,194.Actinobacteria, Bacteroidetes, Firmicutes, and Proteobacteria. In particular, 16 s rRNA sequences assigned to the lactic acid bacterial group are higher in rural air [Indeed, significant differences have been noted between the microbial content of urban vs. rural air—results showing greater overall diversity in the rural near-surface atmosphere. There is also relatively higher abundance of bacteria in rural samples, including the microbial phyla that make up the portions of the human skin and intestinal microbiota such as ural air . A 4-dayural air , which aThe results of a recent European studies provide contextual meaning to the public health implications of biodiversity loss at the microbial level. Lower biodiversity of vegetation surrounding one’s residence has been associated with higher odds of an allergic IgE reaction to common allergens and lower diversity of select bacteria on the skin . In factGammaproteobacteria family, in particular, can influence the immune system beyond the skin itself [It seems likely that this is the type of research with which Dubos would have been most impressed. Reductionist technique immediately provides clear relevance to the broad environment. Since these environmentally influenced skin microbes, members of the n itself , similarA number of academic articles have concluded that modern humans would do well to exercise in ways that reflect our hunting and gathering past ,201. IndBeyond the classically known benefits of physical activity , and the more indirect sensory and psychological  value, there is a third dimension of potential benefit related to outdoor activities. We consider the potential diversity of microbial contact to be important and often overlooked consideration. In addition to vegetation as mentioned above, outdoor air has a greater phylogenetic diversity of bacterial communities than does indoor air .Outdoor play, gardening, or any activity that might bring contact with soil, trees, and plant life will increase the opportunity for exposure to microbial diversity. If the activity is conducted in natural environments, it increases the likelihood that the individual will inhale natural phytoncides  that are associated with human stress reduction and immune system benefits ,212. TheRecently, it was reported that athletes who make frequent contact with natural grass, soil, and mud (Rugby players) have greater diversity of gut microbiota vs. physical size, age- and gender-matched controls . The facMycobacterium vaccae has recently been shown to improve cognition and reduce experimental signs of anxiety in an animal model [M. vaccae is a generally non-pathogenic microbe that, depending on region, can be found in varying amounts within soil, mud, and/or natural water wells [M. vaccae (non-placebo-controlled) in patients with lung cancer indicated that it may attenuate some aspects of deterioration in quality of life [M. vaccae as the “happy” widely available soil bacterium is common, and it may lose sight of the fact that this particular microbe is associated with intellectual property and a long list of patents.The administration of live al model . M. vaccer wells . An earl of life . Media pM. vaccae is often used as a broad term that does not address its many specific strains. There has been little discussion surrounding the specificity of M. vaccae strains and emotional health; probiotic studies in the gut-brain realm suggest that not all microbial strains are alike [M. vaccae in neurocognition? If so, in what environments are these strains most abundant? In our context of natural environments, we would be interested to see if there are behavioral changes as a result of other non-commercially linked, non-pathogenic soil, or phyllosphere-associated microbes.re alike ,223,224.I cannot help but expressing my belief that living things, including man, respond not only to heat, humidity, light and other obvious climatic components which are readily perceived by the senses, but also to many other environmental factors not readily identified, and in part, still unknown” [“unknown” .Human biometeorology is an interdisciplinary science concerned with interactions between atmospheric processes and living organisms. In the context of climate change and environmental degradation, this field has experienced renewed interest . NaturalOne of the more controversial aspects of meteorological conditions as they relate to health of living organisms is that concerning the relative content of charged air ions. Dubos maintained an open mind on the topic. Despite suggesting that air ions may have untold benefits, including an ability to modify beneficial microbes within the intestinal tract , page 12any relevance to the growth and function of living organisms. The preponderance of available evidence shows that air with a relative increase in negatively charged ions may help facilitate positive mental outlook [However, since his writings on the topic, emerging research is undoing the notion that air ions are without  outlook -232. The outlook -235 and  outlook ,237. For outlook . Remarka outlook , indicatIn daily life and sleep, our ancestors would have made much more frequent direct contact with the Earth. Some researchers have speculated that less frequent contact with the surface of the Earth may translate to a deprivation in contact with abundant surface electrons, which in turn could impair diurnal electrical rhythms and burden the antioxidant defense system . Only prFinally, a less speculative area of total environment research is one touched upon in Part I—that of light. As mentioned previously, our current relationship with light is divergent from our ancestral past—higher levels of light at night (LAN) and lower exposure to light during the day are now commonplace. Here, we briefly mention the importance of the blue portion of the light spectrum. In a recent North American study, it was reported that the daily exposure to light intensity above 1,000 lux (levels associated with outdoor light) was only about an hour on average. Interestingly, in that study, those who accumulated the majority of their intense daily light exposure (levels beyond a 500-lux threshold) in the early part of the day were more likely to have a lower body mass index (BMI) . Why wouOne possibility is the higher amounts of shorter wave blue light in the early part of the day . Given tCircadian disturbances have been shown to induce dysbiosis in both mice and humans—and promote glucose intolerance and obesity that are transferrable to germ-free mice upon fecal transplantation . TherefoAfter weaving our way through each of our main sections—natural environments, nutrition, and microbes—we must underscore that not all global cities and districts within cities can be painted with the same brush . On a glLack of green space in urban environments, especially in socioeconomically disadvantaged areas, is often coincident with more grey spaces. These are residential areas with disproportionate industrial and commercial activity, heavy traffic, bars, liquor stores, convenience stores, and fast-food outlets -263. Altabsence of grey space—i.e. less noise, traffic, walkability, environmental toxins, and visible marketing that otherwise cajoles residents toward  unhealthy lifestyle choices [Therefore, many of the mental health benefits of green space may be explained top-line by the  choices ,264,265. choices . PerhapsThis is wonderfully entertaining, titillating kind of science fiction. We organize meetings about it in all sorts of pleasant places to talk about this, and that saves us the responsibility of walking across the street, where 100,000 children are being poisoned every day by lead in paint…something can be done immediately about this problem, but it is not being done because it is not of sufficient interest or as exciting intellectually” [“ctually” .Moreover, we must acknowledge that generalized stress , pollution, marketing toward junk food, smoking, antibiotic prescriptions -270, andPut simply, are we to imagine a world in which the socioeconomically disadvantaged line up for laboratory-generated microbial products, while the environmental forces that might allow dysbiosis to be the default mode remain in place? Are they to be sprinkled on the heavy metal-contaminated grounds  of the lScience and man’s nature. Daedalus: J Am Acad Arts Sci 1965, 94:223–244—that captured so many of his views in a single place. The following extended quotes from this classic piece are presented with permission of MIT Press.The immediate effects of the conflict between the Paleolithic constitution of man and the exigencies of modern life can be documented by chemical, physiological, and psychological measurements, but little is known of their long-range consequences. There is no doubt, however, that many physiological disturbances have their origin in the conflict between the modern environment and the Paleolithic ordering of physiological functions.”“For many thousand years, man has modified his environment by using fire, farming the land, building houses, opening roads, and even controlling his reproduction. The all important difference, however, is that many modern applications of science have nothing to do with human biological needs and aim only at creating new demands, even though these be inimical to health, to happiness, or to the aspirations of mankind.”“A more disturbing aspect of modern science is that the specialist himself commonly loses contact with the aspect of reality which was his primary concern, whether it was matter, life or man…one of the strangest assumptions of present day biology is that knowledge of living man will automatically follow from so-called ‘fundamental’ studies of the elementary structures and reactions of fragments derived from living things. In reality, a very different kind of knowledge is needed to understand the nature of the cohesive forces which maintain man in an integrated state, physically, psychologically, and socially, and enable him to relate successfully to his environment.”“Science and the technologies derived from it now often function as forces independent of human goals. In many cases, as we have seen, knowledge creates concepts that man cannot restate in terms of his experience; and increasingly, technology creates services and products that man does not really need. All too often, knowledge and technology pursue a course which is not guided by pre-determined social philosophy.”“Even though dangers are also inherent in the knowledge concerning automation, synthetic chemicals, or almost any other new technology, surprisingly little is done to evaluate the possible social consequences of these innovations.”“The study of man as an integrated unit, and of the ecosystems in which he functions, is grossly neglected because it is not in the tradition which has dominated experimental science since the 17th Century. Such a study would demand an intellectual approach, as well as research techniques and facilities, different from those which are fashionable and professionally profitable in the academic establishment.”“Having read stacks of Dubos writings, we found one paper —Science René Dubos was a city-loving, technology-embracing microbiologist who was well versed in the value of reductionist technique. He readily acknowledged that ancestral experiences were often brutish and that the solution to contemporary problems was not to be found in a romanticized “return to nature” ,279. He even when man has become an urbane city dweller, the Paleolithic bull that survives in his inner self still paws the earth” [Amidst the optimism, he raised warning flags concerning unintended consequences. He placed them along a river-like course into which the tributaries of natural environments, biodiversity, microbial ecology, and quality of nutrition would flow. The ultimate destination of this collective current was toward generalized aspects of well-being, quality of life, and the promotion of personal and planetary health. He referred to this as humanistic biology and reminded his audiences that “e earth” .Air, water, soil, fire and the natural rhythms and diversity of living species are important not only as chemical combinations, physical forces, or biological phenomena but also because it is under their influence that human life has been fashioned. They have created in man deep-rooted needs that will not change in any near future” [“ future” .A contemporary look at the work of Dubos would quickly reveal words such as these delivered to the World Health Organization’s 1969 Annual AssemblyIt would be surprising if such acquired dietary habits, in addition to being physiologically objectionable, did not also have unfavorable behavioral manifestations.” Pushing it further, he stated that humans, should they continue to become disconnected from nature in the emerging technological society, would begin to resemble animals in captivity: “The domesticated farm animals and the laboratory rodents on controlled nutritional regimens in controlled environments will then become true models for the study of man.” [In 1968, while addressing an audience at the United States National Institute of Mental Health, he suggested that shifting dietary practices in affluent nations would take its toll in the mental health realm: “of man.” , page 67is associated with the promotion of inflammation and chronic disease development [Science discovers, genius invents, industry applies, and man adapts himself to, or is molded by, new things…Man uses and it affects his environment, changes his whole habit of thought and of living. Individuals, groups, entire races of men fall into step with the slow or swift movement of the march of science and industry” [“ndustry” .That highly controlled, sanitized, and calorie-dense environment, we are now learning, elopment . Dubos wGuidebook were obvious. His interpretation: “It implied that man must conform to the environment created by industry, instead of using science and technology to develop conditions really suited to fundamental human needs…it is not man which must conform to technology, but technology which must be made to conform to the human condition.” [Where does the swift portion of the march of science and industry meet with unintended consequences? For Dubos, the implications of such words within the dition.” .Decades before terms such as “biophilia,” “hygiene hypothesis,” “developmental origins of health and disease,” “green space,” “blue space,” “nutritional psychiatry,” “narcissism epidemic/empathy drought,” “intestinal microbiota ecology,” “microbial deprivation,” “fecal microbiota transplantation,” “epigenetics,” “biodiversity hypothesis,” “screen time,” “evolutionary mismatch,” et al. became popularized, Dubos was already directly (or indirectly by sewing together various strands of ideas and publications of his peers) researching, writing, and paving the way for these realms. For any researchers tempted to claim that trans-generational and/or social-behavioral interactions with microbiota and physiological end points are novel concepts, a read at his work on specific pathogen-free mice ,289 woulAlthough such gene pools can change over long stretches of time, the needs of humankind are so pressing that we can hardly pin our hopes on changes in our genetic endowment. If we are to survive, Dubos argues, we must exploit the plasticity of expression of our genetic endowment” [His concerns about the future implications of these broad issues were sometimes based on published evidence, and at other times, they were self-admittedly of a speculative nature. Critics of the day pointed out that much of his positioning remained on the side of opinion rather than available evidence; however, they still understood his primary message. Renowned philosopher of science David L. Hull captured it in elegant fashion: “dowment” .Based on research outlined in this review, his forewarnings may have at least some contemporary scientific validation.Like other biological sciences, medicine is a complex structure resting on several supports. If it were limited to the art of the medical practitioner and to the reductionist philosophy of the biochemist, it would be a two-legged structure and would soon collapse through lack of balance and adequate support” [“support” .Dubos began his scientific career in the most reductionist way possible—combing through countless soil microbes to get to the species which would help him synthesize a clinically relevant antibiotic. At the end of his life, he continued to underscore the necessity of the reductionist approach in experimental science. However, he was keenly aware of its limitations as a means to inform clinical relevancy to humans in their total environment. For Dubos, it was the interactions and synergy between micro- and macro-environmental variables that required more study.Each of our three main sections—natural environments, nutrition, and microbes—are potentially intertwined. For example, lack of sensory experience  in natural environments could influence affect, cognitive restoration, stress resiliency, and sleep quality. In an environment where cognitive load and screen technology use is often high, this could very well influence dietary choices . These dLack of experience in natural environments, or certain dietary patterns, may also influence individual microbial diversity. This, in turn, may have many health consequences. Lack of natural light and a compromised ability to secure normal circadian rhythms can interact with all of the above ,293-297.As surely as discussions concerning beneficial microbes and brain health were on the fringes in the early 2000s , the tidcollective deficiency of ancestral influences in the modern landscape? What is the fallout from more time indoors and less experience with variables associated with natural environments or parts thereof? The “less” we refer to is broad—it ranges from the diversity of birdsong and non-pathogenic microbes to the blue spectrum of daylight and varieties of vegetation around a residence. It includes less dietary diversity via loss of traditional foods and the diminishing phytochemicals within them. In the context of evolutionary experience, we consider these to be modern deficits.What are the psychological consequences of a collective deficit manifest in a “disorder,” a sort of paleo-deficit disorder, that while not pathological per se, taps into unrealized quality of life, empathy, perspective taking, low-grade anxiety, psychological distress, resiliency, and negative mental outlook? Could this deficit accelerate an individual toward the checkmarks required for medicalized diagnoses? Might the collective deficit in “Paleolithic experiences” compromise an individual’s ability to maintain optimal emotional health and by extension, prevent optimal health of neighborhoods, cities, societies, and nations, especially those undergoing rapid urbanization? Please see Figure We wonder could this The evidence discussed in this review forces many questions concerning the deeper level essentiality of natural environments and the elements within them. Trees, of course, remove millions of tonnes of airborne pollutants from cities each year . Their pFuture research in the area of environmental variables and mental health should consider the application of simple, validated instruments such as the Nature Relatedness (NR-6)  and scalThe existing research, despite its many limitations, does suggest that natural environments and “access” to biodiversity  are indeed essential to public health, especially in urban settings. We need to learn more concerning the socioeconomic and political factors that influence ecosystem services and promote healthy cities  for all citizens . This enzeitgeist, we should point out some important and seemingly overlooked references. Stress can promote systemic inflammation independently of microbiota [At the same time, we cannot assume that in the Gold Rush known as the microbiome, where so many are staking a claim, microbes will provide us with all the answers. Lest our own very broad discussion get confined to the all-microbe crobiota . Moreovecrobiota ,325. Thecollective deficit—the total environment—in which dysbiotic microbiota is a part. Put simply, one might have in their procession the most ideal microbiota profile, the gold standard against which all future commercial fecal products will be measured, and still fall well short of optimal mental health.As cited above, microbiota are undeniably linked to many variables highlighted throughout our discussion; at a certain tipping point , bacterihow and even why an individual responds in a differential manner to visual, olfactory, and other sensory aspects of natural environments. Microbial interactions with genetic factors will likely be linked to Nature Relatedness, emotional well-being, and intestinal or skin microbiota. Indeed, that is our primary point—in common parlance, “it’s all connected”.Our stance does not dismiss the strong probability that lifetime microbial experiences, especially the early ones, could have long-lasting influences on Reading Dubos, it would be tempting to state that there is nothing new under the sun. Maybe we have reached a point where theory after theory, hypothesis upon hypotheses, are all variants on the same theme. Perhaps discussions of natural environments, biodiversity, microbiota, nutrition, and mental health are often one in the same. We consider this to be an important consideration simply because it might help guide plausible solutions.The etymological meaning of allergy is, of course, ‘altered reactivity.’ In this sense, all aspects of life can be considered as manifestations of allergy, since most anatomical and functional characterizes of man can be modified by the stimuli—physical, chemical, social—that impinge on him throughout life…developing counter technologies to correct new kinds of damage constantly being created by technological innovations is a policy of despair…we must try to imagine the kind of surroundings and of life we want, lest we end up with a jumble of technologies that will eventually smother body and soul” [“nd soul” .Decades before the global rise in allergic diseases were considered to be at epidemic proportions; Dubos addressed membership of the American Academy of Allergy at its annual meeting. We close on his words, communicated in 1969, as keynote speaker to his audience of allergists:


Although migrants constitute an important proportion of the European population, little is known about migrant sexual health. Existing research mainly focuses on migrants’ sexual health risks and accessibility issues while recommendations on adequate sexual health promotion are rarely provided. Hence, this paper explores how refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands define sexual health, search for sexual health information and perceive sexual health determinants.Applying Community-based Participatory Research as the overarching research approach, we conducted 223 in-depth interviews with refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands. The Framework Analysis Technique was used to analyse qualitative data. We checked the extensiveness of the qualitative data and analysed the quantitative socio-demographic data with SPSS.Our results indicate that gender and age do not appear to be decisive determinants. However, incorporated cultural norms and education attainment are important to consider in desirable sexual health promotion in refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands. Furthermore, our results demonstrate that these migrants have a predominant internal health locus of control. Yet, most of them feel that this personal attitude is hugely challenged by the Belgian and Dutch asylum system and migration laws which force them into a structural dependent situation inducing sexual ill-health.Refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands are at risk of sexual ill-health. Incorporated cultural norms and attained education are important determinants to address in desirable sexual health promotion. Yet, as their legal status demonstrates to be the key determinant, the prime concern is to alter organizational and societal factors linked to the Belgian and Dutch asylum system. Refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands should be granted the same opportunity as Belgian and Dutch citizens have, to become equally in control of their sexual health and sexuality. Sexual health and sexuality are both health concepts that are still prone to definition modelling worldwide. Since the recognition of sexual and reproductive health as a human right at the International Conference of Population and Development of 1994 in Cairo, more need was felt to come to a global consensus. Starting from this rights-based and public health approach, the World Health Organisation WHO, 2010) defines sexual health as “a state of physical, emotional, mental and social well-being in relation to sexuality; and is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive, respectful approach to sexuality and sexual relationships and the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled” [010 definFrom a socio-ecological perspective on health , these fMigration movements in Europe recently increased in size and complexity. In 2011, 6.6% (33.3 million) of the EU population were “third-country” or “extra-EU” nationals . AccordiAlthough migrants constitute an important proportion of the European population, relatively little is known about migrant sexual health and sexuality. This gap in knowledge can be largely explained by a variety of technical and political reasons. First, throughout Europe, there is a great variability in the main denominators of citizenship, residency and immigration status in available databases ,9. In adMany determinants in sexual health and sexuality are known, yet the link to migrants in Europe is rarely made. When it is done, the main focus is on their higher risk to sexual health problems or on barriers in their access to sexual health programmes and services . These sThe general objective of this study is to provide more insight in how the sexual health of refugees, asylum seekers and undocumented migrant in Belgium and the Netherlands can be promoted in a more desirable, ethically sound and culturally competent way. To that end, this paper aims to explore how refugees, asylum seekers and undocumented migrants define sexual health; to examine what pathways they use in search of sexual health information and to identify risk and protective factors they perceive as determinants after having fled to and applied for asylum in Belgium or the Netherlands.This paper describes one part of a larger participatory study on sexual health and sexual violence in refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands. The results on sexual violence experience and prevention have been published elsewhere .This study is grounded in a phenomenological and dialogical research perspective and supports an interpretive, feminist communitarian epistemology ,30. ConsStarting from this conceptual framework, we adopted Community -Based Participatory Research (CBPR) as our overarching qualitative research approach. CBPR in public health focuses on social, structural and physical environmental inequalities and aims to improve the health and well-being of community members by integrating gained knowledge in action, including social and policy change ,33. A laGiven the piloting nature of this study and the fact that the population was hard to reach; we opted for criterion and chain sampling  of the rBetween January and April 2007, CRs were asked to conduct 10 to 12 in-depth interviews with respondents meeting the inclusion criteria and of the same gender as the CR. In order to maximise the match between ‘inner speech’ and the language used ; to optiThis paper covers the sexual health data. In order to come to better sexual health promotion in refugees, asylum seekers and undocumented migrants, we firstly assessed how these migrants define sexual health and sexual maturity. Secondly, we explored the sexual health information sources they are accustomed to address and the pathways they use. Thirdly, we examined the risk and protective factors they perceived as affecting one’s sexual health and influencing one’s sexual behaviour. For each of their answers we asked the respondents to differentiate according to  maturity (adults-youth) and gender where applicable in their opinion. The interviews were audiotaped and the CRs took notes on their interview guides. Upon completion of the interview, we checked, and if necessary, organised professional psychological, medical, social, or judicial assistance. Respondents also received a package with sexual health and violence information in their mother tongue, referral addresses, condoms and some samples for daily hygiene  provided by a pharmacy. In line with the CBPR methodology , safety We considered interviews only valid when having signed informed consent and when the taped interview matched the notes that were taken by the CR on the interview guide. Duplicates of interviews were checked for, but none were found. All open questions were written ad verbatim and translated to Dutch or English. We used the Framework Analysis Technique to sort, code and constantly compare the qualitative data. We started by inductively grouping the coded data into analytical themes and categories conceived as meaningful and important to the involved communities while using the respondents’ definitions and wordings. Subsequently, we applied our conceptual framework, which resulted in an analysis along five sexual health core components:1. General well-being and development with factors related to personal health practice & lifestyle, physical, mental, social  well-being2. Safe and satisfying sex life3. Respectful approach to sexual relationships and sexuality4. Family planning and fertility5. Access to Information & CareThis qualitative analytical process was itinerated by the first author and a fellow researcher who independently from each other coded and analysed the data. They discussed and agreed on every aspect before heading to the next analytical step. In addition, at regular interval, preliminary results were discussed and interpreted with CRs and CAB members before moving to a next level of analysis. Subsequently, we used SPSS to analyse the quantitative socio-demographic data and to check the extensiveness (the volume of and the diversity within) of the qualitative data . We hereOf the 250 conducted in-depth interviews, 223 were considered valid. This regarded 132 interviews in Belgium and 91 in the Netherlands with refugees (46%), asylum seekers (41%) and undocumented migrants (13%). The respondents comprised 88 males and 135 females from Iranian (40), Iraqi (12), Slovakian and Czech Roma (36), Kurdish from Iran and Iraq (58), Somali 14), Afghan (24) and CIS (39) descent. Two transsexuals in Belgium were included as women in the analysis upon their request. The respondents were relatively young and generally highly educated women and men. Slightly more than half of them did not have a steady partner and the majority was not or only fairly accompanied by other adults or children. In their appreciation of their profile, respondents indicated that having poor social networks to rely and build on and being hampered in participating actively in society was wearing them down. Furthermore, respondents complained of a socio-economic setback compared to their country of origin as is reflected in the daily activities in Table , Afghan “Some people think that sexual contact between people is just a biological process and they do not think about feelings and the mental side of 2 people. While, this is give and take, so with nice words and soft touching you should help each other to become ready for sex” Our respondents generally defined sexual health of adults and youth in the same terms. To them, being sexually healthy meant above all being generally well (A: 60%-Y: 52%), and subsequently also being sexually safe and satisfied (A: 39%-Y: 33%) and respectful to sexual partners (A: 39%-Y: 26%). Yet, family planning and fertility (A: 22%-Y: 18%) and being informed and medically cared for (A: 13%-Y: 14%) seemed of less importance.General well-being (n 132) was mostly formulated as “not having a sexually transmitted disease or infection”, being “both physically as well as mentally healthy and ready”, or being “fully physically healthy”.A safe and satisfying sex life (n 86) was frequently described as: “being completely comfortable with having sex ”, “using contraception”, “enjoying sex” or “having sex on a regular basis”.A respectful approach to sexuality and sexual relationships (n 87) was mainly formulated as “having sex only from the moment you are married and within the marriage”, “being conscientious about risk behaviour and limits of yourself and your partner” and by “having one steady partner”.Family planning and fertility (n 48) was largely defined in terms of “being able to bare children”, “being fertile” and “having healthy children”.Having access to information and care (n 28) was mostly described as “having enough information on what sexual health is” and as “knowing what the risks of having sex can be”.“When I was 17, I had a boyfriend who kissed me once. I got wounds on my lips, so I thought God had punished me and gave me lip cancer” It is noteworthy that age and gender of the respondents did not impact these results, while educational attainment and country of origin did. Although being generally well was the most important to the majority of all attained education levels, its perceived importance raised along with the level of education up to the highest value for the ones with higher university or non-university education. A respectful approach was equally important to about 30% of all attained levels. Access to information and care and a safe and satisfying sex life became more important the higher the education attainment while family planning was mostly an issue to those with intermediate levels of education. For every origin, general well-being was important to more than half of the respondents. However respondents from the CIS mentioned this much more frequently, closely followed by Iranian and Iraqi respondents. Both a respectful approach as well as a safe and satisfying sex life was predominantly indicated as an important aspect of sexual health by respondents from Somalia and the Middle East. To the Slovakian and Czech Roma respondents and those from the CIS, family planning seemed to be more of an issue. Access to information and care was not important to any of these groups and even not mentioned at all by these Roma respondents. Taking all five components into account, the data suggests that people from Iraq and Iran have the most balanced interpretation of what constitutes sexual health according to the WHO definition used here.“A man has to be mature with his head and not only with his penis and balls” When asked how one could make a distinction between adults and youth, the following criteria were set. For both females and males, the same top three of criteria were given: it firstly depended on their general physical, mental and social development; secondly on their age and thirdly on their respectful approach to relationships and sexuality. The gender, age and the level of education of the respondents did not impact the results, yet country of origin did have some influence.The moment where a girl turns into a woman depended for the majority (59% or 131) on their general development. The phrasing was mostly related to mental health aspects as: “being mentally mature”, “being able to take up responsibility” but also more physically as “when girls got their first menstruation”. For all countries of origin those descriptions were spontaneously given by more than half of the respondents, yet the physical aspect of menstruation as a turning point was particularly stressed by Somali and Slovakian Roma respondents. About a fourth of the respondents (60) said that becoming a woman had to do with age, but the age they set was quite different. Eight respondents put the limit at 13/14 years; a third said 15/17 years, while for more than half of them one had to be at least 18 or older. The indication of age was provided by the majority of Somali and Afghan respondents and all the references to being 13 or 14 as maturity age were found in this group. In other origins age was indicated by less than a third. Another fourth of the respondents (57) said that turning into a woman depended on one’s approach to relationships and sexuality and the utmost majority of them (80%) related this to “being married”. Only a few (15) from all origins except Somalia, related becoming a woman to family planning and described this as “having the feeling of motherhood after having bared the first child”, “being able to become a mother” and “being able to become pregnant”. Even less (11 or 5%) related this to sexual debut.For about 48% (107) of respondents, a boy becomes a man when he is physically, mentally and socially well developed. Half of them defined this as “being mentally mature”, a third as “being able to take up responsibility” and a fifth as “has had his first wet dream”. Nearly a third of the respondents believed that male maturity was related to age, mainly defined as “being more than 18”. Some 20 respondents exclusively from the Middle East and Somalia found that being between 15 and 17 was old enough. Another fourth, again predominantly originating from the Middle East, said this depended on their approach to relationships and sexuality, again primarily defined as being married (73%). From all origins but Somalia, 30 respondents mentioned sexual debut as a turning point and 20 family planning or fertility as “having a family to take care of” or “being a father”.“When I married it was my mother-in-law who informed me on sex, I was so afraid of sex that during the first week, I slept with her” Asking respondents where adults as well as youth in their home country turned to in order to find information on sexual health, 40% stated that there was not really an official place or person where you could turn to, or that it was a big taboo. However 60% of the respondents mentioned several SHI-sources which we categorized as health sector, one’s direct environment, media and institutions. The respondents were convinced that adults and youth do consult the same type of SHI-sources, yet they did not follow the same pathways. Adult primarily searched for information in the health sector (60%), and to a much lesser extent in one’s direct environment (30%), in media (18%) and institutions (16%). The majority (64%) was convinced that these pathways were equally consulted by adult women and men. Yet, if they indicated differences, this was mostly to nuance that men turn to men and women to women. As for youth, our respondents stated that the SHI-source that stood out for both female and male youth is their direct environment (43%). At a second level, the health sector (30%), the media (29%) and institutions (27%) are equally important sources they consult. Testing for age, educational level and origin of the respondents did not appear to influence the mentioned pathways decisively. However, the gender of the respondents revealed to be determining the pathways to obtain sexual health information.For both female and male respondents (M: 64%- F: 58%), it was a matter of course that an adult turned to the health sector in search of SHI. However, we saw that the lower the education level of the respondents, the less the health sector was considered as the most obvious SHI-source . According to half of the respondents, seeing a general practitioner was the readiest medical SHI source regardless of age or sex (Y: 56%- A: 49%). Seeing a gynaecologist and an outpatients’ clinic were mentioned by a fourth of them with female and young respondents preferring a gynaecologist  while male and adult ones preferred the outpatients’ clinic . Urologists and a general health centre were mentioned by 10%.In general, youth considered their direct environment as most important SHI-source (44%) while adults of both sexes considered it as subordinate to the health sector. Yet, adult women consulted their direct environment as SHI-source considerably more than their male counterparts (F: 43%-M: 19%). Finally, for Kurdish respondents as well as for respondents who did not go to school, the direct environment was not the second, but the first SHI-source (K:51%- NS: 50%). Within the answers indicating direct environment as SHI-source the most important were family (75%) and friends (67%). When family was specified, it predominantly regarded parents, brothers and sisters and only occasionally a further relative. Adult women and youth seemed to attribute more importance to friends (W: 58%-Y: 67%) than family (W: 41%-Y: 54%), while for adult men these are equally important sources (40%).Using the media as an information tool was slightly more relevant for female than for male (F: 20%-M: 14%) and for respondents in Belgium than the ones in the Netherlands (B: 21%- NL: 13%). Their age and education level does not impact this, while origin did: media as an SHI source was the most popular among Iranian and Kurdish respondents. For the respondents indicating media as a SHI source, the tools that were mentioned mostly for adults were: books (46%), internet (33%) and TV (27%), while for youth seeking SHI they considered internet (55%) as preferable source over books (42%) and TV (22%). Books were more accessed by female respondents compared to males (F: 62%-M: 17%) and by people with higher education levels. Male respondents preferred internet (F: 31%-M: 42%) and TV (F: 19%-M: 33%). Internet was about equally important to all levels of education while TV was more important to respondents with a lower education attainment level (HE: 11%- LE: 75%).Turning to institutions as a source of SHI was relevant for 15% of female and male respondents with levels of education of secondary school and more. According to them school/university was the readiest institutional SHI source for both adults and youth (A: 58%-Y: 83%) followed by religious institutions (A: 18%-Y: 8%). Yet, more importance was attributed to them for females than for males  In general, institutions as a SHI source were more popular for respondents in Belgium (71%) than in the Netherlands (42%).“Good behaviour makes people beautiful, they make you feel safe” The factors they perceived as influencing one’s sexual health can be divided into internal and external health locus of control factors.“Refugees who are sexually frustrated and who don’t have enough money to pay a prostitute should masturbate” More than half of the respondents (54%) distributed among all levels of education, thought that by assuring to have a safe sex life one could obtain good sexual health. The descriptions most given were “using a condom”, “using contraception in general” and “considering the health status of the sex partner before having sex”. Irrespective of one’s level of education, age and origin, about half of the respondents (49%) believed that one should take responsibility of one’s sexual health by doing things that contributed to a general well-being and lifestyle as “looking after personal physical care & hygiene”, “eat healthy”, “do sports” and “detent and stress less”.“You have to inform yourself on STI’s, that’s not so difficult, but not only look for health information but also on how to make love” They were equally convinced that having access to information and care was a determinant. They phrased this as “getting informed on sex, sexual risks and sexual health” and as “seeing a medical professional on a regular basis” or “seeing a doctor at least when problems occur”. Respondents from the Middle East stressed the information part more while the others rather emphasized the accessibility of care. A third of the respondents, mostly with higher education levels, said that in order to have good sexual health, one needed a respectful approach by “having one sex partner” or “knowing the sex partner before having sex”. Respondents from the Middle East mentioned more relational aspects as “free choice of partner”, “no forced marriage” and “good communication” than people from the CIS, Somalia and the Slovakian and Czech Roma who emphasized the importance of having “one steady” and “healthy partner”.The majority of the respondents (68%) said that there were additional external factors which could influence one’s sexual health in a positive or negative way. Factors which could have a positive or a negative impact were situated in the sphere of informal help of powerful others and were defined as “friends”, and “one’s upbringing”. Religion was only mentioned by three respondents. The extent to which “sexual health is publicly debatable” and “having sexual education at school” were mostly mentioned as external positive factors. Yet, “drugs/alcohol”, “sexual diseases and problems”, “having “stress”, “bad financial situation”, “separated from family”, “unavailability of having sex” or “forced sex”, were considered as negatively influencing one’s general and sexual health and well-being.“Because of all her traumatic experiences she could not sleep with her husband. She relived everything; in the end she committed suicide” Most respondents felt that given the asylum situation in which they live(d), they were made heavily dependent on formal help of powerful others. They thus could not manage work, financial or asylum issues personally, which was indicated as being very frustrating and causing “relational problems” and “negative emotions”.“Like me for example, because I’m depressed I never think of having sex, due to long stay at the centre, the problems in relations and discrimination by white Dutch people, you don’t feel well” Many respondents also mentioned “the asylum procedure” as such as a negative influence on their sexual health. The education level influenced this perception and dominates small differences in age, gender and origin. The higher the education attainment, the broader interpersonal and structural factors were indicated as negatively influencing one’s health. People with lower levels of education attainment were more likely to mention individual and intimate interpersonal factors as sexual risk behaviour, relational tension and violence.“Sexual Health is dead in my body” Our results demonstrate that refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands have a fair good understanding of the different aspects comprising sexual health. Moreover, they are also to identify a variety of determinants. Some of these determinants are important requiring consideration in future sexual health promotion research and activities. Given our conceptual framework, we discuss the determinants according to the socio-ecological level they can be classified in.Age does not play a decisive role in defining sexual health in our study population. Both young and adult respondents define sexual health in a rather balanced way identifying aspects of general well-being, a respectful approach of sexual relationships and sexuality, a safe and pleasurable sex life, family planning and fertility and access to information and care. Yet pathways to search for sexual health information differ. Youth indicate their direct environment as primary sexual health source while the health sector, media - preferably internet- and educational institutions share an equal important second place. In identifying determinants, respondents attribute more importance to a safe and satisfying sex life than adults and indicate determinants preferably in the individual and intimate interpersonal level. “A human being is a human being, whether you’re a man or a woman” Gender Although it is often assumed that gender imbalances induced by beliefs, practices and norms of the countries of origin of our respondents might have a negative effect on their sexual health, our results rather confirm earlier findings [findings  that thefindings -42. Howefindings ,43-47. RThe only differences we could find between genders were the explored pathways in search for SHI. Compared to their male counterparts, women and girls tend to address people in their direct environment and especially friends much more. They also prefer media –especially books- more than men who then prefer internet if they indicate media as source of sexual health information. Women also indicated institutions more, preferably educational institutions but also religious ones. Thus, future sexual health promotion activities towards migrants descending from these origins can be gender inclusive when it concerns content. Only the channels through which the messages are conveyed could be diversified to maximize the possibilities of getting the message across.Cultural beliefs and norms that have been equally incorporated by women and men seem to influence their sexual health frame of reference decisively.“In Iran they say you get blind if you masturbate, here they say it’s good for your health” When respondents described criteria for sexual maturity, all stressed the importance of a balanced mental, physical and social development as the most decisive element for both genders. Age and respectful approach were criteria for both girls and boys and were indicated by a third to a fourth of the respondents. Yet, we saw that country of origin clearly influences these findings. Somali and Afghan respondents tended to emphasize the physical development aspects and an earlier age of sexual maturity  more than the others. For them, issues related to sexual debut, fertility and family planning were rarely mentioned, while aspects of respectful approach were stressed. This tendency is consistent with their definition of sexual health whereby aspects of general well-being and a safe and satisfying sex life are mentioned as important aspects to all origins. However, respondents from Somalia, Iraq, Iran and Afghanistan stressed that this should happen within a steady relation (mostly marriage) where one feels respected, trusted and at ease. Yet, for CIS respondents and the Slovakian and Czech Roma ones, family planning seemed to be more of an issue in addition to a general well-being and a safe and satisfying sex life. This confirms literature stating that cultural norms, beliefs and attitudes bolster one’s self-esteem and self-efficacy, provide a coherent structure for interpreting life events  and are The attained education does not influence the perception of sexual maturity criteria, the importance of general well-being, a respectful approach or the personal health responsibility. Yet respondents with no or low education attainment levels tend to diversify their definition of sexual health less. Moreover, they particularly stress individual and intimate interpersonal sexual health determinants and consider family and friends as first sexual health information sources, additionally taking up on info spread by TV. Respondents with higher educational levels considered safety and satisfaction more as well as access to information and care. In addition, they mentioned more organizational and societal determinants and also preferred the health sector above all other sexual health information sources. This indicates that sexual health promotion activities could be more effective if they do not differentiate the content, but rather use other channels whereby migrants with lower education attainment seem to be more susceptible to gaining knowledge through experienced peers , while migrants with higher education attainment give more appraisal to persons who gained their knowledge and expertise through education and profession .Health locus of control Our respondents demonstrated a predominant internal health locus of control as the majority was convinced that one is responsible for shaping and maintaining good sexual health. They were convinced this could be done by having a general healthy life style, using contraceptives, not having multiple sex partners, being informed on risks and prevention strategies and seeing a doctor when necessary. This is in line with earlier findings on internal health locus of control and sexual health [l health -57. Yet,“I have no hope for the future. I live in a reception centre without any contact with other people. I have no money, no work and no contact with girls.” Additionally, given the societal aspects of their restricted legal status which reduce possibilities to participate in Belgian and Dutch society , respondAlthough 80% of the respondents reported to be practicing religion, only very rarely religion was mentioned as a determinant and in the analysis no links could be found either.“Men are very proud if they speak about sex with their friends and it is a declaration of their sex excellence; but for women it is embarrassing to talk about sex. And I don’t think that the religion has an effect here.” This questions the often suggested intervention to set up health promotion campaigns through religious institutions and by religious key people. In our, mostly highly educated, group of respondents it seemed that other institutional and public channels are preferable to address, as there is media, educational bodies and the health sector. Our findings confirm that in addition to traditional channels as TV, radio, books, magazines; it is wise to invest in social media as channels for culturally competent sexual health promotion activities emphasizing a positive, yet critical and balanced approach to sexual health and sexuality, especially when targeting youth ,66. EducFinally, although the respondents demonstrated a predominantly internal health locus of control, most of them emphasized that this personal attitude is challenged, given the structural dependent situation enforced upon them by the current organization of the Belgian and Dutch asylum reception system and migration law.“During this long period refugees are under constant fear, anxiety, stress and other mental disorder. They see no future and end up into drug abuse, frustration, sleeplessness and change of behaviour” They indicated that the asylum system and its procedures brought about stress, sadness and frustration, which they perceive as negatively impacting their sexual health. Moreover, the asylum system also creates barriers to being sexually active. Due to infrastructural limitations, the privacy for couples and families can physically nor emotionally be guaranteed, and both genders are either forced to live together or on the contrary separated from each other, irrespective of what residents would prefer as housing rules. Furthermore, in a lot of reception facilities there are strict rules on receiving guests. This all adds up to unavailability of intimacy and sex opportunities which are perceived as negative factors. Also in other domains of life as seeing a doctor, cooking, managing administration, participation in social activities outside the facilities, work and others; asylum seekers are taken care off and room for autonomy, own initiative or responsibility is heavily reduced. These social, political and practical challenges linked to the Belgian and Dutch asylum reception system dependency force migrants to have a more external passive health locus of control, reduced autonomy, low self-esteem, heightened stress and sexual unavailability. According to literature, these aspects are known to create sexual difficulties in both genders -42,68-70Our results demonstrate that being a refugee, asylum seeker or undocumented migrant in Belgium and the Netherlands is a risk factor for sexual ill-health and confirms that migration and legal status in this matter can be considered a health determinant as such . Yet, asAs a pilot study on sexual health in hard to reach populations, the sampling of the respondents was done through criterion and chain sampling within the networks of the coordinators, the CRs, the CAB members and some asylum reception centres. Although we initiated our search for respondents from a vast pool of primary sources, this sampling method cannot assure a representative sample. In addition, although all CRs participated in the same training, and questionnaires were translated and back-translated, we cannot guarantee that their epistemological perspective while conducting and translating the in-depth interviews might have differed slightly from the ones of the main researchers. Both these elements might induce biases in the data which we consider not generalizable. Yet, we do believe they are transferable to similar populations in comparable settings. Furthermore, this research addressed the main groups of asylum seekers, refugees and undocumented migrants in Belgium and the Netherlands at that time. Therefore, cultural aspects linked to those origins cannot be plainly extrapolated to any other refugee, asylum seeking and undocumented community present in Belgium or the Netherlands.The authors declare that they have no competing interests.IK conducted the research from conception to final reporting of the results to the funding body and coordinated the participatory approach in all phases of the research project in collegiate collaboration with CRs and the CAB. IK also drafted this manuscript. NV, KR and MT participated in the CAB as experts and thus had decisive input in every phase of the research project. They all contributed to the draft of the manuscript and approved the final version.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/14/416/prepub