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Introducción. La pandemia mundial del COVID-19 ha generado una repercusión negativa en la salud mental de la población mundial. Tanto el miedo como la ansiedad han resultado factores comunes en todas las sociedades. El objetivo del estudio es el de analizar el perfil sociodemográfico y clínico de las derivaciones realizadas desde Atención Primaria (AP) a una Unidad de Salud Mental (USM) durante los primeros meses de pandemia y confinamiento en España. Material y métodos. Se ha llevado a cabo un estudio retrospectivo descriptivo transversal mediante un cuestionario ad-hoc, de 105 sujetos, durante los meses de marzo y octubre de 2020. La variable principal de estudio fue si la demanda fue consecuencia de la COVID-19 o no. Las variables secundarias son el perfil sociodemográfico (género, edad, lugar de residencia, hábitos de vida saludable y situación laboral) y el perfil clínico (diagnóstico, principal y secundario y de COVID-19, episodio de recidiva, antecedentes médicos, consumo de sustancias y uso de psicofármacos). Resultados. Los pacientes derivados están principalmente diagnosticados de ansiedad y depresión, y consideran la COVID-19 como la principal causante de su malestar mental si son personas que residen en un núcleo urbano, si su diagnóstico principal era hipocondría, o si no consumían sustancias. Discusión. Las consecuencias de la pandemia COVID-19 pueden varias según el perfil sociodemográfico y clínico de la población, por tanto, tienen que ser estudiadas más a fondo, sobre todo en pacientes con problemas de salud mental previos.

Purpose Health factors that enhance an individual's ability to perceive and maintain health and well-being are referred to as "health assets". Of these assets, resilience, mindfulness and self-compassion are considered to be of special importance. The objective of this study was to analyze the association between these psychological constructs on the perception of physical and mental health in a general population. Patients and methods A descriptive and analytical cross-sectional study was conducted with 845 participating subjects. The outcome variable was the individual´s perception of physical and mental health, measured using the SF-36 questionnaire. The independent variables were: sociodemographic variables, medical information, physical activity performance (using the International Physical Activity Questionnaire), tobacco and alcohol consumption, anxiety and/or depression (using the Goldberg Anxiety and Depression Scale), resilience (using the Connor-Davidson Resilience Scale), mindfulness (with the Five Facets of Mindfulness Questionnaire Short Form) and self-compassion (using the Self-compassion scale-short form). A correlation analysis, simple linear regression and multiple linear regression were carried out, controlling for the influence of the distinct independent variables. Results The constructs of resilience, mindfulness and self-compassion are significant, in the perception of both physical and mental health. Other factors appearing in the multiple regression are gender, age, educational level, physical activity and tobacco consumption, in a positive or negative sense. Conclusion The study of these associations is fundamental for the understanding of underlying regulation processes of healthy lifestyles in the general population.

Objective: To analyse the effect of general and specific self-efficacy on the adherence to a gluten free diet (GFD) in patients with celiac disease along with the effect of other relevant variables...

There is currently little scientific evidence available that allows us to understand patterns of knowledge, risk perception, attitudes, and behaviours among adolescents in relation to COVID-19. This study aims to analyse the relationship between knowledge about COVID-19, risk perception, and psychological variables and the adherence to preventive measures among the adolescent population. It is a descriptive cross-sectional study, which included adolescents between the ages of 12 and 18 (n = 354). The questionnaire was sent to several secondary schools chosen by convenience sampling and following a non-probabilistic snowball sampling. Descriptive, univariate, and multivariate analyses were carried out in order to determine whether knowledge about COVID-19, risk perception, tolerance of frustration, planning and decision-making, family functionality, self-efficacy, self-esteem, and social skills are related to preventive measures. The adoption among adolescents of behaviours which protect them against COVID-19 depends on knowledge about the disease, the perception of the risk it poses to them, as well as their tolerance of frustration and planning and decision-making abilities. The relationship between the individual variables among adolescents with the adoption of behaviours which protect them against COVID-19 has been confirmed. The development of intervention and communication strategies that take the psychosocial situation of adolescents into account will help to increase the adoption of protective health behaviours in the context of a pandemic.

Resumen Introduccion Existe una elevada variabilidad en la adecuacion de las solicitudes de determinaciones de laboratorio para el diagnostico y seguimiento de la hipertension arterial, la dislipemia y la diabetes mellitus (factores de riesgo cardiovascular), siendo esta una de las actividades preventivas y asistenciales mas importantes y numerosas que se llevan a cabo en atencion primaria (AP). El objetivo del presente estudio fue analizar la variabilidad en la adecuacion existente en los procedimientos analiticos solicitados rutinariamente por los medicos de AP en relacion con el diagnostico y seguimiento de la hipertension arterial, la dislipemia y la diabetes mellitus, y valorar comparativamente los costes de dichas solicitudes analiticas rutinarias y las alternativas propuestas por la evidencia. Material y metodos Estudio transversal, retrospectivo, descriptivo desarrollado en el sector sanitario de Teruel (75.800 habitantes: 50,20% hombres y 49,80% mujeres), 24,20% mayores de 65 anos, distribuidos en 17 equipos de AP, en el ano 2012. Resultados Se han procesado un total de 725.179 determinaciones analiticas. Se realizaron 174.608 determinaciones en el seguimiento de las patologias de estudio, de las que el 69,74% no estaban justificadas por los protocolos de seguimiento. El nivel de control analitico de las tres patologias estudiadas es bajo, y las analiticas solicitadas difieren muy poco entre si. Conclusiones La diferencia entre lo que la evidencia determina que debe solicitarse para el diagnostico y seguimiento de la hipertension arterial, la dislipemia y la diabetes mellitus presenta un elevado porcentaje y coste asociado, dejando patente la necesidad de mejorar en la utilizacion de los recursos sanitarios.

Cardiovascular events pose a major health problem worldwide. Smoking, hypertension, dyslipidemia and diabetes mellitus are considered essential cardiovascular risk factors. There is a high variability in laboratory determinations application in medical practice, including the disparity of criteria in analytical determinations to control these diseases. The aim is to summarize the available scientific evidence on the different routine analytical procedures recommended in the diagnosis and control of dyslipidemia, diabetes and hypertension. A bibliographic review of the existing literature about recommendations of the main scientific societies and organizations, national and international, about precise laboratory determinations for diagnosis, monitoring and control of these diseases was performed. A total of 34 documents were obtained, once scientific evidence and quality of them revised, the analysis focused on six documents. The main recommendations are: a) diabetes: baseline fasting plasma glucose, glycosylated hemoglobin, lipid profile, creatinine, urinalysis, urine sediment, microalbuminuria, electrolytes; annual. b) Dyslipidemia: complete lipid profile; based on annual or LDL- cholesterol basis. If statin therapy: transaminases, creatine phosphokinase. c) Hypertension: glucose, total cholesterol, creatinine and systematic urinalysis; lipid profile, uric acid, electrolytes and microalbuminuria; annual. These recommendations are intended to assist in improving the application of analytical procedures on what scientific evidence recommends, trying to reduce variability.

Background: Celiac disease (CD) is an autoimmune chronic enteropathy of the small intestine caused by exposure to gluten in genetically predisposed individuals. CD is not easy to diagnose due to its unspecific symptomatology, especially in adults, a diagnosed/undiagnosed ratio of 1:7 is estimated. CD does not have its own code in the International Classification of Primary Care (ICPC) but it is coded under code D99 “Disease digestive system, other”, which hinders diagnosis, intervention and research. The aim of this study is to investigate the prevalence of CD in Arago´n, Spain, using the information available from Primary Care, as well as to discuss the difficulties involved in determining prevalence of CD from data collected at this level of medical intervention. Methods: We designed an epidemiological cross-sectional study and analysed 26,964 electronic clinical records from the Aragonese Health Service under code ICPC D99 collected up to December 31st, 2016. The clinical records were classified by their editable field “descriptor” according to their probability of being related to CD. Analyses of gender, age, age at diagnosis, province and health sector were carried out. Results: We found 4534 clinical records under 293 different descriptors with a high probability of referring to CD. Prevalence in Arago´n was estimated to be 0.35% ranging from 0.24 to 0.81% with important differences among health sectors. Conclusions: The prevalence of 0.35% is a long way from the generally accepted 1% but within the usually considered ratio 1:7 of diagnosed:undiagnosed cases. Differences among sectors should be carefully analysed. Lacking its own ICPC code, diagnosis of CD in Primary Care Services is not included in a single category, but it is distributed under several descriptors, which makes it difficult to offer any firm diagnosis for treatment and hinders research. Finally, the high prevalence of CD justifies its own ICPC code and the need to withdraw CD from the generic D99 code “Disease digestive system other”.

The validation of Five Facets Mindfulness Questionnaire (FFMQ)—short version was performed in a general population of a city in a region of Galicia (Spain), the sample was composed of randomly selected Spanish Health Care patients (N = 845). The results on the goodness of fit of the non-hierarchical, five-dimensional factorial model met the criteria for good and acceptable model adjustment (after eliminating item 18 and despite the correlations detected among the errors included in the model), explaining a 55.5%.of the variance. As the second objective has been analysed the association between the scores obtained in the different facets of the FFMQ-SF and the risk of suffering an episode of depression. (The Odd Ratio, the Hosmer-Lemeshow test and the ROC curve were calculated.) Participants who were currently suffering from an episode of depression were more likely to have low scores in "describing" facet of Mindfulness (adjusted OR = 1.58, 95% CI = 1.04–2.40, linear trend: ¿2 = 3.74, df = 1, p = 0.053) as well as low scores on "acting with awareness" (adjusted OR = 2.19, 95% CI = 1.461–3.30, linear trend: ¿2 = 9.52, df = 1; = 0.002) and "non judging" (adjusted OR = 2.05, 95% CI = 1.36–3.09, linear trend: ¿2 = 143.21, df = 1; p < 0.001). Participants with a previous episode of depression were more likely to have low scores on the subscale "acting with awareness" (adjusted OR = 2.37, 95% CI = 1.43–3.93, linear trend: ¿2 = 9.62, df = 1, p = 0.002) and "non-reactivity" (adjusted OR = 2.14, 95% CI = 1.28–3.56, linear trend: ¿2 = 8.30; df = 1; p = 0.004. Questionnaire FFMQ-SF is an adequate questionnaire for the evaluation of mindfulness in non-clinical multi- occupational population.

BackgroundPrimary health care (PHC) is the ideal setting to provide integrated services centred on the person and to implement health promotion (HP) activities. ObjectiveTo identify proposals to approach HP in the context of primary care according to health-care users aged 45-75years, key community informants and primary care centre (PCC) workers. MethodsDescriptive-interpretive qualitative research with 276 participants from 14 PCC of seven Spanish regions. A theoretical sampling was used for selection. A total of 25 discussion groups, two triangular groups and 30 semi-structured interviews were carried out. A thematic interpretive contents analysis was carried out. ResultsParticipants consider that HP is not solely a matter for the health sector and they emphasize intersectoral collaboration. They believe that it is important to strengthen community initiatives and to create a healthy social environment that encourages greater responsibility and participation of health-care users in decisions regarding their own health and better management of public services and resources. HP, care in the community and demedicalization should be priorities for PHC. Participants propose organizational changes in the PCC to improve HP. PCC workers are aware that HP falls within the scope of their responsibilities and propose to increase their training, motivation, competences and knowledge of the social environment. Informants emphasize that HP should be person-centred approach and empathic communication. HP activities should be appealing, ludic and of proven effectiveness. ConclusionsAccording to a socio-ecological and intersectoral model, PHC services must get actively involved in HP together with community and through outreach interventions., This project has been funded by the Carlos III Health Institute (Ministry of Economy and Competitiveness, Spain) with a grant for research projects on health (PI12/01914; PI12/00616; PI12/02608; PI12/01974; PI12/02774; PI12/02635; PI12/02379) through the Network for Prevention and Health Promotion in Primary Care (redIAPP, RD12/0005/0001) and by European Union ERDF funds.

Employees working in the hospitality industry are constantly exposed to occupational stressors that may lead employees into experiencing burnout syndrome. Research addressing the interactive effects of control, community and value congruence to alleviate the impact of workplace demands on experiencing burnout is relatively limited. The present study examined relationships among control, community and value congruence, workplace demands and the three components of burnout. A sample of 418 employees working in a variety of hospitality associations including restaurants and hotels in Spain were recruited. Moderation analyses and linear regressions analyzed the predictive power of control, community and value congruence as moderating variables. Results indicate that control, community and value congruence were successful buffers in the relationships between workplace demands and the burnout dimensions. The present findings offer suggestions for future research on potential moderating variables, as well as implications for reducing burnout among hospitality employees.

Background: Although some articles have analysed the definitions of health and health promotion from the perspective of health-care users and health care professionals, no published studies include the simultaneous participation of health-care users, primary health care professionals and key community informants. Understanding the perception of health and health promotion amongst these different stakeholders is crucial for the design and implementation of successful, equitable and sustainable measures that improve the health and wellbeing of populations. Furthermore, the identification of different health assets and deficits by the different informants will generate new evidence to promote healthy behaviours, improve community health and wellbeing and reduce preventable inequalities. The objective of this study is to explore the concept of health and health promotion and to compare health assets and deficits as identified by health-care users, key community informants and primary health care workers with the ultimate purpose to collect the necessary data for the design and implementation of a successful health promotion intervention. Methods: A descriptive-interpretive qualitative research was conducted with 276 participants from 14 primary care centres of 7 Spanish regions. Theoretical sampling was used for selection. We organized 11 discussion groups and 2 triangular groups with health-care users; 30 semi-structured interviews with key community informants; and 14 discussion groups with primary health care workers. A thematic content analysis was carried out. Results: Health-care users and key community informants agree that health is a complex, broad, multifactorial concept that encompasses several interrelated dimensions (physical, psychological-emotional, social, occupational, intellectual, spiritual and environmental). The three participants' profiles consider health promotion indispensable despite defining it as complex and vague. In fact, most health-care users admit to having implemented some change to promote their health. The most powerful motivators to change lifestyles are having a disease, fear of becoming ill and taking care of oneself to maintain health. Health-care users believe that the main difficulties are associated with the physical, social, working and family environment, as well as lack of determination and motivation. They also highlight the need for more information. In relation to the assets and deficits of the neighbourhood, each group identifies those closer to their role. Conclusions: Generally, participants showed a holistic and positive concept of health and a more traditional, individual approach to health promotion. We consider therefore crucial to depart from the model of health services that focuses on the individual and the disease toward a socio-ecological health model that substantially increases the participation of health-care users and emphasizes health promotion, wellbeing and community participation., This work was supported by the Carlos III Health Institute (Ministry of Economy and Competitiveness, Spain) with a grant for research projects on health (PI15/00114) through the Network for Prevention and Health Promotion in Primary Care (redIAPP, RD16/0007), and by European Union ERDF funds.

espanolAntecedentes y objetivos: la dieta sin gluten es, hasta la fecha, el unico tratamiento para la enfermedad celiaca, pero revisiones sistematicas indican que solo entre un 42% y un 91% de los pacientes siguen la dieta estrictamente, dependiendo del metodo de evaluacion y de la definicion de adherencia. Es importante contar con herramientas adaptadas transculturalmente que permitan evaluar la adherencia mas alla de preguntas autoinformadas o de invasivas analiticas. El objetivo es adaptar transculturalmente y validar el Celiac Dietary Adherence Test de Leffler a la poblacion espanola en lengua castellana. Metodos: estudio transversal observacional en dos fases: una primera de traduccion/retrotraduccion por cuatro traductores cualificados y una fase de validacion en la que se aplico el cuestionario a 306 pacientes de Aragon con enfermedad celiaca entre los 12 y los 72 anos. Se evaluaron la estructura factorial, la validez de criterio y la consistencia interna. Resultados: la traduccion al castellano mantuvo sus 7 items con una estructura de 3 factores. La factibilidad fue muy buena con todas las preguntas contestadas y con efectos suelo y techo muy bajos (4,3% y 1%, respectivamente). La correlacion de Spearman con las escalas de autoeficacia y calidad de vida y la pregunta autoinformada resultaron estadisticamente significativas (p Conclusion: la adaptacion espanola del CDAT muestra unas propiedades psicometricas adecuadas, por lo que su uso estaria indicado para el estudio de la adherencia a la dieta sin gluten en entornos clinicos y de investigacion. EnglishBackground and aims: A gluten-free diet is to date the only treatment available to celiac disease sufferers. However, systematic reviews indicate that, depending on the method of evaluation used, only 42% to 91% of patients adhere to the diet strictly. Transculturally adapted tools that evaluate adherence beyond simple self-informed questions or invasive analyses are, therefore, of importance. The aim is to obtain a Spanish transcultural adaption and validation of Leffler’s Celiac Dietary Adherence Test. Methods: A two-stage observational transversal study: translation and back translation by four qualified translators followed by a validation stage in which the questionnaire was administered to 306 celiac disease patients aged between 12 and 72 years and resident in Aragon. Factorial structure, criteria validity and internal consistency were evaluated. Results: The Spanish version maintained the 7 items in a 3-factor structure. Feasibility was very high in all the questions answered and the floor and ceiling effects were very low (4.3% and 1%, respectively). The Spearman correlation with the selfefficacy and life quality scales and the self-informed question were statistically significant (p Conclusion: The Spanish version of the Celiac Dietary Adherence Test shows appropriate psychometric properties and is, therefore, suitable for studying adherence to a gluten-free diet in clinical and research environments.

La resiliencia se caracteriza por un afrontamiento efectivo de los eventos estresantes y depende de las características específicas de las situaciones estresantes y de los individuos, así como de la interacción de la persona y su entorno humano. La resiliencia en salud se ha conceptualizado como la capacidad de mantener una buena salud en medio de una gran adversidad, capacidad que puede emerger en el desarrollo relacional, adquiriéndose en el ambiente. Es escasa la investigación llevada a cabo sobre relaciones establecidas entre la resiliencia y la salud física; sin embargo, es amplia la investigación en resiliencia y salud mental, centrada principalmente en variables psicológicas y patologías como el estrés, la ansiedad y la depresión. Este trabajo realiza una revisión, desde los conocimientos actuales, del impacto positivo para la salud física y mental de la resiliencia.

Background: Celiac disease is a chronic autoimmune disorder consisting of a permanent intolerance for gluten, with a prevalence of 1%, for which the only treatment to date is to follow a strict gluten free diet for life. Lack of adherence to this treatment is related to severe health problems while compliance leads to normalization. Recently, self-efficacy has been associated with self-management behaviors in chronic disease and health status in many fields.Aims: To construct and validate a self-administered scale to measure self-efficacy in adherence to gluten free diet in the different areas a patient with celiac disease must face everyday.Material and Methods: For the validation phase, the research team aims to recruit 500 celiac individuals over 12 years of age from primary care services and patient associations. The scale will be designed to explore specific self efficacy to adhere to a gluten free diet in the following areas: purchases, eating out, eating at home with others, travelling and at work or school. An expert panel will be conducted to assure quality of the items and utility of the scale. The preliminary form will be tested in as many pilot studies as necessary. An exploratory factor analysis will be applied to study construct validity while concurrent validity will be measured with the correlation coefficient between the new instrument and the Baessler and Schwarzer General Self Efficacy Scale. The reliability of the instrument as well as that of each of the factors extracted from the prior analysis will be analyzed using Cronbach’s alpha internal consistency coefficient. Two weeks later, the scale will be administered to, at least, one third of the sample as a retest in the validation process and to allow for confirmatory factor analysis.Results: This research will design, develop and validate a questionnaire for two types of measures: A score for Self-Efficacy for the management of celiac disease, and a score of self-efficacy for each of the identified key areas. This research will result in the first scale to assess specific self efficacy while following a strict gluten free diet and will allow further research in the role that this expectation may play in patient´s adherence to the unique treatment developed to date and it may be useful in both clinical and research settings. The new scale will be easy to apply and it is expected to have a higher predictive value than instruments assessing general self-efficacy.Conclusions: This questionnaire will be the first of its kind to determine levels of self-efficacy for adherence to gluten free diet and will help to the design of self-management interventions for celiac patients.

Background Burnout is the result of prolonged workplace exposure to chronic stress factors and may present itself in one of the following subtypes: “frenetic”, “under-challenged” and “worn-out”. The aims of the present study were to identify the causes of workplace discomfort that affect employees in large organizations and to determine the predictive power of these causes with regard to the burnout subtypes. Method We employed a qualitative and quantitative analysis (QQA), using a cross-sectional design with an online survey administered to a randomly selected sample of University workers (n = 409). To determine the causes of discomfort, we raised the following open question: “What aspects of your work generate discomfort for you?”. The responses were subjected to content analysis and categorized by three independent referees. The concordance between the responses was estimated with the kappa coefficient (k). Subtype classification was assessed according to the “Burnout Clinical Subtype Questionnaire” (BCSQ-36). The degree of association between the motives for the complaint and the burnout profiles was evaluated using adjusted odds ratio (OR), which was based on multivariate logistic regression models. Results The causes of discomfort included: physical environment (setting aspects, material conditions, journey/access), organization (schedules, structure, functions, interpersonal relations) and individual conditions (workload, powerlessness, rewards, negligence). The concordance index between the referees was k = 0.80. Employees who were upset with the hierarchical structure were more likely to be classified as frenetic (OR = 4.32; 95% CI = 1.43-13.06; p = 0.010); those who complained of routine duties were more likely to be classified as under-challenged (OR = 5.33; 95% CI = 1.84-15.40; p = 0.002); those whose discomfort was caused by structure control systems were more likely to be classified as worn-out (OR = 6.13; 95% CI = 1.57-23.91; p = 0.009). Conclusions The causes of discomfort among the different burnout subtypes are primarily attributable to the organization itself, in response to the structure and functions. The associations observed between the different subtypes and motives for complaint are consistent with the clinical profile-based syndrome definition, which suggests that interventions should be case-specific.

[EN] The rate at which the phenomenon of child-to-parent violence occurs appears to be increasing. In the present study a non-experimental, descriptive and transversal design was used. Data collection was made using surveys, psychological tests and questionnaires applied to parents, minors, at-risk youth counsellors and child adolescent mental health services professionals in the provinces of Zaragoza and Huesca, Spain. The main results are: the minors who committed child-to-parent violence were adolescent males; the victims were mostly mothers; this phenomenon did not occur more frequently in the immigrant population; more cases occurred in families with lower income levels; adoption may have been a characteristic feature of these families, but not the separation of the parents; these adolescents presented problems at school and attention deficit hyperactivity disorder and also took drugs; intimate partner violence and child abuse were present. The application of different rehabilitation measures by the pertinent child protection services was verified. The most commonly used psychotherapy was family therapy; the number of minors on pharmacological treatment appeared to be high. The findings will serve as a guide for guiding intervention and tailor services to the needs of these children and their families, [ES] La incidencia del fenómeno de la violencia filio-parental parece estar aumentando. Se ha utilizado un diseño descriptivo y transversal. La recogida de datos se ha realizado con encuestas, tests psicológicos y cuestionarios, aplicados a padres, menores, educadores de servicios sociales y profesionales de Salud Mental Infanto-Juvenil de Zaragoza y Huesca, España. Los principales resultados encontrados son: los menores agresores son varones adolescentes; la madre es la persona más agredida; existen más casos de familias con niveles socioeconómicos bajos; la adopción puede ser un elemento característico de estas familias, pero no, la separación de los padres; estos adolescentes presentan problemas escolares y trastorno de hiperactividad con déficit de atención, asimismo consumen drogas; la violencia de género y el maltrato infantil están presentes. Además, se ha comprobado que se aplican diferentes medidas rehabilitadoras siendo el modelo de psicoterapia más utilizado el sistémico familiar y parece elevado el número de menores con tratamiento farmacológico. Los hallazgos obtenidos servirán de guía para orientar la intervención y ajustar los servicios a las necesidades de estos menores y de sus familias, Este estudio es un Proyecto de investigación FIS, financiado por el Instituto de Salud Carlos III de Madrid y el Instituto Aragonés de Ciencias de la Salud (Programa I+D+I). Esta investigación se ha realizado dentro del proyecto FIS PI071043 subvencionado por Instituto de Salud Carlos III

Background Perceived incongruity between the individual and the job on work-life areas such as workload, control, reward, fairness, community and values have implications for the dimensions of burnout syndrome. The “Areas of Work-life Scale” (AWS) is a practical instrument to measure employees´ perceptions of their work environments. AIMS: Validate a Spanish translation of the AWS, and it relationship with Masclach Burnout Inventory dimensions. Methods The study was conducted in three medium-sized hospitals and seven rural and urban Primary Care centres (N = 871) in Spain. The “Maslach Burnout Inventory General Survey” (MBI-GS) and AWS were applied. We developed a complete psychometric analysis of its reliability, and validity. Results Data on the reliability supported a good internal consistency (Cronbach α between .71, and .85). Construct validity was confirmed by a six factor model of the AWS as a good measure of work environments (χ2(352) = 806.21, p