scholarly journals Hubungan Penggunaan APD Terhadap Angka Kejadan Infeksi Nasokomial Pada Pasien Rawat Inap Di RSUD Alimuddin Umar Liwa Kabupaten Lampung Barat

2021 ◽  
Vol 3 (3) ◽  
pp. 353-364
Author(s):  
Andoko Andoko ◽  
M. Arifki Zainaro ◽  
Ismanto Nasim

ABSTRACT: RELATIONSHIP OF THE USE OF PPE TO THE INCIDENCE OF NOSOCOMIAL INFECTION IN INPATIENTS AT ALIMUDDIN HOSPITAL, UMAR LIWA, LAMPUNG BARAT DISTRICT Introduction: After conducting an in-depth survey, it was found that out of 53 medical personnel, it was found that 22 (41.5%) medical personnel did not comply with the use of PPE, and 31 (58.5%) medical personnel always complied. with the use of PPE.Purpose: The purpose of this study was to determine the relationship between the use of PPE with the prevalence rate of nosocomial infections in inpatients at Alimuddin Umar Liwa Hospital, West Lampung Regency in 2020.Methods: The type of research used in this research is quantitative with an analytic design, namely research that explores how and why health phenomena occur using a cross-sectional approach. The population in this study were all nurses at Alimuddin Umar Liwa Hospital, West Lampung Regency, totaling 96 people. The sample in this study amounted to 96 people. In this study, the sampling technique used was total sampling.Results: It is known that in the Alimuddin Umar Liwa Regional Hospital, West Lampung Regency in 2020, most of the respondents used bad PPE, namely 54 respondents (56.3%), and most of the respondents were at risk of experiencing nosocomial infections, amounting to 50 respondents (52.1%)Conclusion: Based on the results of statistical tests, the p-value is 0.000 or p-value <0.05, which means that there is a relationship between the use of PPE and the prevalence of nosocomial infections in hospitalized patients in the Alimuddin Umar Liwa area. West Lampung District Hospital 2020. The results of this study are expected. so that it becomes an input for Alimuddin Umar Hospital regarding the Relationship between the Use of PPE and the Occurrence of Nasocomial Infection in Inpatients so that with the use of good PPE it is hoped that the incidence of HAI can be resolved properly by giving warnings or even sanctions to nurses if they do not use PPE, as well as more supervision of nurses in using PPE. Keywords: Use of Personal Protective Equipment & Incidence Rate of Nasocomial Infection  INTISARI: HUBUNGAN PENGGUNAAN APD TERHADAP ANGKA KEJADAN INFEKSI NASOKOMIAL PADA PASIEN RAWAT INAP DI RSUD ALIMUDDIN UMAR LIWA KABUPATEN LAMPUNG BARAT Pendahuluan : Setelah dilakukan survey lebih dalam diketahui dari 53 tenaga medis, diketahui 22 (41,5%) tenaga medis tidak patuh terhadap penggunaan APD, dan 31 (58,5%) tenaga medis selalu patuh dengan penggunaan APD.Tujuan: tujuan dalam penelitian ini adalah Diketahui Hubungan Penggunaan APD Terhadap Angka Kejadan Infeksi Nasokomial Pada Pasien Rawat Inap Di RSUD Alimuddin Umar Liwa Kabupaten Lampung Barat Tahun 2020.Metode : Jenis penelitian yang digunakan dalam penelitian ini adalah kuantitatif dengan rancangan analitik yang artinya penelitian yang menggali bagaimana dan mengapa fenomena kesehatan itu terjadi, dengan menggunakan pendekatan cross sectional. Populasi dalam penelitian ini adalah seluruh perawat pelaksanaan Di RSUD Alimuddin Umar Liwa Kabupaten Lampung Barat yang berjumlah 96 orang. Sampel dalam penelitian ini berjumlah 96 orang. Dalam penelitian ini teknik sampling yang digunakan adalah Total Sampling. Hasil : Diketahui bahwa Di RSUD Alimuddin Umar Liwa Kabupaten Lampung Barat Tahun 2020, sebagian besar responden menggunakan APD kurang baik yang berjumlah 54 responden (56,3%) dan sebagian besar responden berisiko mengalami infeksi nasokomial yang berjumlah 50 responden (52,1%)Kesimpulan : Berdasarkan hasil uji statistik, didapatkan p-value 0,000 atau p-value < 0,05 yang artinya terdapat Hubungan Penggunaan APD Terhadap Angka Kejadan Infeksi Nasokomial Pada Pasien Rawat Inap Di RSUD Alimuddin Umar Liwa Kabupaten Lampung Barat Tahun 2020. Hasil penelitian ini diharapkan agar menjadi bahan masukan bagi RSUD Alimuddin Umar tentang Hubungan Penggunaan APD Terhadap Angka Kejadan Infeksi Nasokomial Pada Pasien Rawat Inap, sehingga dengan penggunaan APD yang baik diharapkan angka kejadian HAIs dapat di atasi dengan baik dengan cara memberikan peringatan atau bahkan sanksi kepada perawat jika tidak menggunakan APD, serta lebih melakukan pengawasan terhadap perawat dalam penggunaan APD. Kata Kunci: Penggunaan Alat Pelindung Diri & Angka Kejadian Infeksi Nasokomial

2020 ◽  
Vol 2 (1) ◽  
pp. 24
Author(s):  
Larasajeng Permata Sari ◽  
Sarwinanti Sarwinanti ◽  
Sittti Nur Djannah

Maternal deaths in Yogyakarta Special Region are caused by heart disease, bleeding, eclampsia, sepsis/infection. Bleeding is still the number one causes of maternal death. Pregnancy with anaemia is 5 times more at risk of bleeding than who are not. The aims of the research are to determine the relationship of nutritional status with anaemia in pregnant women in Kotagede II Yogyakarta Public Health Center.  This was an observational analytic design and a cross-sectional approach. The sampling method uses accidental sampling technique. The number of respondents was 77 pregnant women in the second and third trimester. The research instrument used questionnaire sheets and medical records. Data were processed by Chi-Square statistical tests. Study found   (p-value) of nutritional status = 0.001.  The conclusion of this study is that there was a significant relationship between nutritional status with the incidence of anaemia at Kotagede II Yogyakarta Health Center 


2018 ◽  
Vol 3 (3) ◽  
pp. 500
Author(s):  
Desmariyenti Desmariyenti ◽  
Nelfi Sarlis ◽  
Rima Fitriani

<p><em>Good weaning time is done at the age of the child reaches 2 years. Weaning at less</em><em> </em><em>than 2 years of age can cause problems in children such as incidence of infectious diseases, especially increased diarrhea, nutritional effects that lead to malnutrition in children and cause the relationship of children and mothers is reduced </em><em>closeness </em><em>because bounding attachment process is disrupted. This study aims to determine the relationship between knowledge  and  attitude  of  the  mother  with  the  decision  of  weaning  time  in</em><em> </em><em>Tangkerang Timur Work Area Puskesmas Tenayan Raya. This research was conducted in </em><em>Mei</em><em>-</em><em>J</em><em>uni 2017 and this research using research type is quantitative data with research design  using  cross  sectional.  Sampling  technique  using  Stratified  random  sampling, population in this study amounted to 368 people and samples 18</em><em>4</em><em> p</em><em>e</em><em>ople in East Tangkerang Village. The analysis used is univariate and bivariate. The result of this research is can be concluded that there is significant relation between knowledge with time weaning (p-value 0,000 &lt;0,05), there is significant relation between attitude with time weaning (p-value 0,000 &lt;0,05). Mothers exclusively breastfeed to their babies until 6 months of age and and continue with breastfeeding until 24 months of age.</em><em></em></p><p> </p><p>Waktu penyapihan yang baik dilakukan pada usia anak mencapai 2 tahun. Penyapihan yang dilakukan pada usia kurang dari 2 tahun dapat menyebabkan masalah pada anak seperti insiden penyakit infeksi terutama diare meningkat, pengaruh gizi yang mengakibatkan malnutrisi  pada  anak  dan  menyebabkan  hubungan  anak  dan  ibu  berkurang  keeratannya karena proses bounding attachment terganggu. Penelitian ini bertujuan untuk mengetahui hubungan antara pengetahuan dan sikap ibu dengan keputusan waktu penyapihan di Keluraan Tangkerang Timur Wilayah Kerja Puskesmas Tenayan Raya. Penelitian ini dilakukan pada bulan Mei-Juni tahum 2017 dan penelitian ini menggunakan jenis penelitian adalah data kuantitatif dengan  desain penelitian menggunakan  cross sectional. Teknik sampling menggunakan Stratified random sampling, Populasi dalam penelitian ini berjumlah 368 orang dan sampel 184 orang di Kelurahan Tangkerang Timur. Analisa yang diunakan adalah univariat dan bivariat. Hasil penelitian didapatkan bahwa ada hubungan bermakna antara pengetahuan dengan waktu penyapihan (p-value 0,000&lt; 0,05), ada   hubungan   bermakna   antara   sikap   dengan   waktu   penyapihan   (p-value   0,000   &lt;0,05). Diharapkan ibu memberikan ASI eksklusif pada bayinya sampai usia 6 bulan dan dan dilanjutkan dengan MPASI sampai usia 24 bulan.</p>


2020 ◽  
Vol 5 (1) ◽  
pp. 36-42
Author(s):  
Yeviza Puspitasari

Hyperbilirubinemia is one of the clinical phenomena most often found in neonates occurring in the first week of life, which is also one of the factors causing infant death is influenced by the immature liver function of the baby to process erythrocytes (red blood cells), resulting in the accumulation of bilirubin. The purpose of this study was to determine the relationship of birth weight of infants with the incidence of hyperbilirubinemia in RSUD dr. Ibnu Soetowo Baturaja Ogan Komering Ulu Regency in 2019. This study uses analytic methods with a cross-sectional approach. The study population was all infants aged 0-7 days in the neonatal room at RSUD dr. Ibnu Soetowo Baturaja Ogan Komering Ulu Regency in 2019, with a random sampling. Data analysis uses univariate analysis and bivariate analysis using distribution tables and Chi-Square statistical tests, with a 95% confidence level. In the univariate analysis, of 203 respondents found 26.5% had hyperbilirubinemia and those without hyperbilirubinemia 72.5%, 24.6% of infants with LBW and non-LBW infants 75.4%. Bivariate analysis showed that there was an LBW relationship with the incidence of hyperbilirubinemia (p-value 0,000).


2020 ◽  
Vol 11 (1) ◽  
pp. 110-119
Author(s):  
Julianto Julianto ◽  
Izma Daud ◽  
Sari Milyati

Abstrak  Latar Belakang :Access block adalah situasi dimana pasien yang mengalami lama rawat di IGD 6 karena kurangnya akses ke ruang rawat inap dan kepadatan jumlah pasien yang tidak terkendali, dampaknya ditemukan bahwa semakin lama access block  semakin tinggi pula perburukan pasien dalam 24 jam.Tujuan : ini bertujuan untuk mengetahui hubungan access block dengan perburukan kondisi pasien di Instalasi Gawat Darurat RSUD Ulin Banjarmasin.Metode :Penelitian menggunakan desain analitik dengan pendekatan cross sectional. Jumlah sampel yang diambil berjumlah 40 orang dengan teknik pengambilan accidental sampling. Analisis data melalui uji spearman rank.Hasil : Hasil uji dipapatkan nilai p hitung 0,000 (0,05) ada hubungan antara access block dengan perburukan kondisi pasien di instalasi gawat darurat RSUD Ulin Banjarmasi.Simpulan: Berdasarka hasil penelitian Ada hubungan antara access block dengan perburukan kondisi pasien di Instalasi Gawat Darurat RSUD Ulin Banjarmasin dengan nilai P= 0,000 nilai α = 0,05 dengan nilai koefisien korelasi 0,588 Kata kunci: Access Block, Perburukan Pasien. Abstract Background :Access block is a situation where patients who experience length of stay in the ED 6 due to lack of access to the inpatient room and uncontrolled density of patients, it is found that the longer the access block the higher the deterioration of patients in 24 hours.Purpose: This study aims to determine the relationship of access block with deteriorating condition of patients in Emergency Installation Ulin Hospital Banjarmasin.Method : The research method uses an analytical design with a cross sectional approach. The number of samples taken is 40 people using the accidental sampling technique. Data analysis through spearman rank test.Result: The test results obtained p value calculated 0,000 (0.05) there is a relationship between the access block and deterioration of the patient's condition at the Ulin Banjarmasin Hospital emergency department.Conclusion: Based on the results of the study, there is a relationship between the access block and the worsening of the patient's condition at the Emergency Department of RSUD Ulin Banjarmasin with a value of P = 0.000 value α = 0.05 with a correlation coefficient value of 0.588. Keywords: Access Block, Patient worsening 


2020 ◽  
Vol 2 (1) ◽  
pp. 31-36
Author(s):  
Wa Ode Hajrah ◽  
Niken Purbowati ◽  
Novia Nuraini

erineal rupture needs attention because it can cause dysfunction of the female reproductive organs, as a source of bleeding, a source, or a way in and out of infection, then it can cause death due to bleeding or sepsis. About 85% of Women who delivery vaginally experience perineal rupture, in the age group 25-30 years 24%, while in maternal age 32-39 years by 62%. In Asia, perineal rupture is also a problem in society, 50 % of the world's occurrence is in Asia. The study aims to determine the relationship of maternal factors to the position of the second stage labor and perineal rupture occurrence. This research applied a descriptive-analytic method using a cross-sectional research design. The research sample was 102 respondents, accidental random sampling, which was all labor with perineal rupture in July to November 2018. Statistical tests used chi-square. The results of perineal rupture with maternal age was p-value 0.042 (p <0.05), perineal rupture with maternal parity was p-value 0.01 (p <0.05). Suggestions for various maternal positions in maternity and ANC classes to prevent perineal rupture.


2021 ◽  
Vol 8 (2) ◽  
pp. 74-79
Author(s):  
Andi Syintha Syintha Ida ◽  
Nurjaya Nurjaya ◽  
Andi Ika Abriani

  Background: Pre-eclampsia is one of the factors causing high maternal and infant mortality rates, especially in developing countries such as Indonesia and this will continue to increase if efforts to prevent not being qualified and professional, one of the treatments of pre-eclampsia is the act of Cesarean section  which for medical personnel is the main choice to save the mother and fetus, because longer delays in delivery will cause serious harm to the mother, fetus or. Purpose: toknow the relationship of Pre-eclampsia with the number of incidents Cesarean section Method: Design analytical observational research with a cross sectional approach. Sampling technique is accidental sampling with the number of samples as many as 40. The results showed that of 40 respondents there were 35 (87.5%) who had pre-eclampsia and 5 (12.5%) who had severe pre-eclampsia. Based on the results of the statistical test, the value p = 0.005 < α = 0.05. There is a significant relationship between the incidence of Pre-eclampsia and the incidence of Cesarean section in RSUP Dr.Wahidin Sudirohusodo Makassar in 2018   Keywords: Pre-eclampsia Relationship, Cesarean section    


Author(s):  
Ana Zakiyah ◽  
Duwi Basuki ◽  
Windu Santoso

Discharge planning is one of the activities in the provision of nursing care on patients in the hospital, it will have a shortening impact on patient care in the hospital and reduce the patient's recurrence rate, but the implementation is not appropriate. so far, implementation of Discharge planning is still to be done after the patient finished having treatment by making a summary of the recording of patients return. Various characteristic factors of nurses can influence the implementation of discharge planning in hospital. The research purpose was to know the relationship of factors that influence discharge planning with the implementation of discharge planning. The research design used was cross-sectional, the instrument used was the questionnaire about the characteristics of the nurses and the implementation of discharge planning. The population of research was nurses who served in the inpatient room RSI Sakinah Mojokerto number of 80 nurses and obtained the number of 67 samples with proportional random sampling technique. The result of analysis with pearson correlation for age, education, length of work and chi-square for marital status showed that the characteristics of nurses related to discharge planning implementation were educational factor with p-value 0,023. The higher the nurse education caused more critical, logical and systematic in thinking so as to improve the quality of its work and the greater the desire to utilize the knowledge and skills it possesses keywords        : discharge planning, nurses, education


2021 ◽  
Vol 3 (1) ◽  
pp. 92-100
Author(s):  
Ana Mariza ◽  
Desi Risna Purnamasari

ABSTRACT :RELATIONSHIP BETWEEN MOTHER'S PARITY AND EVENTS IN THE PLASENTA PREVIA MIDWIFERY HOSPITAL DR. H ABDUL MOELOEK LAMPUNG PROVINCE Introduction: According to WHO in 2010 as many as 356,000 women died due to childbirth problems, maternal mortality was caused by several factors, including bleeding, one of the causes was placenta previa. The frequency of placenta previa increases in high parity, old age, uterine defects such as cesarean section, curettage, myomectomy and so on. Purpose :this study was to determine the relationship between maternal parity and the incidence of placenta previa in the obstetrics room of Dr. H Abdul Moeloek, Lampung Province.Method : This research was conducted using an analytic design with a cross sectional approach. The population in this study were all mothers giving birth at RSUD Dr. H Abdul Moeloek in 2015, which numbered 1435 people. Samples taken using systematic random sampling of 313 people. The analysis used was univariate analysis, namely by presentation and bivariate by chi squere.Result : The results obtained from the study of the frequency of mothers who experienced placenta previa were 49 (15.7%) people, the distribution of the frequency of parity at risk in labor was 193 (61.7%) people, There was a relationship between maternal parity and the incidence of placenta previa based on statistical tests obtained P value = 0.008 with the result of the OR value = 2.786.Conclusion : Suggestions from researchers are that the hospital is expected to further improve human resources by holding training or seminars for midwifery room employees, installing placenta previa protocols in the obstetrics room so that they can improve supervision of both the delivery process with placenta previa or the factors that cause placenta previa. Keyword : Parity, Plasenta Previa  INTISARI : HUBUNGAN ANTARA PARITAS IBU DENGAN KEJADIAN PLASENTA PREVIA DI RUANG KEBIDANAN RSUD DR. H ABDUL MOELOEK PROVINSI LAMPUNG Latar Belakang :Menurut WHO pada tahun 2010 sebanyak 356.000 perempuan meninggal akibat masalah persalinan, kematian ibu disebabkan beberapa faktor diantaranya adalah faktor perdarahan, salah satu penyebabnya adalah plasenta previa. Frekuensi plasenta previa meningkat pada paritas tinggi, usia lanjut, cacat rahim misalnya bekas bedah sesar, kuretase,miomektomi dan sebagainya.Tujuan: tujuan penelitian ini adalah mengetahui hubungan antara paritas ibu dengan kejadian plasenta previa di ruang kebidanan RSUD Dr. H Abdul Moeloek Provinsi Lampung.Metode penelitian :Penelitian ini dilakukan dengan menggunakan desain analitik dengan pendekatan cross sectional. Populasi pada penelitian ini adalah seluruh ibu bersalin di RSUD Dr. H Abdul Moeloek pada tahun 2015, yang berjumlah 1435 orang. Sample yang di ambil menggunakan systematic random sampling sejumlah 313 orang. Analisa yang digunakan adalah analisa univariat yaitu secara presentasi dan bivariat secara chi squere.Hasil : Didapatkan hasil penelitian frekuensi ibu yang mengalami plasenta previa sebanyak 49  (15.7 %) orang, Distribusi frekuensi paritas beresiko pada ibu bersalin sebanyak 193 (61.7 %) orang, Terdapat hubungan antara paritas ibu dengan kejadian plasenta previa berdasarkan uji statistik didapat P Value = 0,008dengan hasil nilai OR =2.786. Kesimpulan : diharapkan rumah sakit lebih meningkatkan SDM dengan diadakannya pelatihan ataupun seminar bagi pegawai ruang kebidanan, memasang protab-protab plasenta previa di ruang kebidanan sehingga dapat meningkatkan pengawasan baik proses persalinan dengan plasenta previa atau faktor-faktor penyebab terjadinya plasenta previa. Kata Kunci     : Paritas, Plasenta Previa


2020 ◽  
Vol 3 (2) ◽  
pp. 51
Author(s):  
Ikawati Setyaningrum ◽  
Firman Hidayat ◽  
Ratna Widhiastuti

Preceptorship is one method of guidance with one to one relationship in the scope of nursing which is considered good enough to add skills in care, both soft skills, hard skills and attitude of the nursing profession. Many factors affect the implementation of preceptorsip in hospitals. This study aims to determine the relationship between clinical instructional motivation and the implementation of preseptorship at Dr. Soeselo Slawi. This research is a quantitative study and the type of descriptive correlation research design with cross sectional approach. The sampling technique used was a total sampling of 39 people. The research instrument uses a motivation questionnaire containing 26 statements, whereas for Preceptorship uses a questionnaire containing 10 statements. Chi square analysis results showed that the p value was 0.007 (<0.005), which means there was a significant relationship between CI motivation and the implementation of Preseptorship. The hospital is expected to be able to choose nurses who will become CIs according to certain competency and knowledge standards, as well as specializing CI assignments so that they do not overlap with patient service tasks.  Keywords: Motivation. Clinical instructure, preceptorship


2020 ◽  
Vol 7 (2) ◽  
pp. 838-843
Author(s):  
Suzana Indragiri

Kebakaran merupakan salah satu kecelakaan yang paling sering terjadi selain menimbulkan korban jiwa dan kerugian material, kebakaran juga dapat merusak lingkungan serta gangguan kesehatan yang diakibatkan dari asap kebakaran. Oleh karena itu, untuk meminimalisasi terjadinya kebakaran maka perlu penerapan Keselamatan dan Kesehatan Kerja sebagai upaya pencegahan dan penanggulangan kecelakaan termasuk kebakaran. Pengetahuan, sikap dan upaya karyawan merupakan suatu hal penting dalam menghadapi situasi tanggap darurat bencana kebakaran. Tujuan penelitian ini adalah untuk mengetahui hubungan pengetahuan dan sikap dengan upaya penanggulangan kebakaran pada karyawan di PD Surabraja Food Industry Kasugengan Kidul Kabupaten Cirebon Tahun 2016.Penelitian ini menggunakan pendekatan kuantitatif dengan desain cross sectional. Populasi dalam penelitian ini yaitu seluruh karyawan di PD Surabraja Food Industry Kasugengan Kidul Kabupaten Cirebon yang berjumlah 106 orang. Teknik pengambilan sampel dalam penelitian ini menggunakan sampling jenuh pada bulan Agustus 2016, instrumen penelitian menggunakan kuesioner dan metode penelitian wawancara, analisa data menggunakan uji statistik chi square.Hasil uji bivariat dengan menggunakan uji statistik, pada variabel pengetahuan menunjukan nilai p value = 0,035, hal ini menunjukkan ada hubungan pengetahuan dengan upaya penanggulangan kebakaran dan variabel sikap menunjukan nilai p value = 0,084, hal ini menunjukan tidak ada hubungan sikap dengan upaya penanggulangan kebakaran di PD Surabraja Food Industry Kasugengan Kidul Kabupaten Cirebon Tahun 2016.Perlunya meningkatkan pengetahuan terhadap upaya penanggulangan kebakaran pada karyawan, diharapkan perusahaan mengadakan pelatihan dan sosialisasi terhadap tenaga kerja guna meningkatkan pengetahuan tentang penanggulangan kebakaran di tempat kerja di PD Surabraja Food Industry Kasugengan Kidul Kabupaten Cirebon Tahun 2016.Kata Kunci     : Pengetahuan, Sikap, Upaya Penanggulangan Kebakaran ABSTRACTFire is one of the most common accidents besides causing casualties and material losses, fires can also damage the environment and health problems resulting from smoke fire. Therefore, to minimize the occurrence of fire, the necessary implementation of Health and Safety as prevention and control of accidents including fire. Knowledge, attitudes and behavior of employees is an important thing in the face of a fire emergency response situations.Knowledge, attitude and effort of employees is an important thing in dealing with emergency response situation fire. The purpose this study was to determine the relationship of knowledge and attitude with the fire-fighting effort in employees in PD Surabraja Food Industry Kasugengan Kidul, Cirebon 2016.This study uses a quantitative approach to the cross-sectional design. The population in this research that all employees in PD Surabraja Food Industry Kasugengan Kidul, Cirebon regency totaling 106 people. The sampling technique in this study using saturation sampling in August 2016, research instruments using a questionnaire and interview research methods, data analysis using chi square test.Bivariate test results using statistical tests on the knowledge variables showed p value = 0.035, this shows there is a relationship of knowledge with the fire-fighting effort and attitude variables showed p value = 0.084, this shows there is no correlation with the attitude of fire fighting effort, Companies are expected to conduct training and socialization of labor in order to increase knowledge about fire prevention in PD Surabraja Food Industry Kasugengan Kidul, Cirebon 2016.The need to improve the knowledge of the fire-fighting effort in employees in PD Surabraja Food Industry Kasugengan Kidul, Cirebon 2016Keyword                : Knowledge, Attitude, Fire Fighting Effort


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