FIELDWORK
SESSION NOTES
PURPOSE AND CONTENT
This session includes a half day preparatory session and a full day actual
fieldwork and presentation of results. It aims to give participants experience in
developing tools for research on drug use problems as well as experience in
conducting qualitative research. The results of the fieldwork are not analysed
fully, but used to re-focus the problem analysis diagram which was designed in
the RAP session and to reflect on the strengths and weaknesses of the various
methods used. The Session Notes give some general background on how to
conduct the study, and present four group activities.
OBJECTIVES
At the end of the session participants will:
1. Be able to define the research methods.
2. Be able to develop research tools.
3. Have experience with key methods to study drug use practices and ideas,
e.g. semi-structured interviews, drug inventories in pharmacies and
community drug stores, and simulated client visits.
4. Have gained insight into the strengths and weaknesses of the different
research methods.
5. Have an understanding of the way in which qualitative research can be used
to re-focus and refine a problem analysis diagram.
PREPARATION
1. Read the Session Notes.
2. Review the tools, prepared for the fieldwork by the host institution, found at
the end of these Session Notes.
3. Review the module Investigating drug use patterns and identifying problems; it
contains methods that can be used for the rapid appraisal.
© World Health Organization 2002
Fieldwork
Session Notes
A. INTRODUCTION TO THE FIELDWORK
This session deals with Step 4 in the RAP process, outlined in the module
Conducting a rapid appraisal to analyse problems and identify possible solutions. It is
unlikely that after reviewing the literature (Step 1), doing interviews with key
informants (Step 2) and conducting a multi-stakeholder workshop (Step 3) you
have sufficient information on your core problem to conduct an intervention.
Using the problem analysis diagram which you made in the activity of the RAP
module, and considering the background information on the selected drug
problem which has been prepared by the host institution, you can define what
questions need to be answered in fieldwork.
The host institution has made a pack of tools, including:
 proposed guides for semi-structured interviews with health workers, and
drug sellers; and
 proposed guides for semi-structured interviews/illness recalls with mothers
of under-five children and with young men.
To prepare for the fieldwork, in this module, you review and revise the tools to
meet the objectives of your fieldwork, and make additional tools.
The fieldwork focuses on two distinct problems:
 the use of medicines in self-care of childhood fevers or acute respiratory
infections
 the use of antibiotics for the treatment of male sexually transmitted diseases or
respiratory tract infections in women.
Participants will be divided into two groups, each working on one of these
problems. Within each group, two sub-groups are formed. One will conduct
fieldwork at the health institution level (including in pharmacies) and one at the
community level (including in community drug stores).
B. TRIANGULATION
A mix of methods is usually the most appropriate for answering your research
questions. When doing research to analyse a drug use problem and prepare for
an intervention you will generally need to use both quantitative and qualitative
methods. This allows you to answer questions on how often practices occur as
well as on why they occur. Quantitative methods are important as they allow
you to collect baseline data on the drug use problem, which can be used to
evaluate the effect of the intervention. In the module Monitoring and evaluation we
discuss how you can define relevant outcome measures on which you would
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Fieldwork
Session Notes
need to collect baseline data. In this fieldwork exercise, however, we only use
qualitative methods. These will allow you to gain insights in people’s ideas and
practices, based on which you can re-focus the problem analysis diagram.
You will use a set of different methods to cross-check on findings and look at the
problem from different ‘angles’. This is called triangulation, which we have seen
is one of the principles for rapid appraisal.
The methods proposed for your fieldwork are:
 semi-structured interviews
 simulated client visits.
Semi-structured interviews
Semi-structured interviews are based on the use of an interview guide. This is a
written list of questions or topics that need to be covered during the interview.
Semi-structured interviews follow an open and informal interview style. They
allow for a listing of health problems using local illness terms and a listing of
medicines commonly used, as well as an exploration of problems and views
concerning drug provision and use. Interviewers can continue to ask questions
until they have fully understood the situation. Ordinary conversation makes it
easier to reassure informants and to win their co-operation and trust.
You will need to limit the number of such interviews, as they are quite timeconsuming to conduct and analyse. The aim is not to get a representative sample
of the various categories of informants, but to gather a substantial body of
information from them.
When conducting semi-structured interviews, the interviewer is prepared with a
list of questions and topics to be discussed. However, the order of the questions
and topics is undefined. It depends on the flow of the discussion. The researcher
acts as a moderator, guiding the respondent from one topic to another.
It is best to do a small pilot study in which the interview guides are pretested,
preferably not in the community where the actual study will be done.
The results of semi-structured interviews are hard to generalise, as they are
based on interviews with a limited number of people. Focus group discussions
can be used to further validate to what extent the problems identified reflect
what people in the community perceive to be problems, and to compare the
practices and views of different categories of people.
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Fieldwork
Session Notes
The best way to conduct a semi-structured interview depends on the
communication rules that exist in any given society. Generally the following
guidelines can help you.
Ground rules for a good interview
Conducting the interview :
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Greet your informant at the beginning of the interview in a culturally appropriate way.
Explain the purpose of the interview and ask the informant for consent and for permission to
record the session if you plan to do so.
Arrange comfortable seating to facilitate communication.
Introduce the people present at the interview. The respondent should be asked for permission
for all of them to stay.
Start with a topic that is not sensitive and is important to the respondent. This helps create an
informal, friendly atmosphere facilitating a ‘natural’ flow of ideas and opinions.
Be an “active” listener; look at your informant’s face (not at your interview guide).
Pick up phrases that the informant uses and use these to phrase your questions. Instruct your
translator to do this too.
Avoid giving opinions or judgements about what the informant says and treat them as an
equal.
Jokes, or friendly gestures towards any small children present can help break the ice.
Use open-ended questions not closed ones which only allow for ‘yes’ – or – ‘no’ answers.
Avoid asking leading questions.
Follow the flow of the discussion, but make sure that all the topics are covered.
Ask ‘probing’ questions to clarify points or to encourage more explanation.
Respond to issues raised by your informants, which are not on your interview guide, and
probe on these as well.
Thank the informant at the end and give him/her time to ask more questions.
Recording the interview :
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Use ‘telegram-style’ to record the responses of your interviewee but where s/he uses
important terms or interesting expressions record as much as possible of the responses
‘verbatim’(using the words the informant used).
Find a balance between taking notes (looking down at the paper) and talking with the
respondent. (S)he will feel uncomfortable if you spend too much time writing. If you conduct
the interview in pairs, then one person can do the interviewing and the other can make the
notes.
Complete the interview record immediately after the interview so you can still recall what was
said.
Observe and make notes on non-verbal communication like silences, laughing, worried
expressions, etc.
Simulated client visits
Simulated client methods are often used to measure the quality of prescribing
drugs in health facilities, pharmacies and drug shops. It involves a researcher
posing as a client and going to a health centre or pharmacy with a complaint. The
objective is to determine how a sample of providers react to the complaint; what
treatments they recommend, and what information they give.
4
Fieldwork
Session Notes
The method is somewhat controversial. One can question how ethical it is to
conduct such visits without asking health workers and/or drug sellers for
informed consent. The ethical issue can be resolved by asking the respondents
for consent before conducting the visits and without giving details on when the
visit will take place, to avoid bias. In the fieldwork it is recommended to use the
simulated client visit to observe what information and advice drug sellers give.
An advantage of the simulated client visit is that it is a rapid method. A typical
transaction does not last more than five minutes. It can also be used as a
quantitative method.
Decisions are needed on how to sample the drug outlets and how many
observations to do per outlet. It is important to consider the usual opening hours
and the volume of transaction by day. For example on market day, pharmacies
may be very busy and minimal advice given.
The following guidelines will help you conduct effective simulated client visits:
Ground rules for conducting good simulated client visits
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Simulating a client requires insight into how clients usually behave. This can be obtained by
conducting unobtrusive observations in pharmacies; or by asking informants during semistructured interviews how they would ask for medicines/present a complaint at a pharmacy.
Researchers should make sure that they dress/act as typical clients. It may be best to train
people from the communities studied to conduct the visits.
Consider also the details of the transactions: will the advice be followed and a medication
bought? What if the medicine is very expensive? Does the client then ask for a cheaper
alternative?
On recording:
 You cannot record what happens during the visit, as that would be unnatural, but this should
be done immediately afterwards. Design a form for this purpose to make sure all relevant
information is covered.
C. SAMPLING SITES AND RESPONDENTS
In planning fieldwork you normally need to take decisions on how many
surveys, interviews and observations you want to do. Sampling strategies are
different for the qualitative and quantitative methods.
In most studies you will apply a multi-stage sampling strategy. First you decide
on the communities or population groups in which you will conduct your study.
Then you draw a random sample of respondents for your quantitative surveys
and you purposely select respondents for the qualitative methods.
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Fieldwork
Session Notes
Selecting research sites/population groups: The selection of population-group
and/or communities you intend to study depends both on the objectives of the
study and on pragmatic factors (such as distance to be travelled, and contacts
that can facilitate entry into the community). The appraisal of drug use problems
is done as preparation for interventions. It makes sense to select communities
where interventions can be implemented. The advantage is that the appraisal
will result in baseline data which you can use to evaluate if the intervention had
any effect.
Annex 1 gives suggested sampling strategies for each of the methods proposed
above. It is best to decide on sampling issues in consultation with a statistician.
The advice we give helps you to ask the statistician the right questions.
In Activity 3 details are given of the number of semi-structured interviews and
simulated client visits which you will conduct for the fieldwork exercise.
ADDITIONAL READING
Odoi et al. (1996) Popular Pills. Amsterdam, Het Spinhuis.
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Fieldwork
Session Notes
FIELDWORK ACTIVITY 1:
MAKING AN APPRAISAL MATRIX AND PREPARING TOOLS
(60 MINUTES)
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The group work continues in the same groups as used in module Conducting a rapid
appraisal to analyse problems and identify possible solutions.
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To decide on which methods to use review the research questions which you
formulated in Activity 1 of the module Conducting a rapid appraisal to analyse
problems and identify possible solutions: what do you want to know and how can you
find it out? To adapt the matrix you should consider the objective of your appraisal
which you formulated in Activity 1 of the module Conducting a rapid appraisal to
analyse problems and identify possible solutions, and the factors in your problem
analysis diagram. Are all factors translated into research questions? Delete the
research questions that are not relevant for your objective. Note that these questions
are research questions and not interview questions. You will find the latter in the
section “Fieldwork tools”.
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You have got an appraisal matrix for the selected drug use problems. It shows which
research questions will be answered using which methods. Adapt this matrix so it
includes the questions you consider important.
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Discuss the advantages and disadvantages of using the proposed methods.
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The group divides into two sub-groups: one sub-group will be dealing with health
professionals, and the other sub-group will be dealing with ARV users. Both subgroups will revise revise and/or develop the tools they will use in the field.
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Review the prepared research tools. Using the matrix, check if the tools include all
relevant questions. Amend the tools, and add ones which are not included in the pack.
Formulating good research questions as well as selecting appropriate study methods are
essential to the success of the appraisal. The matrix overleaf provides an example of
questions and methods that you can choose and adapt.
.
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Fieldwork
Session Notes
APPRAISAL MATRIX: NON-ADHERENCE TO HIGHLY ACTIVE
ANTIRETROVIRAL THERAPY (HAART)
Research Questions
Suggested Methods
HEALTH FACILITY ASSESSMENT
On access to ARVs:
1. Which ARVs are in stock in the health facility? Did any
stock-out of ARVs occur in the past 3 months?
2. Which combinations of ARVs are prescribed to patients
as first-line therapies?
3. How are decisions concerning the switching of
treatments taken?
4. Which selection criteria / conditions are used to select
ARV users? Do these criteria / conditions include the
consideration of factors which are likely to determine
adherence (such as disclosure of HIV status, partner
notification, bringing a buddy, and/or adherence to
prophylactic treatment to prevent opportunistic
infections)
5. What is the cost of the first line treatment to users,
(including transport and related costs for diagnostics
etc)? Are the costs a barrier to consumers?
6. Are there any other barriers to use of ARVs?
On Information and communication:
7. Do new & switching ARV-users receive information on:
 How ARVs work
 How to use them
 The need to continue treatment
 What to do if a pill is forgotten
 Possible interactions with other drugs
 Which side effects can occur & what to do if they occur
 (Breast) feeding requirements
 When and where to get re-supply
Do clients receive written information about these
points?
8. Are health workers:
 treating ARV users with respect, and in privacy?
 listening to ARV users and let them ask questions about
the treatments and the effects on their bodies and their
lives?
 ask the ARV users about their experiences with ARVs in
their everyday life when they come for follow-up visits,
and to take problems with the drugs serious?
9. Do health workers fear acquiring AIDS?
Specifically, do they think they can get AIDS:
 by shaking hands with an AIDS patient
 by using the same toilet
 if an AIDS patient coughs in their vicinity.
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Interview with health
staff involved in ARV
prescribing and
counseling
Exit Interview
Observations of stock of
ARVs
Review of records
Interview with health
staff involved in ARV
prescribing and
counseling
Exit Interview with
ARV users
Structured observations
Fieldwork
Session Notes
Research Questions
Suggested Methods
10. Do health workers liase with family and community
members to enhance adherence to ARVs? In what ways
do they do so? How effective are these adherence
support measures in their view? How could they be
improved?
11. Does the health facility have a system to follow-up ARV
users?
12. What are the levels of non-adherence to ARV regimes
according to the health workers? What are the reasons
for non-adherence according to them? Who adheres best
and worst? What are main factors?
On technical competence, human resource issues and
available facilities:
13. Are health workers working in the ARV treatment
programs trained in comprehensive AIDS Care,
including both technical and psycho-social skills?
14. Are guidelines on care for PLWA available?
15. Is prescription in accordance with the guidelines?
Specifically which CD4 count cut-off points are used for
treatment initiation?
16. For new users, is the history of ARVs used previously
checked?
17. Are diagnostic facilities (CD4 counts, viral loads)
available? Which? Are they used appropriately? IF not,
are clinical markers used to initiate and monitor
treatment outcomes?
18. In what way does the ARV treatment program affect the
workload and job-satisfaction of health workers?
19. What do health workers consider as major problems
regarding treatment of and care for ARV users?
9
Fieldwork
Session Notes
Research Questions
Suggested Methods
In-depth interview at a
location of choice with
PLWA using ARVs for more
than one month

Focus group discussion
with men and women ARV
users
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PLWA USING ARVS
1.
What is the view of PLWA on the quality of ARV
care in the different health facilities offering care?
What is considered good and what is considered
problematic in the care provided by the different
facilities available to them?
2. Do ARV users feel listened to and treated with
respect at the health facilities, specifically do they get
a chance to ask questions about the treatments and
the effects on their bodies and their lives?
3. Do ARV users trust the health workers?
4. Do they feel dependent on the health workers, and
do they fear this dependence on them as source of
life-prolonging treatment?
5. What are the views of ARV users on efficacy and
safety of the ARVs that they are taking?
6. What are their experiences with the drugs. What is it
like to take drugs? How do they fit in everyday life
routines, like going to town, working, going to
school?
7. How should the drugs be used according to them?
Are they aware of the correct treatment schedule?
Do they know why they need to adhere to the
schedule?
8. Have there been times when they could not take
medicines according to the prescription? If so, why
not? What were the consequences of missing a dose?
Was it perceived to be a problem? If yes, what is
done to avoid missing a dose? Specifically in the past
week, were doses missed? When and why?
9. What is the cost of the treatment to the users,
including transportation, food, diagnostic tests and
other related costs.
10. Are appointments with the ART facility kept? If not,
why not? (delay, waiting time, waiting space)
11. Do the users experience side-effects? Which? What
have they done to diminish these side-effects? Did
they or do they want to switch drugs?
12. Do family friends and members know that ARVs are
taken by the user? If yes, do they support the ARV
users in his/her treatment? How? If not, why has
the user not disclosed their HIV status and/or use of
medicines? Do they have a designated buddy
system?
13. What do they perceive as most problematic
regarding adherence to ARV treatment? What could
be done to improve this?
10
Fieldwork
Session Notes
Research Questions
Suggested Methods
1.
2.
3.
4.
5.
6.
7.
8.
9.
Semi-structured
interviews with
community leaders
(teachers, community
health workers,
community support
groups. Organizations of
PLWA, church groups,
social workers etc)
 Focus group discussion
with adult married men
and women, and young
men and women.
 Focus groups with men
and women living with
HIV/AIDS
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Community
What local terms are used to refer to HIV/AIDS?
Is HIV/AIDS a stigmatizing condition? Are PLWA
subject to discrimination at health facilities, work,
school or in the community. What types of
stigmatization occur. Has the availability of ARVs in
the health facilities diminished stigma? If not, why
not?
Do people generally disclose their HIV status? Do
they disclose that they are taking medicines? If not,
why not?
Do people know how HIV is transmitted? And how
it is not transmitted?
Are people aware of voluntary testing and
counseling facilities? To what extent do they use
them? If not, why not?
Are people aware of the availability of AIDS
medicines in health facilities? What is their view of
the quality of care of the different facilities providing
ARVs? What are the advantages and disadvantages
of the different facilities providing ARV care in the
area?
Have community organizations, church
organizations, and/or organizations of people living
with HIV and AIDS living in the community been
involved in preparing for the introduction of ARVs
in the facilites? Are these organizations involved in
treatment literacy and adherence support programs?
What are the costs and benefits of taking ARVs
according to PLWA, and their family members and
relatives?
Do community members want an AIDS treatment
facility to be established in their community? If yes,
what would the community be willing to contribute?
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Fieldwork
Session Notes
ACTIVITY 2:
PRETESTING THE TOOLS (90 MINUTES)
The groups now pre-test the tools in role-plays.
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The sub-group ‘health professionals’ will conduct semi-structured interviews with
health professionals and pharmacists, do observations of ARV stock, and
observations of consultations of ARV users with health professionals.
The sub-group ‘ARV users’ will conduct semi-structured interviews with ARV
users and do exit interviews with them.
Pretest the tools as follows: One group member conducts the interview; another group
member acts as the respondent, while the other sub-group members observe and make
notes. Make sure that you all get a turn in interviewing.
Based on the experience in practising with the tools, the team makes a detailed plan for
the one-day fieldwork which is to be done the next day. Tasks are divided, see Activity 3.
ACTIVITY 3:
CONDUCTING FIELDWORK (HALF DAY SESSION)
The host institution has identified health facilities where interviews with health
professionals and ARV users will be held. A list of health facilities to be visited and a
division of group members / facilitators will be handed out. The facilities may also
provide an opportunity to interview community members.
The number of interviews to be done is based on pragmatic arguments: you only have half
a day to conduct the fieldwork. The following number of interviews have been arranged
by the host-institution.
At the health institution level each team is expected to conduct:
a)
b)
c)
d)
e)
f)
Exit interviews with ARV users
Semi-structured interviews with ARV users
Semi-structured interviews with health workers and pharmacists.
Observation of ARV stock and procedures
Optional: observation of consultations of ARV users with health workers
Optional: semi-structured interview with community members
Ideally, each participant practises conducting one semi-structured interview.
For each interview you need to appoint one recorder (to make notes), and one observer
who notes of how the interview was conducted (see above guidelines).
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Fieldwork
Session Notes
ACTIVITY 4
(3 HOURS AFTERNOON, 1 ½ HOURS EVENING)
From 3pm–6pm each group evaluates the fieldwork and refines their original problem
analysis diagram. To do so, each sub-group appoints a facilitator and recorder and
conducts the following activities:
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General discussion on what was learnt in the fieldwork about the problem: what are
the main findings – these are summarised by the recorder.
The facilitator asks the group to review the problem analysis diagram: should it be
changed based on the finding of the study? Changes are made for presentation in
plenary.
General discussion on how the fieldwork went, evaluating the tools.
Discuss strengths and weaknesses of how the methods were used in practice. Record
these on an overhead or flipchart, to be presented in plenary. Be honest: dare to tell
the others what went wrong. Use examples to make the presentation more lively.
During the evening session all groups present their refined problem analysis diagram and
the strengths and weakness of the methods used (15 minutes per group). The discussion is
facilitated by the trainers.
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Fieldwork
Session Notes
ANNEX 1: SAMPLING STRATEGIES
This annex outlines sampling strategies which you can use for the quantitative
and qualitative methods which are often used to study drug use problems.
Sampling for the health/medicine use surveys
When conducting a health/medicine use survey it is rarely possible to include
every person in the selected population. You therefore need to select a
representative sample of respondents for the survey. A truly random and
statistically representative sample allows for generalisation from the sample to
the larger population. The purpose of such sampling methods is not to gain indepth understanding of an issue, but to be able to generalise findings. Random
sampling is appropriate if the aim is to measure variables and generalise findings
obtained from a sample to the total study population.
To draw a representative random sample from the total population you will be
confronted with the following questions:
What is your study unit? In some studies you aim to learn more about
household drug use practices; in others about those of particular individuals (for
example adolescents age 10-18; or adult men). To decide on your sampling frame
you need to first define your study units clearly.
How many study units are needed in the sample? To answer this question you
need the advice of a statistician. The number depends on what you want to
measure and how often it occurs in your study population (you should be able to
give an informed estimate). Or you can also decide on pragmatic grounds: what
time and resources do you have and how many families can you interview?
How will these study units be selected? To select a simple random sample you
need to:
 Make a numbered list of all the households/people in the population from
which you want to draw a sample.
 Select the required number of households or individuals, using a `lottery'
method or a table of random numbers.
If you do not have a list of households/individuals in the communities, you can
also walk through the community starting at its central square. You decide on
which direction to follow by spinning a bottle on its side. Then you visit every
2nd or 3rd house that you find as you walk towards the outskirts of the village.
Repeat this procedure in another direction, until you have the number of
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Fieldwork
Session Notes
households you intend to interview. This method is often used to survey
immunization coverage.
Sampling for focused illness recalls
Sampling procedures for the focused illness recalls are similar to those for the
health surveys. A random sample of a study population is drawn. All selected
respondents are asked if they or their family members suffered from the illness
in the past week. If yes, the illness recalls are done. If not, then the next
household/individual on the list is interviewed. You need to decide how many
illness recalls you want to do, and you continue interviewing until you have
completed the number. Aim at doing at least 50 interviews per type of illness.
This is sufficient to give you a good description of treatment practices.
Simulated client/patient visits sampling
The study unit for the simulated patient/client method is not households or
individuals, but health facilities, pharmacies or drug sellers. If the number of
facilities in your study community is limited, you select them all. Conduct a
limited number of visits to each facility, and make sure you do so at different
points of time during the week, as quality of care can differ related to presence of
professional health staff, pharmacists etc. Aim to make at least three visits to
each facility. If the number of health facilities is too large you can draw a sample
of around 10-20 or more health providers, pharmacists or drug sellers.
Sampling medical records/structured observations
For medical record reviews and structured observations, aim to sample all health
facilities in your study area, as proposed for the simulated patient/client
method. If you cannot do so, select 10-20 health facilities. Only review and
conduct observations on medical records and client-provider interactions which
are relevant for your core problem. Collect information on around 30 relevant
medical records and client-provider interactions per facility.
Sampling for semi-structured interviews
First you need to define whom you want to interview. In this stage we aim to
focus our study. So concentrate on people who have direct experience with the
drug use practice which is problematic, and people who are knowledgeable
about it. Snowball sampling is the most common sampling method used in
qualitative studies. It involves identifying one or two individuals who are
relevant to your study objects, for example women with pre-school children, and
then asking them to locate additional useful informants, such as other mothers of
pre-school children. The advantage of this method is that one informant refers
the researcher to another, and the researcher therefore has a good introduction
for the next interview. The disadvantage is that the variation in the sample may
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Fieldwork
Session Notes
be limited because it consists of informants who belong to the networks of the
index cases.
You can also decide to conduct contrast-sampling. This involves selecting
respondents from contrasting sub-groups in the population, for example
respondents who are relatively well off and those who are poor; or educated
women with those who have little education. Contrast groups help you capture
the diversity in drug use practices. It allows you to get insight into the
determinants of drug use problems, if meaningful contrast groups are chosen.
You can get an idea about which groups to select by reviewing your problem
analysis diagram. Which socio-cultural factors seem to be related to the problem?
Can we test these assumptions by comparing ideas and practices in different
groups? It is also useful to contrast groups that use drugs appropriately with
those who do not. Information on whether or not drugs are used appropriately
can be obtained from the focused illness recalls. By conducting semi-structured
interviews with both groups and comparing findings you can get an idea of the
reasons for appropriate and inappropriate practices.
Sampling for focus group discussions
The main decision you need to take when planning focus group discussions is
what focus you intend to have, and how many FGDs you intend to do. FGDs are
often used to contrast views of different ‘focused’ groups: for example:
adolescents versus adults; or men versus women. Decide which population subgroups need to be interviewed. Limit the scope of the study to those sub-groups
which have direct experience with the problem. Usually local leaders are asked
to select respondents for the focus groups. Aim for around 6-8 participants per
group; and conduct at least two FGDs per population group involved. So, for
example, two with men and two with women; or two with adults and two with
adolescents.
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