USAID KENYA 
APHIAplus WESTERN KENYA PROJECT
An Outcomes Evaluation Report
of 
SPLASH! INSIDE OUT (SIO) Interventions
July 2015
USAID KENYA 
APHIAplus WESTERN KENYA 
AN OUTCOMES EVALUATION REPORT OF 
SPLASH INSIDE-OUT INTERVENTIONS 
Award No: AID-623-A-11-00002 
Prepared by 
PATH’s COUNTRY OFFICE IN KENYA
ACS Plaza, 4th Floor 
Lenana and Galana Road 
PO Box 76634 
Nairobi 00100 
Kenya 
July 2015 
DISCLAIMER 
The auThors’ views expressed in This evaluation report do not necessarily reflect 
the views of the United States Agency for International Development or the United 
States Government.
i 
ACKNOWLEDGEMENTS 
PATH acknowledges the contribution of several individuals and stakeholders who 
made this report possible. First and foremost we acknowledge the American People 
and the United States Government, through USAID, for providing the funds and 
support for the APHIAplus Western Kenya project that is implementing the SIO 
interventions. Second, we appreciate the support provided by the National 
Government and County Governments of Kisumu and Busia for approving the 
evaluation and providing on ground support. 
We are grateful to the local implementing partners and the health activists who 
ensured that logistics were in place including contacting the respondents for 
interviews and focus group discussions. We appreciate and heavily indebted to all 
the respondents who took time off their schedules to provide much needed 
information that is the substance of this report. 
We would like to express our gratitude to the team of research assistants and 
supervisors who spent long hours reaching out to and seeking information from the 
respondents. 
And last, but not least; PATH would like to recognize the contribution of the lead 
consultant, the Principal and Co-Investigators and the APHIAplus project staff in 
ensuring that all the planned activities were implemented as scheduled and this 
report is finalized. 
SIO Evaluation Report (July 2015) ii
TABLE OF CONTENTS 
Acknowledgments ......................................................................................................... i 
Acronyms and abbreviations ......................................................................................... v 
Executive summary ....................................................................................................... vi 
Section 1: Introduction ....................................................................................... 1 
1.1 Background .............................................................................................................. 1 
1.2 About Splash! Inside Out .......................................................................................... 2 
1.3 SIO evaluation hypothesis and objectives ................................................................ 3 
Section 2: Methods ............................................................................................ 5 
2.1 Sampling frame and sample selection ...................................................................... 5 
2.2 Training of the research team .................................................................................. 5 
2.3 Data collection ......................................................................................................... 5 
2.4 Data analysis ............................................................................................................ 6 
2.5 Ethical approvals and consenting ............................................................................. 7 
2.6 Key challenges ......................................................................................................... 7 
Section 3. Results on the implementation process ..................................................... 8 
3.1 The initiation of SIO .................................................................................................. 8 
3.2 Program reach .......................................................................................................... 8 
3.3 SIO implementation process and lessons learned..................................................... 9 
3.4 Key challenges experienced by the LIPs and health activists ................................... 11 
3.5 Sustainability of SIO activities ................................................................................. 12 
Section 4: Results on project outcomes .............................................................. 13 
4.1 Socio-demographic characteristics of the respondents ........................................... 13 
4.2 Knowledge on HIV and AIDS, PMTCT, and STIs ...................................................... 14 
4.3 HIV and AIDS accepting attitudes and stigma ......................................................... 16 
4.4 HIV and AIDS behavior change and practices .......................................................... 16 
4.4.1 Sexual experience ............................................................................................ 16 
4.4.2 Alcohol and drug use ....................................................................................... 16 
4.4.3 HIV risk perceptions including risk of TB and malaria ....................................... 17 
4.4.4 Family planning ............................................................................................... 18 
4.5 HIV counseling and testing and voluntary medical male circumcision ..................... 19 
4.6 Exposure to and effects of SIO ................................................................................20
4.6.1 Number of sessions attended ..........................................................................20
4.6.2 Effects of SIO ................................................................................................... 21 
4.6.3 Rating of SIO services ...................................................................................... 22 
4.6.4 Risk reduction .................................................................................................. 23 
4.7 Information sharing on HIV and AIDS ...................................................................... 26 
4.8 Exposure to health promotion messages ................................................................ 27 
4.9 SIO efficacy analysis ................................................................................................ 27 
4.9.1 SIO efficacy among the target population ....................................................... 29 
Section 5: Discussion ......................................................................................... 31 
SIO Evaluation Report (July 2015) iii
Section 6: Conclusion and recommendations ...................................................... 35 
6.1 Conclusion ............................................................................................................... 35 
6.2 General recommendations ...................................................................................... 35 
6.3 Recommendation on SIO ........................................................................................ 36 
References ....................................................................................................... 38 
List of tables 
Table 1: A summary of the tools used to generate data for the evaluation .................... 6 
Table 2: Flow of activities toward the establishment of Splash! Inside Out .................... 8 
Table 3: Number of beneficiaries reached, by target population .................................... 8 
Table 4: Socio-demographic characteristics of questionnaire respondents .................. 13 
Table 5: Perceptions toward HIV risk, by target group .................................................. 15 
Table 6: Percentage who reported HIV accepting and stigmatizing behavior ............... 16
Table 7: Percentage who reported consumption of alcohol and drugs in the past 3 
months ..................................................................................................................... 17
Table 8: Percentage who reported sexual intercourse under the influence of 
alcohol/drugs............................................................................................................ 17 
Table 9: Perceived risk by target population ................................................................. 18 
Table 10: Family planning methods cited (percentage) ................................................. 19 
Table 11: Reported use of contraception (percentage).................................................. 19 
Table 12: Reported HIV testing, by target group (percentage) ...................................... 19 
Table 13: Reported topics discussed in Splash! Inside Out sessions (percentage) ......... 21 
Table 14: Reported action taken after exposure to Splash! Inside Out, by target 
group (percentage) ................................................................................................... 21 
Table 15: Reported risk behavior, by target group (percentage) ................................... 23 
Table 16: Occurrence of other sex-related behavior (percentage) ................................ 24
Table 17: Modes of communication on health promotion messages (percentage) ....... 27 
Table 18: Splash! Inside Out efficacy analysis, by key indicators ................................... 28 
Table 19: Splash! Inside Out efficacy analysis, by target population .............................30
List of figures 
Figure 1: Reported ways through which HIV is transmitted (percentage) ..................... 14 
Figure 2: HIV prevention strategies reported by target group (percentage).................. 15 
Figure 3: Perceived risk of contracting HIV, STI, TB, and malaria (percentage) ............. 17 
Figure 4: Reported number of Splash! Inside Out sessions attended (percentage) ....... 20 
Figure 5: Rating of Splash! Inside Out services by respondents .................................... 23 
Annexes 
Annex 1: Evaluation tools .............................................................................................. 39 
Annex 2: Splash! Inside Out sites and implementers ..................................................... 45 
Annex 3: Ethics committee approvals ........................................................................... 46 
Annex 4: Evaluation work plan ...................................................................................... 48 
Annex 5: Scopes of work for research team and consultant .......................................... 52 
Annex 6: Lead consultant CV ........................................................................................ 54 
SIO Evaluation Report (July 2015) iv
ACRONYMS AND ABBREVIATIONS 
ADS Anglican Development Services 
AIDS Acquired immune-deficiency syndrome 
APHIAplus AIDS, Population and Health Integrated Assistance 
ARV Antiretroviral 
CHW Community health workers 
EII Evidence-informed intervention
FF Fisher folk 
FGD Focus group discussion 
FP Family planning 
FSW Female sex worker 
GoK Government of Kenya 
HA Health activist 
HIV Human immune-deficiency virus 
HTC HIV testing and counseling 
IDI In-depth interviews 
IDUs Injecting drug users 
IGA Income-generating activity 
IUD Intrauterine device 
KAIS Kenya AIDS Indicator Survey 
KASF Kenya AIDS Strategic Framework 
KASH Keeping Alive Societies Hope 
KII Key informant interviews 
KNBS Kenya National Bureau of Statistics 
KRCS Kenya Red Cross Society 
LIP Local implementing partner 
MARPs Most-at-risk populations 
MFIs Microfinance institutions
MSM Men who have sex with men 
MSW Male sex worker 
NASCOP National AIDS & STI Control Programme
NHIF National Hospital Insurance Fund
OSIEA Open Society Initiative for Eastern Africa 
PATH Program for Appropriate Technology in Health 
PWIDs People who inject drugs 
PMTCT Prevention of mother-to-child transmission 
PWPs Prevention with Persons with HIV 
SIO Splash! Inside Out
SRH Sexual and reproductive health 
STI Sexually transmitted infections 
TB Tuberculosis 
USAID United States Agency for International Development 
VMMC Voluntary medical male circumcision 
YOS Youth out of school 
YTLI Youth in tertiary learning institutions
SIO Evaluation Report (July 2015) v
EXECUTIVE SUMMARY 
Project background: The AIDS, Population, and Health Integrated Assistance 
(APHIAplus) Western Kenya is a five-year project (January 2011 to December 2015) 
funded by the United States Agency for International Development (USAID). The 
project is being implemented by a consortium led by PATH, comprising the 
Elizabeth Glaser Pediatric AIDS Foundation, Jhpiego, and World Vision. 
The project’s strategic objective is “improved health outcomes and impact through 
sustainable country-led programs and partnerships.” Within this objective, two 
main result areas, in particular, contribute to the work and priorities of USAID 
Kenya. Result 3 focuses on improving and expanding availability of high-impact and 
high-quality health services at the facility and community levels, increasing demand 
for those services, as well as improving health-seeking behaviors of the 
communities. Result 4 addresses social determinants of health. It aims to improve 
the health and well-being of marginalized, poor, and underserved households, 
families, and children by enhancing and increasing access to economic security 
initiatives; food and nutrition security; education, life skills, and literacy; and safe 
water, sanitation, and hygiene. This will be reinforced by expanding social 
mobilization for health. 
About Splash Inside Out (SIO) interventions: SIO is a combination prevention 
intervention that the AIDS, Population and Health Integrated Assistance 
(APHIAplus) project is implementing to reach key populations—mainly men who 
have sex with men (MSM) and female sex workers (FSWs)—and vulnerable groups 
including men and women in workplaces, fisher folk (FF), youth out of school (YOS),
and youth in tertiary learning institutions (YTLI). SIO is an evidence-informed 
intervention (EII) that utilizes trained health activists (HAs) to reach out to these 
populations with appropriate prevention messages by recruiting beneficiaries, 
conducting sessions, and accompanying peers to service delivery points. 
Objectives and key questions of the evaluation: The outcomes evaluation was 
conducted from May to July 2015 to: (i) examine the status of behavioral outcomes 
among beneficiaries of the interventions; (ii) study the efficacy of Splash! Inside Out 
(SIO) as a combination prevention intervention; and (iii) make appropriate 
recommendations. The evaluation was guided by the following key questions: 
 Are there behavior changes observed among people who received full 
benefits of SIO in line with the SIO logic model (expected outcomes)? Were 
there any unanticipated outcomes? 
 Are there any differences among the different key populations targeted? 
 What changed among beneficiaries who did not receive full set of SIO 
intervention? 
 Can the changes be attributed to SIO interventions? 
Methods: The evaluation was conducted in Busia and Kisumu, two of the ten 
counties involved in SIO interventions. A mixed methods approach was used to 
generate the information used for this evaluation: 459 interviewer-based 
SIO Evaluation Report (July 2015) vi
questionnaires were implemented among the project beneficiaries; 35 key 
informant interviews (KIIs) among health activities, project coordinators, and 
program managers; and 12 focus group discussions (FGDs) with groups of HAs, FF, 
FSWs, and MSM. The data were analyzed using descriptive techniques then tested 
for differences between respondents with low exposure level (1 to 4 sessions) and 
those with high exposure level (5+ sessions) using the chi-square test of 
independence for categorical variables. The analysis focused on measures related to 
HIV-related knowledge, attitudes, and practices. The qualitative data were analyzed 
manually based on the evaluation objectives. 
Findings: The results are presented in two sections: (i) results on the 
implementation process and (ii) results on project outcomes. The results on the 
implementation process indicate that SIO reached 17,459 FF, FSWs, and MSM in 
2013 (9,839, 7,081, and 539, respectively) while in 2014 it reached 75,677 (48,717, 
23,986, and 2,974, respectively). The two SIO models of sharing information with 
peers—one-on-one and small group sessions (of 5 to 25 people) worked well for 
different target groups. Some peers, especially the MSM and FSWs, preferred one￾on-one discussions rather than being part of group discussions. The adoption of a 
HA model was considered more beneficial than the traditional peer education 
model. Some of the key elements highlighted about SIO were: (i) the open process 
of selecting HAs; (ii) the training provided to the local implementing partners (LIPs), 
coordinators, and HAs; (iii) holding regular review meetings that provided 
opportunities to share progress and challenges and to find solutions to emerging 
issues; and (iv) access to legal support, health services, and commodities (condoms 
and water-based lubricants). The key challenges identified by the study participants 
included: (i) late release of funds by APHIAPlus that caused the suspension or delay 
in the execution of some activities; (ii) poor record-keeping; (iii) management of 
expectations; and (iv) ineffectiveness of some partnership arrangements. 
In terms of project outcomes, the results indicate that all the respondents had heard 
of HIV and AIDS and almost all (97%) knew about antiretrovirals (ARVs). The most 
common means of HIV transmission cited by the respondents was unprotected sex 
(98.1%). A high proportion of the respondents indicated that they would buy food 
from a vendor who is HIV positive (93.1%), that they would care for an infected 
family member (97.9%), and that an infected female teacher should be allowed to 
continue teaching (94.3%). However, more than half (57%) indicated that they 
would keep it a secret if a family member were infected with HIV. 
Over one-tenth (14%) of the respondents reported, unprompted, that they were HIV 
positive. In terms of risk perception at a personal level, there were some differences 
between the target populations ,with the FF considering themselves to be at a lower 
risk of HIV transmission (24.7% medium and 15.2% high), compared to the FSWs 
(27.7% medium and 20% high) and the MSM (38.6% medium and 15.9% high). 
During the in-depth interviews (IDIs) and FGDs the MSM were perceived to be at 
higher risk of HIV infection because of higher levels of stigma and discrimination. A 
high proportion of the respondents (75.5%) reported to have had an HIV test in the 
three months preceding the evaluation and 98.2% had received their results. The 
FSWs reported that they discussed their HIV status among themselves and 
SIO Evaluation Report (July 2015) vii
supported each other with treatment, whereas this was less apparent among the 
MSM. 
Over two-fifths (42.4%) of the beneficiaries reported that they went for an HIV test 
(FF-53.1%, FSW-68.3%, and MSM-61.2%) after going through SIO sessions. Another 
25.3% made a decision to use condoms all the time (FF-15.4%, FSWs-40.3%, and 
MSM-25.3%). The HAs reported that they had observed changes in the 
communities, including better understanding of re-infection and the willingness of 
women to seek condoms. The rating of SIO activities was generally high, with most 
activities being rated at good or satisfactory. Risk-taking was, however, still high 
among the respondents: 23.9% reported to have had sex without protection with 
someone whose HIV status was unknown (FF-15.8%, FSWs-34.2%, and MSM￾32.7%). During an FGD with FSWs it emerged that through SIO they had acquired 
skills to negotiate for safe sex. Access to legal services through the LIPs had reduced 
abuse among the male sex workers (MSWs) and FSWs. 
Slightly over four-fifths (84.1%) reported that they had shared the information they 
had gathered with other people. A half (52.6%) of them had talked to friends/peers, 
siblings (12.3%), and other sexual partners (10.5%). The results show that a higher 
proportion of the MSM talked to friends/peers (61.2%) compared to the FSWs 
(48.3%) and FF (44%). The main sources of information about HIV were the radio 
(71% unprompted and 72.4% prompted), health centers (61.8% unprompted and 
74.5% prompted), and peer educator/health activist (45.9% unprompted and 85.9% 
prompted). 
SIO efficacy: The data were analyzed based on the number of SIO sessions 
attended by the respondents to examine the differences in six key outcomes. 
Responses were clustered to differentiate those who attended 1 to 4 sessions (less 
than full exposure) and those who attended 5 sessions or more (full exposure). 
There was strong evidence of relationship between level of exposure (based on 
sessions attended) among FSWs in the following key SIO outcome indictors: (i) had 
HIV test in the 3 months prior to the evaluation (X2
 = 0.800, df = 1, p-value < 0.05); 
(ii) talked to sexual partner about HIV and AIDS in the last 3 months (X2
 = 8.756, df = 
1, p-value < 0.05); and (iii) had unprotected sex with any partner whose HIV status 
was not known to respondent (X2
 = 10.644, df = 1, p-value < 0.05). In addition, there 
was marginal evidence of the effectiveness of the intervention on speaking to a 
sexual partner about HIV and AIDS (X2
 = 10.76, df = 1, p-value = 0.05). However, no 
evidence was observed regarding speaking to anyone about HIV and AIDS (X2 = 
0.023, df = 1, p-value > 0.05). 
Conclusion: The results show that, through the health activism and the linkages 
established with the various service providers, the program was effective in 
achieving its behavioral and biomedical objectives. The analysis on the effectiveness 
of SIO shows that, although the evidence is weak, some of the respondents who had 
attended 5 or more sessions were better able to understand their risks and adopt 
protective behavior. 
SIO Evaluation Report (July 2015) viii
Recommendations: These are presented in two subsections: general and SIO 
specific. 
General recommendations 
i. Address structural determinants: There is a need to tackle structural 
determinants of HIV and AIDS as part of prevention, since poverty and socio￾cultural factors are key facilitators of sexual vulnerability. 
ii. More focus on MSM: Some members have limited access to information and 
services due to fear and stigma. The recruitment and training of more HAs 
should be considered while strengthening the snowball approach to reach 
them. 
iii. Increase preventive interventions in the general population: Although it makes 
epidemiological sense to focus on key and vulnerable populations, it is 
important not to relent on educating the general population on HIV and 
AIDS. 
iv. Address stigma and discrimination: The levels of stigma are still high, 
especially among the MSM; thus, there is a need to focus on measures to 
address HIV and AIDS stigma at the national, county, and community levels. 
v. Support national and county governments’ efforts in implementing the Kenya 
AIDS Strategic Framework (KASF) 2014/5–2018/9: The Framework provides 
suggestions on targeted interventions that could be adopted by counties to 
address their challenges in HIV and AIDS mitigation. 
Recommendations on SIO 
i. A common understanding on what constitutes a session: The APHIAPlus team, 
the LIPs, the HAs, and the peers used the term ‘session’ variably. It is critical 
that the terminology is harmonized to provide a basis for follow-up, 
monitoring, and evaluation of the efficacy of the interventions. 
ii. Reporting: APHIAPlus should consider introducing less bulky reporting tools 
or the adoption of e-reporting tools. 
iii. Referrals: The referral booklets should be produced in triplicate to allow the 
LIPs to keep copies for their records and follow-up. 
iv. Timely release of funds: Delayed release of funds interferes with the capacity 
of LIPs to effectively implement their activities. It also has a negative impact 
on the commitment of HAs and other program actors. 
SIO Evaluation Report (July 2015) 1
SECTION 1: INTRODUCTION 
1.1 Background 
Kenya had approximately 1.6 million people living with HIV in 2012 and about 
57,000 were estimated to have died from AIDS-related illnesses (Kenya AIDS 
Indicator Survey [KAIS] 2012). The country is experiencing a mixed epidemic; both 
generalized and concentrated. The concentrated epidemic is among female sex 
workers (FSWs), men who have sex with men (MSM), and people who inject drugs 
(PWIDs), initially referred to as injecting drug users (IDUs), who collectively 
contribute about 30% to new HIV infections. In 2012, the Lake Victoria region in 
Western Kenya had the highest prevalence rates of HIV ranging, from 6.4% in 
Nyamira to 25.7% in Homa Bay (KASF 2014). 
In recognition of the shift in transmission dynamics, the Government of Kenya 
(GoK) has committed, in the Kenya AIDS Strategic Framework (KASF) 2014/5–
2018/9, to focus on key populations and a range of vulnerable populations. The key 
populations identified for attention are FSWs, MSM, and PWIDs. Vulnerable 
populations include young girls and women, people in prisons and other closed 
settings, fishing communities, truck drivers, street children, and people with 
disabilities. 
Efforts toward reducing the prevalence of HIV and mitigating the impacts of AIDS in 
the country have been going on for over four decades. The United States Agency for 
International Development (USAID) has been at the forefront of funding various 
organizations in the country to address the national key strategic actions toward 
this goal. Under the current USAID-funded AIDS, Population and Health Integrated 
Assistance (APHIAplus), PATH is responsible for the interventions in Western Kenya 
(Zone 1), which is a five-year funded program (2011–2015). The project focus is on 
scale-up of services, integration of health service delivery, strengthening the health 
systems, fostering community involvement, and building capacity of health workers 
and the GoK to offer quality health services to the surrounding populations as well 
as creating innovative methods for effective service delivery initiatives and 
approaches. 
About APHIAplus Western Kenya Project: The AIDS, Population, and Health 
Integrated Assistance (APHIAplus) Western Kenya is a five-year project (January 
2011 to December 2015) funded by the United States Agency for International 
Development (USAID). The project is being implemented by a consortium led by 
PATH, comprising the Elizabeth Glaser Pediatric AIDS Foundation, Jhpiego, and 
World Vision. 
The project’s strategic objective is “improved health outcomes and impact through 
sustainable country-led programs and partnerships.” Within this objective, two 
main result areas, in particular, contribute to the work and priorities of USAID 
Kenya. Result 3 focuses on improving and expanding availability of high-impact and 
high-quality health services at the facility and community levels, increasing demand 
for those services, as well as improving health-seeking behaviors of the 
SIO Evaluation Report (July 2015) 2
communities. Result 4 addresses social determinants of health. It aims to improve 
the health and well-being of marginalized, poor, and underserved households, 
families, and children by enhancing and increasing access to economic security 
initiatives; food and nutrition security; education, life skills, and literacy; and safe 
water, sanitation, and hygiene. This will be reinforced by expanding social 
mobilization for health. 
APHIAplus builds on the experiences of the APHIA II Western project. The project 
operates in ten counties in the Nyanza and Western regions of Kenya. These are: 
Kisumu, Nyamira, Homa Bay, Kisii, Migori, and Siaya in Nyanza; and Busia, 
Kakamega, Bungoma, and Vihiga in Western region. The project’s objectives are to:
i. Expand integrated facility-based services through mentorship, supportive
supervision, and innovative high-impact programming. 
ii. Activate synergies for whole market planning and implementation 
through sub–county level Annual Work Plans (AWP) mechanisms. 
iii. Foster dynamic integration and enhanced linkages between households 
and health and social services through community health workers (CHWs), 
referrals, and community structures. 
iv. Strengthen community capacity for members to advocate for their rights; 
monitor and evaluate services in their community; and own, lead, and 
participate in education and programs tailored to their needs. 
1.2 About Splash! Inside Out
PATH Kenya developed Splash! Inside Out (SIO) in 2012, as a redesign of the 
original SPLASH! peer education HIV prevention intervention developed in 2000 
under the USAID-funded Kenya IMPACT project and subsequently implemented in 
the AMKENI and APHIA II Western Kenya projects. SIO is a combination prevention 
intervention that the APHIAPlus project is implementing to reach key populations,
mainly MSM and FSW and vulnerable groups including men and women in 
workplaces, FF, youth out of school (YOS), and youth in tertiary learning institutions 
(YTLI). SIO is an evidence-informed intervention (EII) that utilizes trained health 
activists (HAs). The HAs reach these populations with appropriate prevention 
messages through recruiting beneficiaries, conducting sessions, and accompanying 
peers to service delivery points. The sessions can be one-on-one or small group 
discussions of between 5 and 25 participants. A training guide containing five 
modules is used to provide the HAs with the requisite skills to support their peers. 
They are also supplied with information packages on the key issues of concern 
including HIV and AIDS, TB, family planning, relationships, voluntary medical male 
circumcision (VMMC), sexually transmitted infections (STIs), and gender issues 
(generally referred to as Health Information Reference Pack or File). The HAs also 
promote the uptake of services and act as distributors of prevention tools such as
condoms and water-based lubricants for MSM and FSWs. Theoretically, SIO is 
based on increasing health literacy above the cognitive level to the point where the 
HA is empowered to advocate for access to treatment and commodities as well as 
champion against the traditions and cultures that increase risk. 
SIO Evaluation Report (July 2015) 3
The topics for discussion during a SIO session are generated by the peers and what 
the HA does is to facilitate the discussion based on the knowledge gained through 
training by the SIO project team. SIO has been implemented since 2012 and as the 
APHIAplus project funding comes to an end, it was considered necessary to conduct 
an evaluation to assess the outcomes of the approach. 
The outcome evaluation was conducted to assess the uptake of self-reported HIV 
testing and counseling (HTC) and effective referrals to other services including HIV 
care and treatment and VMMC; perceptions of respondents toward risk of HIV 
infection; knowledge on HIV prevention strategies including partner reduction and 
male circumcision; and communication or dialogue about health issues at the 
community level. In addition to assessing the outcomes of SIO, the evaluation also 
examined how the intervention was implemented in order to understand the level 
of exposure the target population received. This was done through a review of 
program data and discussions with implementing partners.
1.3 SIO evaluation hypothesis and objectives 
Hypothesis: The hypothesis for the evaluation was that members of key and 
vulnerable populations who are exposed to 5 or more sessions of SIO will be better 
able to accept or seek referral for HIV counseling and testing services and other 
health services and practice safer sex (reduce number of sexual partners and 
increase use of condoms and water-based lubricants), compared to those who are 
exposed to fewer than 5 sessions. 
Objectives: The intervention evaluation sought to address the following objectives: 
i. Examine the status of behavioral outcomes among beneficiaries of the 
interventions. 
ii. Evaluate the efficacy of SIO as a combination prevention intervention. 
iii. Make appropriate recommendations. 
Questions: The evaluation was guided by the following key questions:
i. Are there behavior changes observed among people who received full 
benefits of SIO in line with the SIO logic model (expected outcomes)? Were 
there any unanticipated outcomes? 
ii. Are there any differences among the different key populations targeted? 
iii. What changed among beneficiaries who did not receive full set of SIO 
intervention? 
iv. Can the changes be attributed to SIO interventions? 
The evaluation was conducted in two of the ten counties involved in APHIAPlus, 
namely Busia and Kisumu, which fall within the category of counties categorized as 
HIV and AIDS Prevention, Care, and Treatment ‘Saturation Counties’ whose HIV 
prevalence is between 10% and 28% (NACC and NASCOP 2014). In addition, the 
two counties had the three categories of target population for the evaluation: the 
fisher folk (FF), FSWs, and MSM. Specific characteristics of the county are briefly 
described below. 
SIO Evaluation Report (July 2015) 4
• Busia County has an estimated population of 536,000 people with about 16,970 
on antiretrovirals (ARVs). Mother-to-child transmission of HIV is estimated at 5.3%. 
The malaria positivity rate is 47.2% and tuberculosis (TB) prevalence is 329/100,000 
(Health Policy Project 2012). 
• Kisumu County has an estimated population of 1 million people with about 40,000 
people on ARVs. Mother-to-child transmission of HIV is estimated at 9.3% and TB 
prevalence is 379/100,000 (which is way above the national average of 223/100,000). 
Malaria positivity is estimated at 36.6% (Health Policy Project 2012). 
SIO Evaluation Report (July 2015) 5
SECTION 2: METHODS 
This evaluation was implemented among the FF, MSM, and FSW aged 18 to 49 
years in Kisumu and Busia Counties. The main criterion for inclusion was peers who 
had participated in at least one session between January 2013 and December 2014. 
The data collection process also involved interviewing the HAs, coordinators, and 
leaders of local implementing partner (LIP) organizations. 
2.1 Sampling frame and sample selection 
A mixed method approach that includes both quantitative (interviewer-based 
questionnaire) and qualitative (focus-group discussions [FGDs] and key informant 
interviews [KIIs]) was used to assess SIO outcomes among the target population. 
The selection of the respondents to the quantitative survey entailed several stages: 
i. Selecting two LIPs per county: Keeping Alive Societies Hope (KASH) and 
Kenya Red Cross Society (KRCS) in Kisumu; and Anglican Development 
Services, Western (ADS) and Busia Survivors in Busia. 
ii. For each of the LIPs, a list of the trained and active HAs was drawn and 31 
were randomly selected based on the total number of peers reached by the 
LIPs: ADS Western – 9; Busia Survivors – 10; KRCS – 7; and KASH - 5. 
iii. For each of the selected HAs, a list of all the peers they had interacted with, 
over the period January 2013 to December 2014, was drawn and a random 
sample of 15 to 16 names selected. A replacement name was also selected in 
case the individual selected was not available for the interview. 
2.2 Training of the research team 
Training was held in Kisumu over a three-day period (from May 25 to 28, 2015). In 
total 22 participants attended the training: 12 research assistants, 6 supervisors, and 
4 data entry clerks. Four APHIAPlus staff and a consultant facilitated the training. 
The first two days of training entailed introducing the participants to APHIAPlus and 
SIO, taking them through the evaluation protocol, research ethics, and data 
collection techniques and tools. The process also involved translating the tools into 
Kiswahili and Dholuo. 1 Role-plays were used to help the research team to 
understand the sequence of questions and the skip pattern. 
The third day was used for pre-testing the tools. The KRCS facilitated the pre-test at 
a beach that was not involved in the main data collection exercise. Each research 
team member interviewed one person using the questionnaire, and each supervisor 
conducted one KII. The process was followed by a debriefing session that involved 
reviewing the process and time spent and refining the data collection tools. 
2.3 Data collection 
The process of document review was initiated on May 18, 2015, while primary data 
 
1During the pre-test in Kisumu it emerged that some of the respondents, especially the fisher folk, 
did not understand Kiswahili—hence the need to translate the tool into Dholou for a standardized 
approach to the interviews. 
SIO Evaluation Report (July 2015) 6
were collected from May 28 to June 06, 2015, in the two counties. The approach 
used to gather data is summarized below (a summary of the tools used is presented 
in Table 1; see also Annex 1). 
 
i. Program data review was conducted to determine the number of people 
reached through SIO and the referrals made to access services, as well as 
to analyze any changes in access to key services. These data and records 
were obtained from the HAs, LIPs, and APHIAplus project. 
ii. A review of the implementation process was done with implementing 
partners to get an understanding of the process. The data were 
generated by use of a KII guide. 
iii. Quantitative data: a questionnaire was administered to peers who had 
participated in SIO sessions to establish the level of exposure to the 
intervention and also their knowledge, attitude, and practice. It should 
be noted that in Kisumu the achievement in terms of interviews planned 
and conducted was 94% while for Busia it was 88%. 
iv. Qualitative: FGDs and KIIs were used to gather qualitative data. KIIs were 
conducted to obtain important details about behavior and practice. FGDs 
were held with beneficiaries to capture the changes that have occurred 
as a result of their participation in SIO sessions. 
Table 1: A summary of the tools used to generate data for the evaluation
Tool Kisumu Busia
Planned Achieved Planned Achieved
Questionnaire
FF 123 117 (95%) 144 138 (96%)
FSW 44 41 (93%) 131 120 (92%)
MSM 32 29 (91%) 32 13 (41%)
Total 199 187 (94%) 307 271 (88%)
Key informant interviews
FF 7 7 9 9
FSW 3 3 8 6
MSM 2 2 2 3
Coordinator 2 2 2 2
LIP manager/
director
1 1 1 0
Total 15 15 22 20
Focus group discussions
FF 2 2 2 2
FSW 1 1 1 1
MSM 1 1 1 0
Health activists 2 2 2 5
Total 6 6 6 5
Abbreviations: FF, fisher folk; FSW, female sex worker; LIP, local implementing partner; MSM, men who 
have sex with men. 
2.4 Data analysis 
Analysis of quantitative data: The data were analyzed using descriptive techniques, 
then tested for differences between respondents with low exposure level (1 to 4 
sessions) and those with high exposure level (5+ sessions) using the chi-square test 
of independence for categorical variables. The analysis focused on measures related 
SIO Evaluation Report (July 2015) 7
to HIV-related knowledge, attitude, and practice.
Analysis of qualitative data: The qualitative data were analyzed manually based on 
the evaluation objectives. All the transcripts were typed and read through by the 
consultant. Quotes have been used in this report to give the participants a voice and 
triangulate the quantitative results. 
2.5 Ethical approvals and consenting 
The ethical approvals for the evaluation were obtained from the National 
Commission for Science, Technology and Innovation (NACOSTI) and Maseno 
University Ethical Review Committee. An approval for non-research determination 
was also obtained from PATH’s research and ethical committee. During the training, 
the research team was oriented on the consenting process. For each of the data 
collection tools, the participants were expected to consent and these consent forms 
are in the custody of APHIAplus. All the participants were assured of confidentiality 
and anonymity. 
2.6 Key challenges 
Although the LIPs made great effort to ensure that the HAs were aware of the 
evaluation and that they were available to support the team, there were several 
challenges encountered, especially in Busia: 
i. Refusals: in Busia, some of the MSM declined to participate in the 
evaluation, demanding payment for transport, which had not been 
factored in the evaluation budget. This explains the shortfall in number 
of questionnaires conducted in Busia among this group. 
ii. Working hours: there were some difficulties getting the FSWs and MSM 
during the day. To mitigate this challenge, the research team worked 
during evening hours in Busia town because that was the only time they 
could reach the respondents. 
iii. Poor record-keeping: part of the questionnaire (Section Zero) was to be 
completed based on the records kept by the HAs. However, during the 
assessment it became apparent that some of the HAs’ records were 
poorly kept with missing or incomplete information. The process was 
also laborious and some of the sections of the questionnaire had to be 
completed later (in Kisumu, for instance). 
SIO Evaluation Report (July 2015) 8
SECTION 3: RESULTS ON THE IMPLEMENTATION PROCESS 
The results presented in this section are based on program data review and the 
discussions held with LIP coordinators, managers, and the HAs. The main focus is to 
present the number of people reached, the implementation process and the lessons 
learned, the key challenges faced by the LIPs, and the sustainability of the gains 
made through the SIO intervention. 
3.1 The initiation of SIO 
It is notable that the SIO project intervention was designed based on the lessons 
learned by PATH through the implementation of peer-education activities since 
2000. The planning and training process took close to two years and it involved 
developing documents, selecting LIPs, recruiting HAs, and conducting training as 
summarized in Table 2. 
Table 2: Flow of activities toward the establishment of Splash! Inside Out (SIO)
No. Dates Key activities
1. Jan–Dec 2011 Use of APHIA II Western Project Community Health Volunteers’ Manual to 
reach most-at-risk populations (MARPs)
2. Jan–Apr 2012 SIO concept is adopted by APHIAplus to respond to the needs of the 
MARPS
3. May–Aug 2012 SIO is developed, reviewed, and released as Draft Health Activist Trainers 
Guide; also, Draft Health Activist Manual: How to Engage in Health 
Activism is released
4. Sep 2012 Preparations to conduct SIO training of trainers (TOT) gets underway
5. Oct–Nov 2012 SIO TOT is conducted for representatives of local implementing partners 
(LIPs)
6. Dec 2012 LIPs begin the identification and recruitment of those to be trained as 
health activists
7. Jan–Apr 2013 LIPs conduct SIO health activists training
8. Jan–Jun 2013 SIO rollout gets underway as the draft data collection tools are completed, 
printed, and distributed to LIPs
3.2 Program reach 
Twelve (12) of the original 17 APHIAplus-contracted LIPs have been implementing 
SIO for FSWs, MSM, and FF in the various counties of the Western Region of Kenya. 
Data available to the evaluation team indicate that in 2013 and 2014 the project had 
reached 17,459 and 75,677 beneficiaries among FSWs, MSM, and FF as shown in 
Table 3. 
Although the project was initiated in 2011, the rollout of activities was evident from 
2012 with the recruitment of HAs among the MSM. 
Table 3: Number of beneficiaries reached, by target population
Key Population Year
2013 2014
Female sex workers (FSWs) 9,839 48,717
Fisher folk (FF) 7,081 23,986
Men who have sex with men (MSM) 539 2,974
Total 17,459 75,677
SIO Evaluation Report (July 2015) 9
3.3 SIO implementation process and lessons learned
The four organizations involved in this evaluation (KASH, ADS, Busia Survivors, and 
KRCS) have been involved in HIV and AIDS interventions for at least 10 years. Each 
of the organizations was, at the time of the evaluation, in addition to SIO, 
implementing other interventions funded by other organizations but targeting the 
same population. For instance, KASH was at the time of the evaluation 
implementing a governance project funded by USAID and a human rights project 
funded by the Open Society Initiative for Eastern Africa (OSIEA)with a focus on FSW 
and MSM. Busia Survivors was also receiving financial support from OSIEA. ADS in 
Busia was implementing a human rights component funded by Diaconia Sweden. 
This project deals with justice, economic empowerment, and access to sexual and 
reproductive health (SRH) services. 
The two SIO models of sharing information (one-on-one and small group 
discussions) worked well for different target groups and for the varied topics. It was 
noted that many FSWs in Busia were reported to prefer talking about HIV and AIDS 
during one-on-one discussions rather than during group sessions. This was 
connected to the fear of others knowing one’s HIV status. 
In discussions with the coordinators and project teams, they were in agreement that 
the adoption of a HA model was different from the traditional peer-education 
approach. Several elements of the implementation of SIO highlighted by the HA 
coordinators and LIP managers are summarized below. 
i. The process of selecting HAs: This was reported to be an open process that 
entailed people applying and being interviewed. One MSM HA reported that 
he saw the advertisement, applied, was called for an interview and was 
offered the position. 
ii. The training of LIP coordinators: The coordinators interviewed reported that 
they had attended various training sessions sponsored by APHIAPlus to 
equip them with SIO implementation and management skills including 
reporting. 
iii. The training provided to the HAs: Through the project, the HAs were trained 
for various periods of time on the SIO approach and provided with skills to 
enable them to transfer the knowledge and skills to their peers (this could 
imply a lack of uniform training for all HAs). The main challenge expressed 
during the discussions was the need for refresher courses and training of new 
HAs to replace those who have left for various reasons. 
iv. Regular review meetings: The project holds quarterly review meetings during 
which SIO implementation issues are deliberated, challenges shared, and 
resolutions reached. 
SIO Evaluation Report (July 2015) 10
v. Access to legal support: It was clear during discussions with the FSWs and 
MSM that having a legal officer in the LIP was of critical importance. One of 
the MSM key informants commented: ‘No police officer can mess with me 
now—I just tell them that I will call my lawyer.’ The HAs and peers had also 
been taken through human rights training, and some of them were serving 
as paralegals through other partner funding. The FSWs in Kisumu were 
categorical that they knew their rights and under KASH they were protected. 
vi. Facilitation for the LIPs to link up with service providers: The referral linkages 
established with health facilities were seen as enablers to behavior change. 
The FSWs and MSM cited friendly service points in Kisumu and Busia where 
they sought health care without fear of stigma and discrimination. The 
establishment of the Drop in Center by KASH in Kisumu and the health clinic 
by Busia Survivors was considered by the peers as one of the key milestones 
for the project. 
vii. Supply of commodities, more specifically condoms and lubricants to the FSWs 
and MSM: Access to lubricants was identified as an important intervention 
for both the FSWs and MSM. 
viii. Facilitation of the HAs as a motivation for them to continue performing their 
roles on the project: The allowances given to the HAs were contingent upon 
them submitting their monthly reports. The KES 1,500 given to each HA 
monthly is a considerable investment by APHIAPlus. However, a majority of 
the HAs complained that the amount of money given was not 
commensurate with the tasks they were expected to perform. The 
suggested amount was ‘over KES 5,000 per month’ and that they should be 
on contract. 
In summary, the evaluation participants cited the following as some of the key 
achievements of SIO: 
i. Involvement of the police: there are joint activities between the FSWs and 
the police. 
ii. Sensitizing bar owners, public health officers, and city/county police officers 
on the needs of the MSM and FSWs. 
iii. The peers were more confident and enthusiastic and the level of their 
engagement in project activities had increased over time. 
iv. Feedback from the beneficiaries indicated that the HAs were contributing to 
their communities. 
v. Referrals and access to services were working well. There was, however, a 
suggestion that the referral forms should be in triplicate so that a copy can 
be retained by the LIP. 
vi. Through Community PWPs there has been a reduction in the number of 
people who are sick and those not adhering to treatment. 
vii. Reduction of sex workers living in denial of HIV infection. 
viii. Increased family planning (FP) uptake and reduced number of abortions. 
SIO Evaluation Report (July 2015) 11
ix. Increased access to psychosocial support: access to continuous counseling 
on need basis. 
x. Increased access to prevention of mother-to-child transmission (PMTCT) of 
HIV. 
xi. Access to legal support, which had led to a reduction in the abuse of the 
rights of FSWs, MSM and FF. 
xii. Opportunities for international representation for some members: one of 
the FSWs in Kisumu had been to an international conference prior to the 
assessment and she was very happy with the opportunity accorded to her. 
3.4 Key challenges experienced by the LIPs and health activists 
During the FGDs and KIIs, the participants shared their challenges in implementing 
SIO, including those listed below. 
i. Late remittance of funds by 
APHIAPlus: Late fund dispersal led 
to the cancellation of some 
activities and resulted in some 
HAs abandoning their activities. 
For instance, the ADS lost 14 
activists (from 56 to 42). The 
KASH team reported that the 
delay had led to the cancellation 
of the monthly review meetings, 
yet these were considered 
important forums for sharing 
information, assuring quality, and 
finding solutions to challenges. 
ii. Reporting: Poor record-keeping was reported and observed during the 
evaluation. 
iii. Managing expectations: Some of the peers, especially the MSM, expected 
handouts if they were to be involved in any project activity. 
iv. Effectiveness of partnership arrangements: Challenges were reported with 
respect to partnerships that were agreed upon between the LIP and 
APHIAPlus. For instance, the arrangement between Busia Survivors and 
APHIAPlus whereby Jhpiego was expected to provide HTC counselors 
and conduct HTC as per Jhpiego’s APHIAPlus mandate was reported not 
to have worked well. A key informant stated that: 
The arrangement is that Jhpiego provides counselors but this has not 
worked well. Busia Survivors mobilizes its members and then it is informed 
that the counselors are not available. (KII, Busia) 
In summary, the challenges reported by the evaluation participants are listed below. 
i. The reporting tools were considered too many and bulky. In addition, the 
bags provided for carrying the tools were termed inappropriate given the 
size and weight of the six books. 
Box 1: Some operation challenges 
 Sometimes the peers do not come for 
the forums such as the group sessions 
when they are called
 The peers sometimes talk like the 
health activists are gaining from the 
program on their behalf when they 
are not gaining financially
 Inadequate and inconsistent access to 
KY jelly and condoms
 Limited advocacy meetings that 
would ensure peers take the sessions 
seriously 
Source: FGD FSWs
SIO Evaluation Report (July 2015) 12
ii. Capacity-building: the need for refresher courses was reported. In addition, 
due to the mobility of the target population, there was a constant need to 
make replacements that required training. 
iii. Regular customers of FSWs abuse the children of FSWs and they have no 
legal recourse. 
3.5 Sustainability of SIO activities 
During the qualitative enquiry, it emerged that the SIO beneficiaries had been 
informed of the pending closure of the APHIAPlus project. The participants were 
therefore asked their views regarding the closure and what impact it would have on 
the target population. The key concern for FSWs and MSM was the possible limited 
access to commodities—condoms and lubricants. They were of the view that they 
would continue to share the knowledge they had acquired although, without the 
facilitation from the LIPs, their efforts would be limited. The following were the 
other activities and opportunities that would be affected with the project’s closure: 
i. Sensitization of new entrants into sex work and fishing-related activities. 
ii. Linkage to service providers, which were perceived to work mainly due to 
the linkages created through the project. 
iii. Networking opportunities that were made possible through APHIAPlus. 
iv. Access to information that was channeled through APHIAPlus to the LIPs 
and then to the project beneficiaries. 
What was, however, clear from the discussions with the HAs was the fact that as 
long as the LIPs would continue to exist, they would be supported in undertaking 
some of the activities. One of the project coordinators noted that, although 
APHIAPlus funding was coming to an end, the limited funds in the organization 
would be used to support the HAs in undertaking some of the activities that do not 
require heavy financial inputs. 
Apart from the expected support by the LIPs, some of the HAs and peers had 
formed income-generating groups. Further, some were involved in other ventures 
that would support them beyond the project. It is probable that the income from 
the income-generating activities (IGAs) will substitute for the monthly stipend, and 
that therefore the HAs may continue conducting sessions. For example: 
i. The FSWs under KASH had formed a merry-go-round and table banking 
where each member was contributing funds on a regular basis and could 
borrow when in need. 
ii. At Sio Port Beach, members had started contributing to National 
Hospital Insurance Fund (NHIF) to ensure access to health services. In 
addition, they had established a savings and credit cooperative (SACCO) 
through which they would be able to access funds for development and 
emergencies. 
iii. At Busia Survivors, members were involved in table banking. 
Additionally, they had enrolled in an Emergency Support Scheme where 
they contribute Ksh.50 per month and could access funds when in need 
of treatment. 
SIO Evaluation Report (July 2015) 13
SECTION 4: RESULTS ON PROJECT OUTCOMES 
This section presents the key results of the evaluation in nine subsections based on 
both the quantitative and qualitative data: (i) socio-demographic characteristics of 
the respondents; (ii) knowledge on HIV and AIDS, PMTCT, and STIs; (iii) HIV and 
AIDS accepting attitudes; (iv) HIV and AIDS behavior change and practices; (v) HIV 
counseling and testing and voluntary medical male circumcision; (vi) exposure to 
and effects of SIO; (vii) information sharing on HIV and AIDS; (viii) exposure to 
health promotion messages; and (ix) SIO efficacy analysis. Quotes are used to give 
voice to the participants who took part in the qualitative aspects of the evaluation. 
4.1 Socio-demographic characteristics of the respondents 
The questionnaire was implemented among the three target groups: FF, FSWs, and 
MSM. About two-thirds (67%) of the respondents were female and about two-fifths 
(41.8%) were married or living with a partner, as summarized in Table 4. 
Table 4: Socio-demographic characteristics of questionnaire respondents
Characteristic N=439 %
Sex Male 33.0
Female 67.0
Education Never attended school 2.7
Attended primary school 38.6
Completed primary school 18.9
Attended secondary school 20.3
Completed secondary school 15.5
University 1.1
Attended tertiary college 2.3
Attended vocational or technical school 0.5
Marital status Never married 21.9
Currently married/living with a partner 41.8
Married live separately 1.6
Divorced/separated 18.3
Widowed 16.4
Employment 
status
Employed 16.0
Not employed 84.0
If not employed, he/she earned income in the last 2 
months
87.9
Location Kisumu 41.7
Busia 58.3
Key population Fisher folk (FF) 54.9
Female sex workers (FSWs) 33.9
Men who have sex with men (MSM) 11.2
It is notable that although most of the study respondents were not employed they 
earned income in the last 2 months prior to the evaluation. It was reported that 
some of the MSM and FSWs in Busia were engaged in other income-generating 
activities (IGAs) as a way of camouflaging their real source of income. A key 
informant observed that: 
SIO Evaluation Report (July 2015) 14
Most of our members are involved in other activities during the day. Some sell 
second-hand clothes, others are barmaids while others do petty trade. They do this 
to cover up their sex work. Those who have children try to hide the sex work from 
them. (KII, Busia) 
4.2 Knowledge on HIV and AIDS, PMTCT, and STIs 
It is notable that all the respondents had heard about HIV and AIDS and almost all 
(97%) had heard about ARVs. In terms of citing ways through which HIV is 
transmitted, the results indicate high levels of knowledge among all the categories 
of respondents as shown in Figure 1. 
Figure 1: Reported ways through which HIV is transmitted (percentage) 
When asked about the most common means of transmitting HIV in Kenya, most of 
the respondents (98.1%) cited unprotected sex. 
The respondents were also asked to name measures someone can take to protect 
him/herself from contracting HIV. The most common form of prevention cited was 
consistent use of condoms (86.6%). The results based on the target groups (FF, 
FSWs, and MSM) differed in terms of the importance placed on the preventive 
measures, as shown in Figure 2. 
98.1
82.1
89.5
84.4
72
14.6
0 20 40 60 80 100 120
Unprotected sex
Sharing needles
Breast feeding
Pregnancy/delivery
Donating/receiving blood
Other
%
SIO Evaluation Report (July 2015) 15
Figure 2: HIV prevention strategies reported by target group (percentage) 
Abbreviations: FF, fisher folk; FSW, female sex worker; MSM, men who have sex with men. 
During the qualitative enquiry, the FSWs were of the view that abstinence was 
unrealistic since their business was to sell sex. A male FF noted that it was not 
possible for grown men and women to abstain, thus: 
You come from the Lake after several days… It is impossible to abstain. The only 
thing that can work is to be faithful to your partner or you use condoms. (KII, FF, 
Busia) 
The respondents were asked a range of questions to assess their knowledge levels 
on HIV and AIDS. The responses summarized in Table 5 indicate a high level of 
knowledge regarding risky behaviors that can expose one to HIV infection. 
Table 5: Perceptions toward HIV risk, by target group
No. Question % (Yes)
FF FSW MSM Total
1. Can the risk of HIV transmission be reduced by having 
sex with only one faithful partner?
85.4 78.2 81.6 82.6
2. Can the risk of HIV transmission be reduced by using 
condoms?
95.4 98.6 93.9 96.3
3. Can a healthy-looking person have HIV? 92.1 96.6 98.0 94.3
4. Can people protect themselves from getting infected 
with HIV by having no sexual intercourse?
61.8 72.8 55.1 64.8
5. Is there anything a person infected with HIV can do to 
be cured?
27.1 29.7 10.2 26.1
6. Can a healthy-looking person transmit HIV? 89.6 96.6 98.0 92.9
7. Can a person get HIV from mosquito bites? 28.3 29.7 14.3 27.2
8. Can people get HIV because of witchcraft or through 
other supernatural means?
7.5 3.4 8.2 6.2
9. Can the virus that causes HIV be transmitted to a 
baby during pregnancy?
57.1 63.5 55.1 59.0
10. Can the virus that causes HIV be transmitted to a 
baby during delivery?
92.9 95.3 83.7 92.7
11. Can the virus that causes HIV be transmitted to a 
baby through breastfeeding?
87.9 87.2 85.7 87.7
Abbreviations: FF, fisher folk; FSW, female sex worker; MSM, men who have sex with men. 
SIO Evaluation Report (July 2015) 16
4.3 HIV and AIDS accepting attitudes and stigma 
The respondents were asked a range of questions regarding how they would relate 
to people infected with HIV to which they answered in the affirmative or not as 
presented in Table 6. 
Table 6: Percentage who reported HIV accepting and stigmatizing behavior
No. Perception %
1. Would you buy fresh vegetables from a vendor with HIV or AIDS? 93.1
2. Would you keep it a secret if a member of your family is infected with HIV? 57.0
3. Would you care for a member of your family infected with HIV? 97.9
4. Should a female teacher infected with HIV be allowed to teach? 94.3
The respondents were also asked to agree or disagree on two statements: Do you 
agree or disagree that PLHIV [people living with HIV] should be ashamed of 
themselves? Do you agree or disagree that PLHIV should be blamed for bringing HIV to 
the community? Most of the respondents (94.5%) disagreed with the statement that 
PLHIV should be ashamed of themselves and 92.5% disagreed with the statement 
that PLHIV should be blamed for bringing HIV into the community. 
In terms of stigma, the qualitative results indicated that it was still prevalent. A 
program coordinator noted that: 
The level of stigma among the MSM is very high. They are also very mobile. They 
have challenges in finding places to do their business in this town. It is difficult for 
them to get guesthouses locally to do their business. (KII, Busia) 
4.4 HIV and AIDS behavior change and practice
4.4.1 Sexual experience 
Almost all the respondents reported to ever have had sex (98.8%) reported that 
they had had sex in the 12 months preceding the evaluation. Of all the respondents 
who reported to have had sex in the last 12 months, 51.9% reported to have had sex 
with more than one sexual partner. The highest proportion of those who reported to 
have had sex with multiple partners in the preceding 12 months was among the 
FSWs (81.2%), followed by the MSM (78.7%), and lastly the FF (27.3%). There were 
no gender differences reported in sex with multiple partners. 
4.4.2 Alcohol and drug use 
In terms of use of alcohol and drugs, about one-third (62.4%) of the respondents 
reported that they had never taken any substances and 18.7% reported that they 
took alcohol at least once a week, as shown in Table 7. 
SIO Evaluation Report (July 2015) 17
Table 7: Percentage who reported consumption of alcohol and drugs 
in the past 3 months (N=439)
No. Frequency %
1. Every day 7.5
2. At least once a week 19.9
3. Less than once a week 5.6
4. Never 66.5
5. No response 0.4
Those who take alcohol/drugs were asked if they had had sex in the 3 months prior 
to the evaluation while under the influence of alcohol/drugs. The results indicate 
that about 35.9% were under the influence as presented in Table 8. 
Table 8: Percentage who reported sexual intercourse under the 
influence of alcohol/drugs
No. Sex under the influence of alcohol/drugs %
1. None of us was 51.5
2. I was 8.8
3. My partner was 16.3
4. Both us were 10.8
5. Not applicable 11.1
6. Don’t know 1.0
7. No response 0.5
4.4.3 HIV risk perception including risk of TB and malaria 
The respondents were also asked to rate the risk of getting infected with a range of 
diseases. It is notable that 14% of them reported, unprompted, to be infected with 
HIV at the time of data collection. The risk of contracting malaria was perceived as 
high as illustrated in Figure 3. 
Figure 3: Perceived risk of contracting HIV, a sexually transmitted infection (STI), tuberculosis 
(TB), and malaria (percentage) 
There were some differences observed in perceived risk among the three target 
populations as illustrated in Table 9. 
12.8
23.6 21.7
5.5
29
44
48.1
20.9
26.5
21 21
29.7
17
11.4
9.3
43.9
0
10
20
30
40
50
60
HIV STI TB Malaria
None
Low
Medium
High
SIO Evaluation Report (July 2015) 18
Table 9: Perceived risk, by target population
No. Risk Perceived risk FF FSW MSM
1. HIV infection No risk 18.8 5.7 4.5
Low risk 33.2 23.6 25.0
Medium risk 24.7 27.7 38.6
High risk 15.2 20.0 15.9
2. STI No risk 31.1 17.5 6.1
Low risk 45.2 39.9 51.0
Medium risk 16.2 24.5 32.7
High risk 7.5 18.2 10.2
3. TB No risk 22.9 22.2 14.3
Low risk 48.5 42.4 63.3
Medium risk 21.1 22.2 16.3
High risk 7.5 13.2 6.1
4. Malaria No risk 5.3 4.9 8.2
Low risk 22.4 14.6 32.7
Medium risk 30.3 28.5 30.6
High risk 42.1 52.1 28.6
Abbreviations: FF, fisher folk; FSW, female sex worker; HIV, human immune-deficiency virus, MSM, men who 
have sex with men; STI, sexually transmitted infection; TB, tuberculosis. 
Exposure to TB was considered a key challenge among the FF due to their nature of 
work as observed by a group of HAs: 
TB is another problem and it is a challenge especially along the beaches where 
people are crowded and the disease can easily spread to people since TB is spread 
through the air. We encourage people to get TB screening and treatment. Some of 
those people I have referred are under medication while some have already 
completed treatment. (KII, FF, Busia) 
There was however a perception among the HAs and coordinators that more effort 
and investment was required to see behavior change among the MSM, since most 
of them were still in the closet. For instance, a coordinator noted that: 
The MSM share sexual partners and they tend to want to get into long-term 
relationships with their clients. In addition, they possess clients and spread 
infections amongst themselves. Recruitment of school boys is a key area of concern 
for us with some of the young boys who want to experiment posing as clients. 
Condom use is also low among the MSM and some of them are not ready to come 
from their closets because some of their clients are pastors and priests who would 
want to remain anonymous. (KII, MSM) 
4.4.4 Family planning 
In terms of knowledge of FP, almost all the respondents knew of ways through 
which pregnancy can be prevented (99.3%). The most commonly cited methods of 
pregnancy prevention were the injectable (72.4%), pills (67.4%), and male condom 
(62.2%) as presented in Table 10. 
SIO Evaluation Report (July 2015) 19
Table 10: Family planning methods cited (N=439) (percentage)
No. Contraceptive method %
1. Injectable 72.4
2. Pills 67.4
3. Male condom 62.2
4. Implants 54.9
5. Intrauterine device (IUD) 34.4
6. Female condom 29.2
7. None 11.2
8. Female sterilization 10.7
9. Rhythm 9.3
10. Male sterilization 8.2
11. Withdrawal 3.0
12. Lactational amenorrhea method (LAM) 2.7
13. Emergency contraceptive 2.3
14. Other 3.6
In addition, the respondents were asked if they had ever used any FP method. The 
results indicate that the most commonly used forms of contraception were male 
condoms (36%) and injectables (31.7%) as summarized in the Table 11. 
Table 11: Reported use of contraception (N=439) (percentage)
No. Contraceptive method %
1. Male condom 36.0
2. Injectable 31.7
3. Implants 18.7
4. Pills 13.7
5. None 11.2
6. Female condom 6.2
7. IUD 4.1
8. Female sterilization 1.6
9. Rhythm 1.8
10. Withdrawal 0.7
11. Male sterilization 0.5
12. Emergency contraceptive 0.7
13. Other 1.1
4.5 HIV counseling and testing and voluntary medical male circumcision 
Almost all the respondents (99.5%) reported that they knew where someone who 
needed to test for HIV could get the test done. About three-quarters of the 
respondents (75.5%) reported that they had been tested in the three months 
preceding the evaluation and 98.2% had received their results, as shown in Table 12. 
Table 12: Reported HIV testing, by target group (percentage)
No. HIV testing %
1. In the last 3 months have you been tested to see if you are infected with HIV? 75.5 
2. Did you find the result of your test? 98.2
3. Tested for HIV in the last 3 months – FF (fisher folk) 74.4
4. Tested for HIV in the last 3 months – FSWs (female sex workers) 73.5
5. Tested for HIV in the last 3 months – MSM (men who have sex with men) 85.7
6. Tested for HIV in the last 3 months – Kisumu 82.0
7. Tested for HIV in the last 4 months – Busia 70.9
SIO Evaluation Report (July 2015) 20
Through the FGDs and KIIs among the FSWs and MSM, it was apparent that they 
approached HIV testing differently. On one hand, the FSWs reported that they 
talked to each other about their results and they knew each other’s status and who 
among them was on treatment. Indeed, they tended to provide information on their 
HIV status unprompted. The MSM, on the other hand, reported that HIV status was 
a personal issue and individuals could chose to share the results or not. 
All male respondents (n=146) were asked if they were circumcised, and the majority 
(73.3%, n=107) responded in the affirmative. A site breakdown showed that 57.3% 
of male respondents in Kisumu County were circumcised compared to 90.1% in 
Busia County. 
4.6 Exposure to and effects of SIO 
The respondents were asked a range of questions regarding their exposure to the 
SIO project and the impact of the intervention on their behavior. The questions 
examined the sessions attended, services sought, and services accorded to them. 
4.6.1 Number of sessions attended 
When asked about the number of sessions the beneficiaries had attended between 
January 2013 and December 2014, about two-fifths (39.2%) had attended more than 
7 sessions as illustrated in Figure 4. 
Figure 4: Reported number of Splash! Inside Out (SIO) sessions attended (percentage) 
19.1
23.7
15.5
39.2
2.5
0
5
10
15
20
25
30
35
40
45
1-2 3-4 5-7 >7 Don't know
Sessions
%
SIO Evaluation Report (July 2015) 21
In terms of the issues discussed during the sessions, the most cited was HIV and 
AIDS, as summarized in Table 13. 
4.6.2 Effects of SIO
The respondents were also asked to name the effects of the intervention on them 
including what actions they had taken since getting involved in the project. The 
responses, summarized in Table 14, indicate that a higher proportion of FSWs than 
other target groups went for an HIV test (68.3%). 
Table 14: Reported action taken after exposure to Splash! Inside Out, by target group
(percentage)
No. Action taken %
FF FSW MSM Total
1. Went for an HIV test 53.1 68.3 61.2 42.4
2. Made a decision to use condoms all the time 15.4 40.3 28.6 25.3
3. Spoke to someone else about behavior change 25.3 21.5 28.6 24.4
4. I reduced sexual partners 13.3 17.4 18.4 15.3
5. My attitude toward people living with HIV (PLHIV)
changed
9.5 21.5 20.4 14.8
6. I realized I was at risk of HIV 12.4 14.1 12.2 13.0
7. Went for voluntary medical male circumcision 
(VMMC)
5.0 0.0 6.1 3.4
8. Other 20.7 14.1 16.3 18.0
Abbreviations: FF, fisher folk; FSW, female sex worker; MSM, men who have sex with men. 
The ‘Other’ category included actions such as willingness to take ARVs, used FP, and 
changed behavior at a personal level. 
During the KIIs, the HAs were asked about what changes they had seen among their 
peers as a result of the SIO intervention. All of them were of the view that 
knowledge levels had increased and some of the peers had adopted risk-reduction 
behavior. One key informant cited four changes he had observed among the FF, 
thus: 
Table 13: Reported topics discussed in Splash! Inside Out sessions (percentage)
No. Topic %
1. HIV and AIDS 87.8
2. Family planning 39.2
3. Sexually transmitted infection (STI) 34.4
4. Care and support of people living with HIV (PLHIV) 28.7
5. Sexuality and relationships 22.5
6. Alcohol and drug abuse 21.5
7. Tuberculosis (TB) 21.3
8. Malaria 19.1
9. Prevention of mother-to-child transmission (PMTCT) of HIV 15.6
10. Maternal health 11.0
11. Gender 7.2
12. Other 20.0
SIO Evaluation Report (July 2015) 22
People are changing slowly. People know protective sex and about re-infections. 
They have access to FP information. They hold monthly meetings during which 
they give and receive feedback. Many children being born are HIV free and many of 
the youth are HIV free because of protective sex.(KII, HA) 
A group of FSWs in Kisumu observed that, due to the project, their peers had a good 
understanding of the risks including the risk of re-infection. They also understood 
the need to be on treatment: 
Due to the sessions with the health activists, the peers now know that those who 
are HIV positive have to live positively and hence they take their drugs without 
missing even when they take alcohol. 
It was reported that the FSW peers reminded each other when it was time to take 
their ARVs because being healthy was seen as one way of keeping customers 
coming back. They also noted that once a customer agreed to use condoms he 
would be protected and he will be alive to come back for more services. 
The discussions and interviews indicated increased access to services. The FF 
accessed health services from nearby health facilities, whereas the FSWs and MSM 
sought services from facilities that were considered friendly. The HAs have referral 
forms that they use to refer their members, which are respected by the health 
facilities. A key informant opined thus:
We refer the peers to Busembe for testing and for ARVs. But if the condition is 
serious, we refer them to Sio Port. We have referral forms that we use for this 
purpose. However, there are some of our members who do not take up the referrals 
or when they go they do not find the provider. (KII, HA, Busia) 
It emerged that, for the collaborating health facilities, there were point persons for 
care but when these individuals were out of the duty station, the referred patients 
would often not get the services required. 
4.6.3 Rating of SIO services 
The respondents were asked to rate the services they had received through the SIO 
project. It is notable that over 60% rated all the services as good or satisfactory as 
illustrated in Figure 5. 
SIO Evaluation Report (July 2015) 23
Figure 5: Rating of Splash! Inside Out (SIO) services by respondents 
Abbreviations: FP, family planning; HIV, human immune-deficiency virus; PMTCT, prevention of 
mother-to-child transmission; SRH, sexual and reproductive health; TB, tuberculosis. 
About half of the respondents (47.4%) reported to have been exposed to messages 
from other groups/organizations apart from SIO. These messages were mainly on 
HIV and AIDS from other service delivery nongovernmental organizations (NGOs)
including the African Medical and Research Foundation (AMREF), Academic Model 
Providing Access to Healthcare (AMPATH), and National AIDS & STI Control 
Programme (NASCOP). 
4.6.4 Risk reduction 
To assess the beneficiaries’ behavior in terms of risk reduction, the respondents 
were asked specific questions on their sexual behavior in the 3 months preceding 
the evaluation. The results on sexual behavior were subjected to further analysis, 
and it is clear that the FSWs and MSM still practice high-risk behaviors as shown in 
Table 15. 
Table 15: Reported risk behavior, by target group (percentage)
No. Behavior %
FF FSW MSM Total
1. Had unprotected penetrative sex with a partner whose HIV 
status is not known to you
15.8 34.2 32.7 23.9
2. Had unprotected penetrative sex with a partner whose HIV 
status is known to you
41.1 29.5 34.7 36.5
3. Had sex with someone with whom you have had no previous 
intimate relationship
6.2 26.0 16.3 14.0
4. Performed oral sex or had oral sex performed on you 5.0 17.2 26.5 11.5
5. Had sex in exchange for gifts 2.1 59.6 42.9 25.9
Abbreviations: FF, fisher folk; FSW, female sex worker; MSM, men who have sex with men.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Poor Fair Good Satisfactory
SIO Evaluation Report (July 2015) 24
The proportion of respondents who reported to have had sex in exchange for money 
was higher among women (32.3%) than men (13.1%). Table 16 presents the results 
on other sex-related behavior among the target populations. Abuse appears to be 
common among the respondents. 
Table 16: Occurrence of other sex-related behavior (percentage)
No. Behavior %
1. Been treated disrespectfully (denied household money, insulted) by your partner, 
a friend, employer, or colleague
27.1
2. Took alcoholic drinks until you forgot to do important things 14.6
3. Been physically assaulted by a family member 14.1
4. Suffered from a persistent cough 12.5
5. Shared a razor blade 11.2
6. Drank alcohol until you blacked out 8.1
7. Been forced, coerced, or fooled (including drugged) into having sexual intercourse 7.7
8. Shared a needle 5.3
9. Sought treatment for a sexually transmitted infection (STI) from a non-qualified 
health provider
3.4
10. Shared any drug paraphernalia with friends 3.2
11 Sought treatment for STI from a traditional healer 2.3
During a FGD with a group of HAs, one of the participants alluded to the gender 
transformation that had occurred as result of exposure to SIO, thus: 
Ladies take condoms and I am impressed by that since in the past generation, 
before the SIO project, ladies were not carrying condoms but nowadays after 
awareness they request for condoms because they now understand that some men 
may take advantage of them. (KII, FF, Busia) 
A group of FSWs in Busia cited the advantages of SIO and how they had gained in 
terms of prevention. They observed: 
M: What about prevention? 
R6: We have always taught them to negotiate for condom use before going to the 
room and the lady should correctly put the condom on an erect penis as we were 
taught during the splash sessions. 
R4: Again, they should check the expiry date of the condoms and how they are 
worn. If possible they should have sex when lights are on. [Giggles and laughter] 
R3: Since we know when you drink you may forget to use condoms, we were taught 
to encourage our peers to drink less, some of us do not drink when we are on duty. 
[Laughter]
R5: In fact, when a client buys you alcohol you keep some and sell it later, because 
when you are drunk you are not able to negotiate well. 
SIO Evaluation Report (July 2015) 25
A program coordinator noted that there were more apparent changes in behavior 
among the FSWs compared to the MSM. This was opined to be due to the fact that 
FSW activities were initiated several years earlier (for KASH in 2003 and for Busia 
Survivors in 2005) and the practice was more acceptable, while the MSM activities 
were added later (2008 and 2012, respectively) in a context of high levels of stigma. 
A respondent from one of the organizations observed that: 
The FSW activities were initiated in 2003 while MSM interventions were introduced 
in 2008. The FSW component is therefore stronger than the MSM. However, the 
main challenge is that MSM still has a lot of stigma. (KII, Busia) 
A group of FSWs noted that new entrants into the trade, who tend to be young girls 
and/or single mothers, face higher risks to HIV infection due to the fact that they do 
not have a good understanding of the trade. They stated thus: 
R6: Most of the new sex workers come from poor backgrounds or they are single 
mothers who badly need money for rent, food or fees so they will rush in for such an 
offer [of sex without condoms] without thinking of the risks of getting HIV and 
unwanted pregnancies 
R5: At a lounge in town men offer KES 2000 for one ‘ shot’ without protection. For a 
new people they would consider this to be a lot of money and maybe at that time 
they are drunk and they have no capacity to say no. 
Among the FF, SIO was reported to have led to a reduction in ‘fish for sex,’ which 
was recognized as a challenge in the past. Several strategies had been designed to 
support the women to gain access to additional funds to support their IGAs. A key 
informant in one of the beaches in Busia observed: 
Fish for sex was a major problem in the past but this has gone down. We have 
encouraged the women to form groups—K-Rep Bank (formerly a Micro-finance 
institute)visits them monthly. However, Ugandan men come and take our girls to 
the other side yet they do not know about SIO. (KII, Busembe Beach, Busia) 
It was however reported that once trained, the MSM seem to want to move on and 
create their own projects as opposed to the FSWs. A LIP director observed that: 
MSM are more aggressive. Two of those trained have established organizations 
that are currently running. However, we have trained many FSWs who have not 
progressed as much. (KII, LIP, Kisumu) 
Box 2: Madam E (female sex worker)
She has been a health activist since 2012. She has mobilized her peers to go for sexually 
transmitted infection (STI) screening and knows that all her peers know their HIV status. In 
addition, all her peers know their rights and they know that sex work is a job like any other. The 
peers have been linked to other groups and they now have table banking, although they are not yet 
registered as a group. The peers are healthy now. For example, STIs have been reduced. Those on 
treatment are supported by group members and are reminded to take their medicines. 
Consequently, they have customers now because they look healthy since ‘no one wants to have sex 
with someone who is coughing all the time.’ In addition, the peers have stopped stealing from their 
customers.
Source: FSW health activist, Kisumu
SIO Evaluation Report (July 2015) 26
It emerged during discussions that MSWs were at a high risk of HIV infection and 
other STIs due to the nature of their interaction and high levels of stigma. A group 
of MSM noted that although their members were sex workers in Busia, it was 
difficult for them to find rooms to do their business. This had implications on their 
mobility—they move constantly between towns (for instance, four of the MSM 
interviewed in Busia came in from Bungoma). It also emerged that despite having 
passed through SIO sessions, they still encountered abuse and risk, thus: 
R1: Some men who have sex with men still have stigma. 
M: So how does this put them at risk? 
R7: They fear going for testing or treatment. 
R1: If I may add, they have sex with people whose HIV status they do not know. The 
people can force them to have unprotected sex because they know some MSM do 
not want to blow their cover, therefore they cannot report them anywhere. 
R3: Some male sex workers do not have lubricants or cannot afford to buy, so they 
use vaseline or saliva, which exposes them to further risk. [Continuous laughter] 
(FGD, FSWs, Busia)
4.7 Information sharing on HIV and AIDS 
A large part of the SIO intervention was on providing information to peers who 
would in turn share it with other people. When the respondents were asked if they 
had shared the information they had gathered with other people in the 3 months 
prior to the survey, slightly over four-fifths (84.1%) responded in the affirmative. A 
higher proportion of them had talked to friends/peers (52.6%), siblings (12.3%), and 
other sexual partners (10.5%). A lower proportion had talked to boyfriend/girlfriend 
(8%), health worker (7.5%), and parents (3.2%). The results show that a higher 
proportion of the MSM talked to friends/peers (61.2%) compared to the FSWs 
(48.3%) and FF (44%). When asked if they had talked to their sexual partners about 
HIV, 74% responded in the affirmative. 
This aspect of information sharing was also captured during the KIIs with the HAs. 
They noted that unlike peer education, which was akin to giving lectures, SIO 
provided them with skills that allowed them to speak out and support others. They 
described SIO as enabling them to “speak out yourself to make others like you to 
speak out” and “accepting yourself and splashing it out to others.” Further, the HAs 
for FF reported that “the communities now trust us and we have become change 
agents.” In fact, an activist in Busia noted that: 
I always carry condoms with me because my clients request for condoms anywhere 
they meet me and if I do not have them they blame me. So to avoid blame, I have to 
carry condoms at all times. (FGD, HA, Busia)
SIO Evaluation Report (July 2015) 27
4.8 Exposure to health promotion messages 
The main modes of exposure to health promotion messages cited by the 
respondents, unprompted, were radio (71.0%), followed by health center (61.8%) 
and peer educator (45.9%). When respondents were prompted, peer educator 
(85.9%) ranked highest followed by community health workers (77.0%) and health 
center (74.5%) as shown in Table 17. 
Table 17: Modes of communication on health promotion messages (percentage)
No. Media Unprompted Prompted
1. Radio spots/shows 71.0 72.4
2. Health center 61.8 74.5
3. Peer educator/health activist 45.9 85.9
4. Television 46.1 57.2
5. Community health worker/volunteer 35.1 77.0
6. Dialogue group 35.4 68.3
7. Health outreach 29.0 63.7
8. Newspapers/magazine 25.8 53.4
9. Community event (baraza) 23.3 56.1
10. Nongovernmental, community-based, or 
faith-based organization (NGO/CBO/FBO)
23.2 73.3
11. Posters/stickers 23.8 66.6
12. T-shirt 16.3 79.6
13. Billboard 11.5 62.7
14. Brochure/newsletters 10.2 51.4
15. Theatre performance 7.6 49.1
16. Sporting event 7.5 42.6
17. Magnet theatre performance 3.8 34.9
It was evident during the interviews that some of the respondents and interviewees 
were oblivious of billboards on HIV and AIDS that were next to where some of the 
interviews and discussions were being held. When prompted, the respondents 
would be surprised that they had not mentioned a billboard while it had been there 
for a long period. 
4.9 SIO efficacy analysis 
In evaluating the efficacy of SIO, the participants were asked about the number of 
SIO sessions they had attended during the period covered by the study. This was 
aimed at identifying the level of exposure to SIO. HAs’ records were also obtained to 
verify the participation of respondents in SIO. The data on sessions attended were 
then analyzed to examine the differences in six key outcomes shown in Table 18. 
Responses were clustered to differentiate those who had attended 1 to 4 sessions 
(less than full exposure) and those who had attended 5 sessions2 or more (full 
exposure). A Pearson’s chi-square test (goodness of fit test) was used to determine 
if the outcomes were independent of the level of exposure. 
Overall, the results show no evidence of relationship between the numbers of 
sessions attended by the study respondents in most of the key outcome indicators 
 
2According to the SIO guide, participants are considered to have full benefit of the intervention if 
they have attended 5 or more sessions. 
SIO Evaluation Report (July 2015) 28
assessed in the evaluation. However strong evidence of relationship was noted in 
two indicators (marked with * in Table 18). 
Table 18: Splash! Inside Out (SIO) efficacy analysis, by key indicators
No. Key outcome 
variable
Measure Exposure level Chi￾square 
(X
2
)
P￾1–4 value
sessions
5 or 
more 
sessions
1. Knowledge of 
HIV risk￾reduction 
methods
Knowledge of all three risk￾reduction methods (condom 
use, abstinence, and being 
faithful to an infected partner)
12.8% 9.6% 1.13 0.287
2. Perception of 
risk
High perception of risk of HIV 
infection
51.5% 50.7% 0.019 0.89
3. HIV counseling 
and testing
Tested in the 3 months prior to 
the evaluation
71.1% 78.8% 3.41 0.065
4. Information 
sharing on HIV 
and AIDS
Talked to anyone about HIV and 
AIDS in the last 3 months
84.4% 83.9% 0.023 0.88
Talked to sexual partner about 
HIV and AIDS in the last 3 
months
71.5% 76.0% 10.76 0.05*
6. Sexual behavior Have you had sex with more 
than one partner in the last 12 
months?
41.6% 59.2% 0.001*
In the last 3 months have you 
had unprotected sex with any 
partner whose HIV status was 
not known to you?
35.8% 36.9% 0.81
Consistent use of condoms 86.7% 86.5% 0.006 0.940
*Shows strong evidence of the relationship between exposure to SIO and the intended outcome.
Knowledge of risk-reduction methods: No evidence of relationship (X2
 = 1.13, df = 1, 
p-value > 0.05).
The analysis indicates that the respondents who attended 5 or more SIO 
sessions were not statistically more knowledgeable about HIV risk-reduction 
methods compared to those who had attended 1 to 4 sessions. 
HIV risk perception: No evidence of relationship (X2 = 0.19, df = 1, p-value > 0.05). 
Likewise, the analysis indicates that the respondents who had attended 5 or 
more SIO sessions were not statistically different from those who had 
attended 1 to 4 sessions in their HIV risk perception. 
HIV counseling and testing: No evidence of relationship (X2
 = 3.41, df = 1, p-value > 
0.05).
The analysis indicates that respondents who attended 5 or more SIO 
sessions were not different in taking HIV testing during the preceding 3 
months compared to those who had attended 1 to 4 sessions. 
Sharing information about HIV and AIDS with others outside the peer network: 
Marginal evidence was observed on the relationship between exposure to 5 
or more sessions and speaking to a sexual partner about HIV and AIDS (X2 = 
SIO Evaluation Report (July 2015) 29
10.76, df = 1, p-value = 0.05). However, no evidence was observed regarding 
speaking to anyone about HIV and AIDS (X2 = 0.023, df = 1, p-value > 0.05). 
Having sex with more than one partner in the last 12 months: Strong evidence of 
relationship (X2 = 110, df = 1, p-value < 0.05). 
There is strong evidence of the relationship between exposure to more than 
5 SIO sessions compared to having attended 1 to 4 sessions. 
Had unprotected sex with a partner whose HIV status was not known to the 
respondent in the last 3 months: No evidence of relationship (X2 = 0.005, df = 1, p￾value > 0.05).
There was no evidence of a relationship between having unprotected sex 
with a partner whose HIV status was unknown to the respondents during the 
3 months preceding the assessment and the number of SIO sessions 
attended. 
Consistent use of condoms: No evidence of relationship (X2
 = 0.006, df = 1, p-value > 
0.05).
There is no evidence of a relationship between consistent use of condoms 
and the number of SIO sessions attended. 
4.9.1 SIO efficacy among the target population 
The results were analyzed based on the target population to assess if there was 
evidence of a relationship between the outcomes and sessions attended (as shown 
in Table 19). Strong evidence of a relationship between level of exposure (based on 
sessions attended) and desired outcomes was observed among FSWs in the 
following key SIO outcome indictors: 
 Had HIV test in the 3 months prior to the evaluation (X2
 = 0.800, df = 1, p￾value < 0.05). 
 Talked to sexual partner about HIV and AIDS in the last 3 months (X2
 = 8.756, 
df = 1, p-value < 0.05). 
 Had unprotected sex with any partner whose HIV status was not known to 
respondent (X2 = 10.644, df = 1, p-value < 0.05). 
SIO Evaluation Report (July 2015) 30
Table 19: Splash! Inside Out (SIO) efficacy analysis, by target population
Measure Key 
populations
Exposure level Chi￾square 
(X
2
)
P-value
1–4 
sessions
5 or more 
sessions
Knowledge of all 3 risk-reduction 
methods (condom use, 
abstinence, and being faithful to 
an infected partner)
FF 11.0% 12.3% 0.092 0.761
FSW 9.5% 6.5% 0.392 0.531
MSM 31.6% 10.0% 3.613 0.57
High perception of risk of HIV 
infection
FF 46.5% 40.6% 0.725 0.395
FSW 61.9% 60.7% 0.010 0.920
MSM 68.8% 61.9% 0.187 0.666
Tested in the 3 months prior to 
the evaluation
FF 74.0% 75.4% 0.064 0.800
FSW 56.1% 80.2% 0.800 0.003*
MSM 84.2% 86.7% 8.803 0.811
Talked to anyone about HIV and
AIDS in the last 3 months
FF 81.9% 81.6% 0.004 0.950
FSW 90.2% 84.6% 0.783 0.376
MSM 88.9% 90.0% 0.015 0.903
Talked to sexual partner about 
HIV and AIDS in the last 3 
months
FF 72.4% 76.3% 3.981 0.137
FSW 64.9% 72.7% 8.756 0.013*
MSM 81.3% 85.2% 0.114 0.735
Have you had sex with more 
than one partner in the last 12 
months?
FF 27.5% 27.0% 0.007 0.932
FSW 69.7% 85.0% 3.807 0.051
MSM 73.7% 82.1% 0.484 0.487
In the last 3 months have you 
had unprotected sex with any 
partner whose HIV status was 
not known to you?
FF 55.9% 62.3% 1.009 0.315
FSW 90.2% 62.9% 10.644 0.001*
MSM 63.2% 66.7% 0.063e 0.801
Consistent use of condoms FF 83.5% 81.6% 0.148 0.700
FSW 95.2% 93.5% 0.168 0.682
MSM 89.5% 80.0% 0.764 0.382
*Shows strong evidence of the relationship between exposure to SIO and the intended outcome.
Abbreviations: FF, fisher folk; FSW, female sex worker; MSM, men who have sex with men.
SIO Evaluation Report (July 2015) 31
SECTION 5: DISCUSSION 
There is a general assumption that development programs that combine evidence￾based strategies tailored to diverse populations while aiming for high coverage can 
have a measurable reduction in population-level HIV transmission (Ramzi et al 
2013). Key components of a comprehensive package of services for HIV 
interventions include empowering peer-led outreach (such as targeted behavior and 
social norm change approaches); community-based services in safe spaces (such as 
drop-in centers); interventions to address gender-based violence; provision of 
condoms and lubricants; STI testing and treatment; HIV testing and counseling; 
clinical care and antiretroviral treatment; and community-based care and support 
for resilience.3
The initiation of SIO was informed by the experience of PATH from 2000 in 
implementing peer-based interventions and a review of literature on programs 
addressing HIV and AIDS. The evidence showed that effective peer-based 
combination prevention interventions among key and vulnerable populations were 
inadequate. Such interventions need to be augmented to support demand creation 
for essential health services, to enhance skills for healthy behavior, and to influence 
social norms around health-seeking behavior in the long-term. The inadequacy in 
the past approaches of reaching key and vulnerable populations is recognized in the 
KASF (2014/5–2018/9). The Framework proposes several approaches that address 
the needs of the general population and those of key and vulnerable populations 
who are sometimes not reached with untargeted interventions. Indeed, one of the 
objectives of the KASF is to ‘reduce HIV-related stigma and discrimination by 50%.’
The third section of the Framework is on ‘using a human rights approach to facilitate 
access to services for PLHIV, key populations and other priority groups in all sectors.’
The four objectives in this section of the KASF have direct relevance to the 
approaches adopted by SIO: (i) remove barriers to access of HIV, SRH, and rights 
information and services in public and private entities; (ii) improve national and 
county legal and policy environment for protection of priority and key populations 
and PLHIV; (iii) improve access to legal and social justice and protection from stigma 
and discrimination in the public and private sector; and (iv) use a human rights 
approach to assist programs to pursue zero tolerance to stigma and discrimination. 
The SIO project was designed to target populations that have long been 
inadequately reached while some (FSWs and MSM) continue to encounter stigma 
and discrimination that negatively impact their ability to access information and 
services. The approach used, of working through HAs, was aimed at going beyond 
peer education to empower the project beneficiaries to become actors and pro￾actively seek information and services to better manage their risk-reduction 
strategies and their health. 
 
3http://www.usaid.gov/what-we-do/global-health/hiv-and-aids/technical-areas/key-populations￾targeted-approaches-toward. 
SIO Evaluation Report (July 2015) 32
The outcome evaluation was aimed at: (i) assessing the status of the behavioral 
outcomes among beneficiaries of the interventions; (ii) assessing the efficacy of SIO 
as a combination prevention intervention; and (iii) making appropriate 
recommendations (presented in section 6 of this report). 
(i) The status of behavioral outcomes among SIO beneficiaries: The assessment 
indicates that the beneficiaries experienced personal changes in terms of perception 
of risk and also in taking measures toward risk reduction (HIV testing, use of 
condoms, and remaining faithful to one partner—mainly for the FF). It is notable 
that the knowledge levels on prevention measures were slightly higher among the 
SIO participants than the general population. For instance, citing of HIV prevention 
by use of condoms was 86.6% among the SIO participants while for the general 
population it was 84% based on the KDHS (2014) preliminary report. In addition, the 
proportion of people who got tested and received their results was higher among 
the SIO group at 75.5% compared to the general population, where 53% of women 
and 45% of men were tested for HIV and received the results. The levels of testing 
among the SIO target group were much higher than those reported nationally. 
The discussions with the target population highlighted a high level of confidence 
among the FSWs regarding their HIV status and their work, which is an indication 
that they have attained a level of self-identity that allows them to speak out (they 
are able to ‘splash it out’), seek, and demand services. Indeed, in their interactions 
with the judicial and justice system, through the support of legal officers attached to 
the LIPs, there were reports that harassment had been reduced and that they felt 
more protected. Furthermore, each of the LIPs has made connections with friendly 
health providers, while two had established operational health facilities that allowed
the FSWs and MSM to access services in friendly environments. 
The perceptions of the beneficiaries toward the program were generally positive 
with HIV and AIDS interventions being lauded as having been successful. It is 
however notable that the FSWs and FF appeared to be more open and accessible 
than the MSM, especially those in Busia. This could be related to the fact that 
stigma is still high among the MSM and disclosure could be accompanied by 
harassment from the community. Disclosure of sexual orientation continues to be a 
key challenge in Kenya, where negative public pronouncements on homosexuality 
are commonplace (KASF 2014). The use of HAs is however one key measure of 
ensuring that MSM can access commodities and services and that they have peers 
they can consult and hold discussions with in confidence. 
Risk reduction was a key element of the SIO interventions. The results indicate that 
following exposure to SIO, some beneficiaries made conscious decisions to go for 
HIV testing, to use condoms consistently, and to be faithful to their sexual partners. 
Although being faithful was considered difficult by the FSWs, the FF cited it as a 
viable risk-reduction measure. Given the target population, abstinence did not rank 
highly among the HIV preventive measures. 
A key outcome of the SIO intervention was the accepting attitude of the 
beneficiaries toward people infected with HIV. Most (over 90%) indicated that they 
SIO Evaluation Report (July 2015) 33
would buy fresh vegetables from an infected person, that they would care for an 
infected family member, and that an infected female teacher should be allowed to 
continue teaching. The results on ‘keeping it a secret if a family member is infected’ 
(57%) indicate that there is still stigma at the community level that should be 
addressed. 
The key areas of behavior change that were expected from the combination 
prevention approach were attained by SIO. Most of the respondents knew their HIV 
status and understood the risk of re-infection, and those needing treatment were on 
treatment. The consistency in protective behavior among the FSWs and MSM 
(especially the MSWs) was, however, limited—perhaps due to poverty and the need 
for money. The fact that some men were willing to pay more for sex without 
condoms may have made it difficult for women and men in need of money to insist 
on condom use. Further, the fear of abuse was seen to limit their ability to insist on 
preventive behavior. 
The various successes experienced by SIO could also be related to the LIPs who used 
resources from other programs to augment the activities funded by APHIAPlus. It 
was noted that SIO was strong on behavioral and biomedical interventions but weak 
on the structural elements. The human rights component of the FF, FSW, and MSM 
interventions were largely funded through other donor funds. The establishment of 
table banking and connections to microfinance institutions (MFIs) were also 
facilitated through alternative funding mechanisms. In terms of sustainability of the 
gains made through SIO and related interventions, the facts that some of the FF in 
Busia were enrolled on NHIF and some members of the Busia Survivors group were 
contributing to an emergency fund were considered structures that would provide 
an income to the HAs, and therefore they would be in a position to continue 
supporting their peers. 
It is clear from the results that the ideal of health activism going beyond peer 
education to change agency was achieved under SIO. The HAs considered 
themselves and were seen by their peers as assets in terms of facilitating access to 
information and services. They felt compelled to help their peers beyond providing 
information. For instance, they moved around with condoms, accompanied the 
peers to access several services, and provided ongoing support for those with 
personal problems. The HAs had become agents of change for themselves and for 
their peers. Asked what would happen when the APHIAPlus funding ends, the HAs 
indicated that since they had the knowledge, they would continue to share this with 
their peers. The only challenge identified going forth was access to commodities 
such as condoms and lubricants. 
(ii) The efficacy of SIO as a combination prevention intervention: Participation in 
SIO sessions was considered complete once a peer had completed a set of 
subsessions within a particular session/topic area. For instance, the session on STIs 
covered an introductory component, risk factors, types of STIs, signs and 
symptoms, management, and prevention. Consequently, a peer was considered to 
have completed the session on STI if he or she participated in all the subsessions, 
which were held at the convenience of the peers. The analysis shows that the 
SIO Evaluation Report (July 2015) 34
intervention was effective in passing critical knowledge to the participants on HIV 
and AIDS and the necessary preventive measures. 
Although knowledge levels among the target population are closely aligned to 
those of the general population (KDHS 2014), it should be noted that by and large 
the FSWs and MSM have for long been isolated, with constrained access to 
information and services due to the criminalization of their activities, work 
schedules, and pervasive stigma and discrimination (mainly faced by the MSM). 
Going for HTC and being on treatment were highlighted in the qualitative 
discussions as key outcomes of the intervention. Indeed, the FSWs were open in 
their discussions and would, unprompted, talk about their status and their 
experience with treatment. The MSM, on the other hand, still face high levels of 
stigma, especially those in Busia. Thus, more investment is required to support 
them to ‘self-identify’ after which it will become easier for them to acknowledge 
their risks and take the necessary preventive actions. It is notable that the FSWs and 
FF respondents felt that risk-taking was higher among the MSM. Because disclosure 
of HIV status within the MSM groups was not as open, compared to the FSWs, there 
were concerns that they could be infecting each other unknowingly. 
It should however be noted that the definition of ‘sessions’ differed among the 
respondents. Some may have counted each encounter with the HA as a session 
while others may have considered a completed session as one session. To counter 
this challenge, the assessment team clustered participation into two categories (1–4 
sessions and 5 or above), but there is a possibility of double counting and 
miscounting. The analysis on SIO efficacy should therefore be interpreted 
cautiously. 
SIO Evaluation Report (July 2015) 35
SECTION 6: CONCLUSION AND RECOMMENDATIONS
6.1 Conclusion 
The outcomes evaluation set out to assess the impact of the SIO intervention 
among key and vulnerable populations in the Western Region of Kenya. The 
adoption of a health activism approach was informed by the need to implement a 
highly effective intervention within an environment that enforces the uptake of risk￾reduction strategies adopted by individuals. The program had three areas of focus: 
behavioral; biomedical; and structural. It is evident that through the health activism 
and the linkages established with the various service providers, the program was 
effective in achieving the behavioral and biomedical imperatives. Structural aspects 
were not effectively addressed mainly due to the fact that such interventions are 
dependent on actors that operated beyond the remit of the project. The LIPs, 
however, used other resources and linkages to connect their members to MFIs and 
to support the formation of table banking groups and the contribution to NHIF, 
among other forms of safeguards. It is critical in future for similar interventions to 
consider the structural components given the socio-cultural and economic 
environments that continue to determine the behavior of key and vulnerable 
populations in the country. 
The assessment sought to test the hypothesis that members of key and vulnerable 
populations who are exposed to 5 or more sessions of SIO will be better able to 
accept or seek referral for HIV counseling and testing services and other health 
services and practice safer sex (reduce number of sexual partners and increase use 
of condoms and water-based lubricants), compared to those who are exposed to 
fewer than 5 sessions. The analysis illustrates that those respondents who had 
attended 5 or more sessions were better able to understand their risks and adopt 
protective behavior on some limited variables. This result could be a factor of the 
interpretation of what a ‘session’ was or due to the fact that the exposure, however 
limited, had a positive influence on the target population. 
6.2 General recommendations 
(i) Address structural determinants: There is a need to tackle structural 
determinants of HIV and AIDS as part of prevention interventions, since 
poverty and socio-cultural factors are key facilitators of sexual vulnerability. 
Prevention programs must therefore include capacity-building to address 
poverty through economic strengthening and deal with issues around 
gender relations and the socio-cultural environment in which people live. 
Cultural practices and traditions that put people at risk, more so women, 
must be re-examined by the key and vulnerable populations in order to 
create social and cultural contexts that support low-risk behavior. In terms of 
increasing the capacity for income generation, the efforts could include 
financial literacy, seed funds for small group activities, membership in 
medical schemes, etc. 
SIO Evaluation Report (July 2015) 36
(ii) More focus on MSM: Although the project has had some impact on MSM, it 
is notable that some are still in the closet, which limits their access to 
information and services. The recruitment and training of additional HAs 
should be considered and the current mode of using the snowball approach 
to reach MSM should be enhanced. In some situations, one-on-one sessions 
could be promoted until the individuals feel comfortable to participate in 
group sessions. 
(iii) Increase preventive interventions in the general population: Although it 
makes epidemiological sense to focus on key and vulnerable populations, it 
is important not to relent on educating the general population on HIV and 
AIDS. The experiences of the FSWs and MSWs indicate that some people 
insist on not using condoms despite not knowing the status of the sex 
workers. There is thus a need for continued information-sharing and 
capacity-building with the general population, especially on prevention, as a 
means of safeguarding the knowledge and skills acquired by members of key 
and vulnerable populations. 
(iv) Address stigma and discrimination: The levels of stigma are still high, 
especially on the MSM. There is thus a need to focus on measures to address 
HIV and AIDS stigma at national, county, and community levels. 
Engagement of representatives of key and vulnerable populations in 
decision-making bodies at the three levels could be one way of addressing 
this. 
(v) Support national and county governments’ efforts in implementing the 
Kenya AIDS Strategic Framework (KASF) 2014/5–2018/9: The Framework 
provides suggestions on targeted interventions that could be adopted by 
counties to address their challenges in HIV and AIDS mitigation. It is 
necessary that APHIAPlus and other partners support counties in identifying 
their needs, prioritizing key actions, and ensuring follow-through of adopted 
interventions while keeping an eye on the needs of key and vulnerable 
populations. 
6.3 Recommendations on SIO 
SIO is an intervention that could be implemented within the context of APHIA or as 
a stand-alone HIV and AIDS intervention. Hence, there are areas in which the 
intervention could be improved based on the outcomes of the evaluation. 
(i) Generate a common understanding of what constitutes a session: During 
the evaluation it was clear that the term ‘session’ was used variably by the 
APHIAPlus team, the LIPs, the HAs, and the peers. It is critical that the 
terminology is harmonized to provide a basis for follow-up, assessment, and 
analysis. 
(ii) Reporting: Several peers and coordinators complained that the reporting 
booklets were too bulky. It is recommended that SIO considers the 
introduction of less bulky reporting tools or the adoption of e-reporting 
tools. 
SIO Evaluation Report (July 2015) 37
(iii) Referrals: The LIPs noted that they do not retain copies of the referrals they 
make for their members and that it would help if the booklets were 
produced in triplicate to allow them to keep copies for their records and 
follow-up. 
(iv) Timely release of funds: Planning and implementation of activities is 
dictated by the flow of funds. Delayed release of funds interferes with the 
capacity of LIPs to effectively implement their activities. It also has a 
negative impact on the commitment of HAs and other program actors. 
SIO Evaluation Report (July 2015) 38
REFERENCES 
Health Policy Project website. Available at: www.healthpolicyproject.com. 
Accessed May 2015. 
Joint United Nations Programme on HIV/AIDS (UNAIDS) (2010). Combination HIV 
Prevention: Tailoring and Coordinating Biomedical, Behavioural and 
Structural Strategies to Reduce New HIV Infections. A UNAIDS Discussion 
Paper. Geneva: UNAIDS; 2010. 
Kenya National Bureau of Statistics (KNBS), ICF Macro, et al. Kenya Demographic 
and Health Survey (DHS): Key Indicators 2014. Nairobi: KNBS; 2015. 
Available at: http://www.dhsprogram.com/publications/publication￾pr55-preliminary-reports-key-indicators-reports.cfm. Accessed June 07, 
2015. 
National AIDS and STI Control Programme (NASCOP), Ministry of Health, Kenya. 
Kenya AIDS Indicator Survey, 2012. Nairobi: NASCOP; 2013.
National AIDS Control Council (NACC). Kenya AIDS Strategic Framework 2014/5–
2018/9. Nairobi: NACC: 2014. 
NACC and NASCOP. Kenya HIV Prevention Revolution Roadmap: Countdown to 
2030. Nairobi: NACC, NASCOP; 2014. Available at: http://
http://www.nacc.or.ke/index.php/about-nacc/418-kenya-hiv-prevention￾revolution-roadmap. 
Ramzi AA, Baeten JM, Celum CL, et al. Understanding the potential impact of a 
combination HIV prevention in hyper-endemic community. PLOS One.
2013;8(1);e54575. 
SIO Evaluation Report (July 2015) 39
ANNEX 1: EVALUATION TOOLS 
CONSENT FORM FOR KEY INFORMANT INTERVIEWS 
SIO Evaluation Report (July 2015) 40
CONSENT FORM FOR FOCUS GROUP DISCUSSIONS 
SIO Evaluation Report (July 2015) 41
DATA COLLECTION PROTOCOLS 
SIO Evaluation Report (July 2015) 42
FOCUS GROUP DISCUSSION GUIDE 
SIO Evaluation Report (July 2015) 43
KEY INFORMANT INTERVIEW DISCUSSION GUIDE 
SIO Evaluation Report (July 2015) 44
SPLASH! INSIDE OUT QUESTIONNAIRE 
SIO Evaluation Report (July 2015) 45
ANNEX 2: SPLASH! INSIDE OUT SITES AND IMPLEMENTERS 
Nyanza Province
National Organization of Peer Educators (NOPE) LIP Prevention – at workplaces/worksites*
YWCA Kisii LIP Prevention – key populations
I Choose Life - Africa (ICL) Prevention – key populations
Migori District New Prevention – key populations
Borabu District New Prevention – key populations
Family Health Options Kenya (FHOK) – Nyanza Prevention – at workplaces/worksites*
Keeping Alive Societies Hope (KASH)
Prevention – key populations (FSWs,
MSM)
Kenya Red Cross Society (KRCS) Prevention – key populations (fisher folk)
Support for Additions Prevention and Treatment in 
Africa (SAPTA) – Kisumu Prevention – key populations (MSM)
Anglican Development Services (ADS) – Nyanza Prevention – key populations (fisher folk)
CSA – Nyanza Prevention – general population
SAIPE – Nyanza Prevention – general population
Nyamira District New Prevention – general population
Rachuonyo District New Prevention – general population
Siaya District New Prevention – general population
Kisumu East District New Gender
Masaba District New Gender
Kuria District New Gender
Rongo District New Gender
Western Province
Anglican Development Services – Western (formerly 
WRCCS) Prevention – key populations (fisher folk)
Busia Survivors Group Prevention – key populations (FSWs,
MSM)
ACE Africa – Western Prevention – key populations (FSWs)
Family Health Options Kenya (FHOK) – Western Prevention – at workplaces/worksites*
KANCO – Western Prevention – key populations (FSWs)
Abbreviations: FSW, female sex workers; LIP, local implementing partner, MSM, men who have sex 
with men. 
SIO Evaluation Report (July 2015) 46
ANNEX 3: ETHICS COMMITTEE APPROVALS 
Maseno University Ethics Review Committee 
SIO Evaluation Report (July 2015) 47
PATH Research Determination Committee Review 
SIO Evaluation Report (July 2015) 0
ANNEX 4: EVALUATION WORK PLAN 
A+ Evaluations SPLASH! Inside Out (SIO) and local 
implementing partner (LIP) interventions Start date End date Responsible Accountable Consulted Informed Planning for data collection
Preparatory activities
Define the evaluation questions and scope –
these includes determining how the SIO - OE 
and the LIPs evaluation can be integrated to 
achieve synergy 22/9/2014 1/10/2014
Oby, Juma, 
Hellen
Oby, Juma, 
Hellen
Kirogo, Tom, 
Steve A+ SMT
Agree on the study methods (the study design 
and sampling methods) – including data 
analysis plans 22/9/2014 1/10/2014 Kirogo Tom & Steve
Oby, Juma, 
Hellen A+ SMT; Jeff
Obtain RDC approval from MUREC 3/2/2015 Kirogo Reninah Steve
Oby, Juma, 
Hellen
Hire data collectors 9/2/2015 11/2/2015 Juma, Hellen Steve; HR Kirogo, Tom, A+ SMT
Finalize data collection tools
Make any necessary final changes to the data 
collection tools (questionnaires, discussion 
guides, change story outline, and informed 
consent forms) 5/2/2015 6/2/2015
Kirogo, Tom, 
Steve Kirogo
Oby, Juma, 
Hellen A+ SMT; Jeff
Translate data collection tools 10/2/2015 10/2/2015 Kirogo Steve
Tom, Juma, 
Hellen, Oby
Pre-test tools 12/2/2015 13/2/2015 Kirogo Steve Tom
Juma, Hellen, 
Oby
Training of data collectors 
Develop training plan 
13/10/201
4
17/10/201
4 Kirogo Steve
Tom, Juma, 
Hellen, Oby
SIO Evaluation Report (July 2015) 1
Conduct training of data collectors on 
quantitative and qualitative methods -
including Most Significant Change (MSC)
techniques 16/2/2015 18/2/2015
Tom, Steve, 
Kirogo Kirogo
Tom, Juma, 
Hellen, Oby
Training on MSC technique for staff who will 
collect change stories 19/2/2015 20/2/2015 Kirogo Kirogo
Steve, Juma, 
Hellen, Oby A+ SMT
Data management
Develop database/data management system 3/2/2015 16/2/2015 Kirogo Steve, Tom
Dominic, 
Sadik 
Determine data collection processes (data flow: 
when/where is data uploaded or saved) 4/2/2015 5/2/2015 Kirogo Steve, Tom
Tom, Juma, 
Hellen, Oby
Plan supervision/data quality checks 4/2/2015 5/2/2015 Kirogo Steve, Tom
Tom, Juma, 
Hellen, Oby
Data analysis and dissemination
Develop data cleaning plan 9/2/2015 13/2/2015 Kirogo Steve, Tom
Tom, Juma, 
Hellen, Oby
Develop data analysis plan 9/2/2015 13/2/2015 Kirogo Steve, Tom
Tom, Juma, 
Hellen, Oby
Materials
Procure materials for data collection 
(questionnaires, pens. photography etc.) 11/2/2015 13/2/2015 Steve Steve Tom, Kirogo
Data 
collectionData collection 
Collect quantitative data from SIO focus 
population (fisher folk, sex workers, etc.) 24/2/2015 4/3/2015 Kirogo, Tom Kirogo A+ SMT
Data entry for quantitative data 3/3/2015 6/3/2015 Kirogo, Tom Kirogo
Steve, Juma, 
Hellen, Oby
SIO Evaluation Report (July 2015) 2
Conduct focus group discussions (FGDs) with 
SIO focus population (fisher folk, sex workers,
etc.) 24/2/2015 4/3/2015 Kirogo, Tom Kirogo
Steve, Juma, 
Hellen, Oby A+ SMT
Conduct key informant interviews (KII) 24/2/2015 4/3/2015 Kirogo, Tom Kirogo
Steve, Juma, 
Hellen, Oby A+ SMT
Collect MSC stories 23/2/2015
no set end 
date Kirogo, Tom Kirogo
Steve, Juma, 
Hellen, Oby A+ SMT
Analysis and reporting
Data analysis 
Clean quantitative data 9/3/2015 9/3/2015 Kirogo Kirogo
Tom, Juma, 
Hellen, Oby A+ SMT
Analyze FGD data 9/3/2015 13/3/2015
Kirogo, 
Allison, Tom Kirogo
Steve, Juma, 
Hellen, Oby
Selection and verification of MSC stories (level 
1, 2, 3) 16/3/2015 20/3/2015
Steve, Tom, 
Kirogo Kirogo
Juma, 
Hellen, Oby A+ SMT
Data reporting
Develop outline of report 9/2/2015 13/2/2015
Kirogo, 
Allison, Tom Kirogo
Tom, Juma, 
Hellen, Oby A+ SMT
Draft report 23/3/2015 27/3/2015
Kirogo, 
Allison, Tom Kirogo
Tom, Juma, 
Hellen, Oby A+ SMT
Circulate draft report 30/3/2015
Kirogo, 
Allison, Tom Kirogo
Tom, Juma, 
Hellen, Oby A+ SMT
Receive feedback 3/4/2015
Kirogo, 
Allison, Tom Kirogo
Tom, Juma, 
Hellen, Oby A+ SMT
Incorporate feedback 6/4/2015 10/4/2015
Kirogo, 
Allison, Tom Kirogo
Tom, Juma, 
Hellen, Oby A+ SMT
SIO Evaluation Report (July 2015) 3
Finalize report 13/4/2015
Kirogo, 
Allison, Tom Steve, Tom
Tom, Juma, 
Hellen, Oby A+ SMT
Share report with stakeholders 16/4/2015 Steve Dr. Mukabi
SIO Evaluation Report (July 2015) 0
ANNEX 5: SCOPES OF WORK FOR TEAM AND CONSULTANT 
Scope of Work for Research Team for Splash! Inside Out Evaluation 
SIO Evaluation Report (July 2015) 1
Scope of Work for Consultant for Splash! Inside Out Evaluation 
SIO Evaluation Report (July 2015) 2
ANNEX 6: LEAD CONSULTANT CV