tion from HIV and STIs, improved hygiene, decreased risk of penile cancer, and improved sexual satisfaction for men and their sex partners; while the primary reasons that men chose not to be circumcised were pain during/after the procedure, long healing period, AEs, culture or religion, and time away from work.[10–13] Reiss et al. reported that recently circumcised men said they were able to perform more rounds of sex; they were able to use condoms more easily; and they sustained fewer cuts on their penis during sex.[14] Because of the consistency of the results of MC acceptability studies across several regions, as Westercamp and Bailey concluded, ‘‘…additional acceptability studies that pose hypothet- ical questions to participants are unnecessary.’’[9] This study, conducted among uncircumcised men in Nyanza Province, Kenya, assessed the non-hypothetical barriers and facilitators of MC uptake after it was proven to be effective by the RCTs, was endorsed by the WHO and UNAIDS, was widely available at no cost, and was actively promoted by the GoK and implementing partners. Methods Ethics Statement All research staff completed the online Collaborative Institu- tional Training Initiative training course on human subject protection. Written consent was obtained from all study participants. The study was approved by the University of Illinois at Chicago Institutional Review Board in Chicago, Illinois, USA (protocol: 2007-0913), and the Kenyatta National Hospital Ethics and Research Committee, in Nairobi, Kenya (protocol: P338/11/ 2007). Study Design We conducted 12 focus group discussions (FGDs) in three out of the eight Luo districts within Nyanza Province. These three districts were chosen because they had an active VMMC program, were contiguous, and represented typical urban (Kisumu East) and rural (Nyando and Kisumu West) populations in Nyanza Province. FGDs were conducted between November-December, 2009, exactly one year after the launch of the VMMC program. The FGDs were moderated by one experienced male facilitator, and a research assistant took notes. The FGD guide consisted of 12 open-ended questions with probes about MC uptake and acceptability (Text S1) that were originally drafted in English, then translated into Kiswahili and Dholuo, and then verified by the research team. Established moderation techniques were employed to ensure active participation by all participants.[15] Participants were recruited using a purposive sampling method at markets, shopping centers, and work places [16]; 121 men participated in the study. Because the aim was to explore the complete range of community opinions about MC among males most at risk for HIV acquisition, participants were recruited from urban and rural areas and from a variety of employment cadres common to the study area, including bicycle transporters (n = 32), students (n = 18), informal sector (n = 18), farmers (n = 12), shop/ kiosk owners (n = 11), and other cadres, including teachers, fishermen, drivers, and religious leaders. To be eligible, potential participants had to be aged 18-40 years, be uncircumcised (based on self-report), have no plans to become circumcised, and reside in one of the three study districts where VMMC services were being widely provided. Interested males were asked to participate in an informed consent process in the language of their choice (English, Dholuo, or Kiswahili), and if they chose subsequently to enroll, they Acceptability of Male Circumcision in Kenya provided signed consent. All enrolled males participated in the discussion, and no one terminated his participation prematurely. Each FGD lasted 60–90 minutes and involved 8–12 uncircum- cised men. Six FGDs were conducted among ‘‘young men’’, aged 18–27 years, and six FGDs were conducted among ‘‘older men’’ aged 28–40 years. For their time, participants were offered a snack, soda, and compensation of 200 Kenya Shillings ($2.50 USD), less than the average daily wage in Kenya. Data Collection and Management Audio recordings were transcribed in the original language of the FGD, translated into English (if necessary), and then the translation was verified by a second staff member who compared it to the original transcript. The translated transcripts were reviewed, themes were identified, and a codebook was developed collabo- ratively by three members of the research team. All of the transcripts were imported into ATLAS.ti (version 6) and were coded independently by two research staff members; any discrepancies were discussed and a consensus was reached. Results Facilitators of male circumcision uptake Three questions were asked to begin the discussion about factors that might act as facilitators to the uptake of MC services: 1. ‘‘What are some things people do to protect themselves, or their sexual partner, against getting HIV?’’ 2. ‘‘When you hear people talk about male circumcision in the community, what are some of the things they say?’’ 3. ‘‘A Luo man, named Onyango, is considering getting circumcised. What are some of the reasons that he might decide to get circumcised?’’ (Please note, the character Onyango, a common name for a Luo man, was used throughout the FGD dialogue.) The primary facilitators of MC uptake that were expressed in every discussion included the beliefs that MC improves hygiene, is influenced by social pressure, improves HIV and STI protection, and improves sexual performance and satisfaction, in order of salience. Hygiene. Improved hygiene was the most common facilitator of MC. Participants described the improvement in hygiene resulting from MC in several ways, including: ‘‘good smelling’’, ‘‘easy to wipe clean’’, ‘‘no smell after sex or bathing’’, and ‘‘HIV and other germs don’t have a place to hide’’. Social pressure. Social pressure was a very common facilitator of MC uptake, especially among young men. Participants discussed, without prompting, several scenarios or social mechanisms that might affect Onyango’s MC decision- making process. 1. A recently circumcised man shares his experience with Onyango and encourages him to become circumcised. 2. Onyango is the only one among his male friends or family who is not circumcised, and he is being teased about being uncircumcised, especially while bathing. 3. Onyango’s female sex partner says that she will leave Onyango or withhold sex until he is circumcised. 4. Female sex partners and/or men from other ethnic groups might call Onyango ‘‘kehe’’, or other derogatory names, to mean that he is a child and not a man since he is not circumcised. PLoS ONE | www.plosone.org 2 May 2011 | Volume 6 | Issue 5 | e19814