This community based study presents the determinants of circumcision and willingness to circumcision among men in Rwanda. The overall prevalence of circumcision was 17% among study population but varied from provinces and districts. The city of Kigali has the highest prevalence (52%) followed by the Western province. There is an increase in national and provincial circumcision rate compared to previous two surveys conducted in Rwanda, the Demographic Health Survey 2005 (9%) and the Intermediate Demographic Health Survey 2008 (12%). However, in 2008 survey, the city of Kigali (35.3%) and the Western Province (18%) had the highest prevalence compared to other provinces [9
The reason for high acceptance rate of circumcision in the City of Kigali is because of the coupling effect of access to information and education compared to other provinces. After the publication of the studies carried out in Kenya, Uganda and South Africa concluding that male circumcision can prevent heterosexual HIV infection from female to male up to 60% [2
], both print and visual media in Kigali focused on the benefits of MC. This is also similar to Uganda, where the capital city of Kampala has the highest prevalence of MC compared to the other regions in the country [14
]. The spread of Muslim religion in Kigali could be another explanation where young men are mixing in schools, sports and social events. This effect was evident in Tanzania where circumcision was found to increase in the ethnic groups (who are traditionally not used to circumcising) because of contacts with circumcising groups especially in schools and other social mixing [15
]. The district of Rusizi in the Western Province sharing the border with The Democratic Republic of Congo (DRC), had the highest prevalence of circumcision (71%). The close contact and exchange with people in DRC, a country where circumcision is a common practice (97%) [16
] could be a strong explanation of such high prevalence. Although after controlling for other variables place for living was not significant anymore.
Many participants defined circumcision as a partial removal of the foreskin, including Muslims. This self reported information proclaims the existence of different styles of circumcision practiced in the community. Several authors in Africa reported three categories of circumcision: "not circumcised: foreskin completely covered the glans of penis; partially circumcised: foreskin partly covered the glans; completely circumcised: foreskin did not cover the glans at all" [17
]. Presence of these categories raises concern over two major issues: the training of Health Care providers to perform effective circumcision and the role of the remaining foreskin to increase or to reduce the risk of HIV transmission from female to male.
Higher education was significantly associated with being circumcised. This corroborates with other African countries like Kenya, Ethiopia, Tanzania and Uganda [1
]. Knowledge on STI/HIV prevention had a significant positive effect not only in men who were circumcised but also in UCM. The prevention of STI and improved hygiene is similar to the findings of other studies as factors associated with the acceptability of MC [8
]. In Zambia, most of the participants reported that if MC is proven to reduce risk for HIV and STIs, they would seek circumcision for themselves or their sons [20
]. In South Africa, more than 70% of UCM report that they would want to be circumcised if MC were effective to protect against STIs [21
The half of the participants (50.2%) in this study was willing to circumcise and 78.5% considered their son/s to be circumcised. These findings are similar to those found in other African communities where circumcision was not practiced traditionally. A review of studies carried out in Botswana, Kenya, Malawi, South Africa, Swaziland, Uganda, Tanzania, Zambia and Zimbabwe, showed that the median proportion of men willing to circumcise was 65% with a range between 29% in Uganda and 87% in Swaziland. In addition, 71% supported the circumcision of their male child/children [8
]. In another study in Dominican Republic, 29% of men were willing to go for circumcision [19
]. Those who are young (below 25 years) are more willing to circumcise than the older ones. Similar findings were reported in Dominican Republic and in some African studies where older men are more agreeable to the procedure for their children rather than themselves [8
Challenges remain in expanding access to circumcision and addressing cultural concerns about the acceptability of the intervention [22
]. The promising fact of this study was that overall willingness for self circumcision and son/s to be circumcised was high. Young people in this study were willing to go for circumcision but fear of pain was found to be a major concern. In other African studies, the major barriers to the acceptability of MC were the fear of pain, concerns for safety and the cost of the procedure [8
]. A recent report from Rwanda argued that while adolescent MC is highly cost effective, adult MC is neither cost-saving nor highly cost effective when only the direct benefit for the circumcised man is considered [7
World Health Organisation recommends that setting with high prevalence, generalized or hyper endemic heterosexual HIV epidemics and low circumcision rates should consider increasing access to circumcision as an additional HIV prevention strategy [23
]. On the other hand, concerns have been expressed over inflated sense of STI/HIV protection of circumcised men which can promote high risk behavior [3
]. Nevertheless, adequate counseling on risk reduction can inhibit the adverse behavioral pattern. Similarly engaging in sex during healing period after circumcision may cause increased exposure to infection but appropriate counseling on the abstinence period could potentially reduce such behavior [28
The study has several strengths. In this nationwide survey participants were nationally distributed, all five provinces and 29 out of 30 districts were covered. The high participation rate (75.6%) and bigger sample size is an indicator for national representation and thus results can be generalized. On the other hand, few limitations are needed to be acknowledged. Firstly self reported circumcision status because the validity of self reported answer without direct observation was questionable. Secondly the quantitative nature of the study didn't allow in depth exploration of knowledge and perceptions as well as attitudes of participants towards circumcision.