OBJECTIVE: To further the understanding of sanitation and hygiene in long-term camp populations. METHODS: Data were collected by structured observation of handwashing (126 households), a questionnaire on sanitation, hygiene and household characteristics (1089 households) and discussions with mothers. Random walk algorithms were used to select households for observation and survey. Respondents for qualitative methods were a convenience sample. RESULTS: Across all key handwash occasions [excluding events with no handwash (n=275)], soap was used for 30% of handwashes. After latrine use, both hands were washed with soap on 20% of occasions observed. Availability of soap in households differed across sites and mirrored the extent to which it was distributed free of charge. Qualitative data suggested lack of free soap as a barrier to 'safe' handwashing. Laundry was the priority for soap. In Ethiopia and Kenya, open defecation was practised by a significant minority and was more prevalent amongst households of rural origin. In Ethiopia, open defecation was significantly more prevalent amongst women. CONCLUSIONS: Despite continuing hygiene education, rates of 'safe' handwashing are sub-optimal. Soap scarcity in some households and the prioritisation of laundry are barriers to safe practice. Heterogeneity with respect to education and place of origin may need to be taken into account in the design of improved interventions.