Background: Diarrheal illnesses are mainly linked with poverty, unhygienic environments, and rapid population growth. Hygiene promotion programs can significantly reduce childhood diarrhea when interventions are tested in stable communities. The aim of the study was to evaluate the impact of a hygiene promotion trial on the incidence of childhood diarrhea in Pugnido and Teirkidi refugee camps in Gambella Region, Ethiopia.

Methods: A cluster randomized controlled trial was conducted in 34 clusters of intervention households (n = 422) and control households (n = 421) in the Teirkidi and Pugnido refugee camps. A household survey instrument was administered at three-time points in the intervention and comparison neighborhood households to assess changes in hygiene behavior outcome variables. Descriptive statistics with Pearson’s chi-square analysis employed to describe the sample, examine distributions and compare study communities at baseline, midterm and end of the study. Intention to treat was applied in analyses of the results of this trial. Logistic, poison regression and generalized estimating equation (GEE) models were used to evaluate changes in cluster level hygiene behaviors and the RRs (risk ratio), period prevalence and incidence of diarrhea with its 95% CI and P < 0.05 significant cutoff point. Intra-class correlation coefficients were calculated to assess within-household repeatability.

Results: The reported episodes of diarrhea were 1307 (15.6 episodes per 100 person-weeks observation) among the intervention households and 1619 (18.9 episodes per 100 person-weeks observation) in the control households. Under-five children living in households that received hygiene promotion had a 15% [P < 0.001; adjusted IRR: 0.85, 95% CI: 0.79    0.92] and a lower incidence rate of diarrhea compared with children living in control households.

Conclusion: The study confirms that hygiene promotion intervention can significantly reduce the incidence rate of childhood diarrhea in refugee camps. Hence, gains in the reduction of childhood diarrhea can be achieved in refugee camps through an enhanced hygiene promotion program. A collective effort from governments and non-government organizations, the private sector, academia, and civil society is urgently needed to implement and evaluate a sustainable applied hygiene promotion program in the vulnerable, refugee communities.

Keywords: Diarrhea; Under-five; Children; Cluster-randomized; hygiene promotion; Refugees; Gambella.