The impact of public health interventions for tropical diseases is limited by lack of understanding of the sociocultural context into which these interventions are delivered. Podoconiosis (endemic non-filarial elephantiasis) is a considerable public health problem in Ethiopia, yet little is known about community understanding of it. This study aimed to assess the knowledge, attitudes and practices of community members towards podoconiosis in a highly endemic area in southern Ethiopia. A cross-sectional study was conducted in January 2007 among 438 study participants selected by multistage probability sampling. Most respondents (93.5%) had seen a patient with podoconiosis and 91.6% had heard of the local terms for podoconiosis. The proportion of respondents holding at least one misconception about causation was 93.4% (95% CI 91.1-95.7%). More than one-half (55.8%) showed stigmatising attitudes towards social interactions with podoconiosis patients and 63.8% had unfavourable attitudes towards the condition. Just over one-half (55.2%) of respondents were wearing shoes during the interview, but shoe wearing was inconsistent and inadequate to prevent podoconiosis. In this highly endemic area, the community held significant misconceptions about causation, care, treatment and prevention of podoconiosis. Community interventions for podoconiosis must include education components aimed at dispelling misconceptions and stigma.