To our knowledge, this is the first ever type of study in Sierra Leone and perhaps in Africa that looks at influenza vaccination status among healthcare workers as well as their knowledge and perception regarding influenza disease and vaccination. As influenza is recognised as a public health challenge, health care providers are considered as vulnerable groups and vectors of transmission. Influenza immunization in the healthcare setting has been shown to be beneficial in reducing patient and health provider morbidity and mortality and as well as productivity [7, 27, 28].

Analysis of our data revealed a low influenza vaccine uptake by HCP (6.5%). Our result is generally in line with other studies done elsewhere although much lower [18,19,20,21, 23, 29,30,31] but slightly higher than the result reported by Khan et al. [16] and Bali et al. [22]. The high cost of the vaccine, lack of awareness among HCP about of influenza vaccine and concerns about influenza vaccine safety were the key reasons for low flu vaccine rate put forward by respondents in this study. Similar reasons were reported elsewhere [20,21,22]. The reasons mentioned above are in contrast to the results reported in studies conducted in Pakistan [16], Qatar [15] and Saudi Arabia [17] in which fear of needle and fear of contracting the illness and misconception of not being at risk were the key reasons put forward by participants respectively. Fear of side effects of the vaccine, its ineffectiveness to prevent the disease, and lack of time are other reasons that have been reported in other studies [17, 20, 31, 32]. Although the lack of knowledge and scepticism about influenza vaccine safety and efficacy are reasons for low vaccine uptake shared by participants in our study and those conducted elsewhere, our own was also based on inaccessibility due to the high cost of the vaccine. A study in Kenya reported a discordance between willingness to be vaccinated and acceptance levels of HCPs towards the vaccine [33]. Further studies should investigate whether HCP’s willingness to be immunised is translated into higher vaccine uptake. However, considering HCP are in short supply in Sierra Leone [34], the need to safeguard and maximize their health and productivity is of importance in ensuring the health of its citizenry is improved. Programs that increase influenza vaccine accessibility and affordability, as well as educational interventions to improve HCPs’ awareness about influenza vaccination in Sierra Leonean hospitals, need to be considered.

As it has been reported in the literature [17, 20, 22, 35], our study has demonstrated knowledge gap among HCPs about influenza and its vaccine. Although high cost and low level of awareness were cited as key reasons for low vaccine uptake, awareness of the disease and the misconception of the vaccine might be a contributing factor. In our study, more than half of HCPs believed that they were less susceptible to influenza virus than non-HCP. Also, most of them were also of the notion that influenza can be only be transmitted by symptomatic patients. These results are similar to a study conducted in Pakistan [16] but in shape contrast to what was reported in Saudi Arabia [21]. Respondents in our study also believed that influenza vaccine could cause influenza- a notion shared by other HCPs in other countries [16, 21, 22, 35]. Also, most (84.3%) of HCP in our study believed that only symptomatic individuals could transmit the disease mirroring finding from a Turkish study [32] but contrasted with results from Saudi Arabia and Pakistan [16, 21]. According to the CDC, the symptoms of influenza usually appear 1—4 days (average: 2 days) [36]. However, most participants (83.2%) in our study lack knowledge about the incubation period of the virus which is inconsistent with findings from Pakistan [16] and Saudi Arabia [21]. The deficit in knowledge in our study was also observed as the majority of HCPs did not know how often influenza vaccine should be administered which is inconsistent with a result of a similar study authored by Alshammari et al. [21]. With such knowledge deficit and low awareness, education interventions such training of HCPs through continuous professional development with help reduce the gap in knowledge and increase influenza vaccine acceptance and uptake.

Inferential statistics indicate that only years of experience was significantly associated with knowledge about influenza and vaccine when knowledge items were summed. HCPs with 6–10 years of experience were more knowledgeable than those with 1–2 years experience based on the scored eleven knowledge questions items. This result contrasts with the study conducted by Kahn et al. in which HCP with 1-2 years experience were more knowledgeable compared to those with more than two years experience. The same study also reported that nurses and physiotherapist were more knowledgeable than the other cadres of health professionals [16]. The fact that HCPs with less working experience in our study exhibited a deficiency in knowledge might be due to the possibility that modules on influenza were not properly taught in college or this cohort of HCPs have had less encounter with patients with or exposure to influenza and influenza-related symptoms. Also, it might be linked to the perception that the disease is self-limiting, and being young offers immunity. Less awareness of the influenza vaccine might affect HCPs’ uptake even if the vaccine is made available. Previous research has reported a positive link between increased knowledge of influenza and its vaccine and higher vaccine uptake among HCPs [17]. It is imperative that the need for increased education about influenza and its vaccine through training be intensified during pre- graduation and immediately after post-graduation. Our study also reported no significant difference in knowledge among the different groups of health care workers – a result that is not consistent with a similar study conducted in Pakistan in which nurses were more knowledgeable than physicians [16]. The difference observed may be linked to variations in study methodology and sample size. Ours was a multi-site study with a larger sample size as compared to that in Pakistan which was quite the opposite. With regards to gender, our study resonates with what was observed in Pakistan [16]. Also, HCPs further demonstrated a lack of knowledge and awareness of influenza vaccination in that more than half of the HCPs surveyed were not aware or were not too sure of CDC’s recommendation for mandatory influenza vaccination among all healthcare providers. We observed similar response with regards to their awareness of the joint CDC and ACIP guidelines on influenza vaccination. Previous research has reported similar observation [21]. It is essential that appropriate education strategies are developed to increase knowledge and awareness among HCPs in Freetown Sierra Leone.

Limitations and strength

A key limitation of this study is that our findings cannot be generalised for the whole country as we surveyed only healthcare professionals in Freetown. Future studies should incorporate a nationwide sample to get a representative view of HCP country wide regarding influenza vaccination. Also, the sampling method used reduces the possibility every HCP to have an equal chance of being selected. However, this sampling method was chosen to target key respondents that can provide meaningful information required to sufficiently test the study hypothesis. Notwithstanding these limitations, a key strength of our study was that we used a large sample size and HCPs were targeted both from both public and private health facilities.