This article is based on my presentation at the 2nd National Conference on Adult Immunization and Allied Medicine of the Indian Society for Adult Immunization (ISAI), Science City, Kolkata, on 15 February 2025. I wish to acknowledge and thank both Charlotte Mbuh and Ian Jones for their invaluable contributions to the Foundation’s work on HPV vaccination.
The implementation challenge
The global landscape of HPV vaccination and cervical cancer prevention reveals a mix of progress and persistent challenges. While 144 countries have introduced HPV vaccines nationally and vaccination has shown remarkable efficacy in reducing cervical cancer incidence, significant disparities persist, particularly in low- and middle-income countries.
Evidence suggests that challenges in implementing and sustaining HPV vaccination programs in developing countries are significantly influenced by gaps between planning at national level and execution at local levels. Multiple studies confirm this disconnect as a primary barrier to effective HPV vaccination programmes.
Traditional approaches to knowledge development in global health often rely on expert committee models characterized by hierarchical knowledge flows, formal meeting processes, and bounded timelines. While these approaches offer strengths like high academic rigor and systematic review, they frequently miss frontline insights, develop slowly, and produce static outputs that may be difficult to translate effectively into action.
The peer learning network alternative
At The Geneva Learning Foundation (TGLF), we have developed a complementary model—one that values the collective intelligence of frontline health workers and creates structured opportunities for their insights to inform policy and practice. This peer learning network model features:
- Large, diverse networks with multi-directional knowledge flow
- Open participation and flexible engagement
- Direct field experience and implementation insights
- Iterative development through experience sharing
- Continuous refinement and living knowledge
This approach captures practical knowledge, enables rapid learning cycles, preserves context, and brings together multiple perspectives in a dynamic process that continuously updates as new information emerges.
The peer learning cycle in action
To address HPV vaccination challenges, we implemented a structured five-stage cycle that connected frontline experiences with policy decisions:
- Experience collection at scale: In June 2023, we engaged over 16,000 health professionals to share their HPV vaccination experiences through our Teach to Reach programme. This stage focused specifically on capturing frontline implementation challenges and solutions across diverse contexts.
- Synthesis and analysis: TGLF’s Insights Unit identified key themes, success patterns, and common challenges while highlighting local innovations and practical solutions that emerged from the field.
- Knowledge deepening: In October 2023, we conducted a second round of experience sharing that built upon earlier discussions at Teach to Reach. This stage featured more in-depth case studies and implementation stories, providing additional contexts and approaches to vaccination challenges.
- National-level review: In January 2024, we facilitated a consultation with national EPI (Expanded Programme on Immunization) planners from 31 countries. This created direct connections between field experience and national strategy, validating and enriching the collected insights.
- Knowledge mobilization: Finally, we synthesized the insights into practical guidance, ready for sharing back to frontline workers, and established a foundation for continued learning cycles.
This process uniquely values the practical wisdom that emerges from implementation experience. Rather than assuming solutions flow from the top down, we recognize that those doing the work often develop the most effective approaches to complex challenges.
Teach to Reach: Building a learning community
Our Teach to Reach programme serves as the hub for this peer learning approach. Since its inception, the community has grown steadily since January 2021 to reach over 24,000 members by December 2024. The participants reflect remarkable diversity.
This diversity of contexts and experiences creates a rich environment for learning. The programme demonstrates significant impact on participants’ professional capabilities—compared to global baselines, Teach to Reach participants show:
- 45% stronger worldview change
- 41% greater impact on professional practice
- 49% higher professional influence
7 insights about HPV vaccination from peer learning at Teach to Reach
Through this process, we uncovered several important implementation insights:
1. Importance of connecting field experience to policy
- Each stage deepened understanding of implementation challenges
- We observed progression from tactical to strategic considerations
- Growing recognition of systemic factors emerged
- Evolution from individual to institutional solutions became apparent
- Value of structured knowledge sharing across levels was demonstrated
2. Implementation learning
- Success requires multi-stakeholder engagement
- Sustained communication proves more effective than one-time campaigns
- School systems provide critical implementation platforms
- Community leadership is essential for acceptance
- Integration with other services increases efficiency
- Local adaptation is key to successful implementation
3. Unexpected implementation findings
- Tribal communities often showed less vaccine hesitancy than urban areas
- Teachers emerged as more influential than health workers in some contexts
- Personal stories proved more persuasive than statistical evidence
- Integration with COVID-19 vaccination improved HPV acceptance
- Social media played both positive and negative roles
- School-based programs sometimes reached out-of-school children
4. Counter-intuitive success factors
- Less formal settings often produced better results
- Simple communication strategies outperformed complex ones
- Male community leaders became strong vaccination advocates
- Religious institutions provided unexpected support
- Health worker vaccination of own children became powerful tool
- Community dialogue proved more effective than expert presentations
5. Unexpected challenges
- Urban areas sometimes showed more resistance than rural areas
- Education level did not correlate with vaccine acceptance
- Health workers themselves sometimes showed hesitancy
- Traditional media was less influential than anticipated
- Formal authority figures were not always the most effective advocates
- Technical knowledge proved less important than communication skills
6. Examples of novel solutions
- Using cancer survivors as advocates
- WhatsApp groups for community health workers
- School children as messengers to families
- Integration with existing women’s groups
- Leveraging religious texts and teachings
- Community theater and storytelling approaches
System-level surprises
- Success was often independent of resource levels
- Informal networks proved more important than formal ones
- Bottom-up strategies were more effective than top-down approaches
- Social factors were more influential than technical ones
- Local adaptation was more important than standardization
- Peer influence was more powerful than expert authority
In some cases, these findings challenge many conventional assumptions about HPV vaccination programmes. In all cases, they highlight the importance of local knowledge, social factors, and adaptation over standardized approaches based solely on technical expertise.
The power of health worker collective intelligence
Our approach demonstrates the value of health worker collective intelligence in improving performance:
- High-quality data and situational intelligence from our network of 60,000+ health workers provides rapid insights
- Field observations on changing disease patterns and resistance can be quickly collected
- Climate change impacts can be tracked through frontline reports
- The TGLF Insights Unit packages this intelligence into knowledge to inform practice and policy
This represents a fundamental shift from assuming expert committees have all the answers to recognizing the distributed expertise that exists throughout health systems.
Continuous learning: The key to improvement
In fact, previous TGLF research has demonstrated that continuous learning is often the “Achilles’ heel” in immunization programs. Common issues include:
- Relative lack of learning opportunities
- Limited ability to experiment and take risks
- Low tolerance for failure
- Focus on task completion at the expense of building capacity for future performance
- Lack of encouragement for learning tied to tangible organizational incentives
In 2020 and 2022, we conducted large-scale measurements of learning culture of more than 10,000 immunization professionals in low- and middle-income countries. The data showed that ‘learning culture’ (a measure of the capacity for change) correlated more strongly with perceived programme performance than individual motivation did. This challenges the common assumption that poor motivation is the root cause of poor performance.
These findings help zero in on six ways to strengthen continuous learning to drive HPV vaccination:
- Motivate health workers to believe strongly in the importance of what they do
- Give them practice dealing with difficult situations they might face
- Build mental resilience for facing obstacles
- Prompt them to enlist coworkers for support
- Help them engage their bosses to provide guidance, support, and resources
- Help them identify and overcome workplace obstacles
Impact and benefits of peer learning
This approach delivers multiple benefits:
- Frontline workers gain broader perspective
- National planners access grounded insights
- Practical solutions spread more quickly
- Policy decisions are informed by field experience
- Continuous improvement cycle gets established
Key success factors include:
- Scale that enables diverse input collection
- Structure that supports quality knowledge creation
- Regular rhythm that maintains engagement
- Multiple levels of review that ensure relevance
- Clear pathways from insight to action
How can we interpret these findings?
This model generates implementation-focused evidence that complements rather than competes with traditional epidemiological data.
The findings emerge from a structured methodology that includes initial experience collection at scale, synthesis and analysis, knowledge deepening through case studies, national-level review by EPI planners from 31 countries, and systematic knowledge mobilization. This approach provides rigor and scale that elevate these observations beyond mere anecdotes.
For epidemiologists who become uncomfortable when evidence is not purely quantitative, it is important to understand that structured peer learning fills a critical gap in implementation science by capturing what quantitative studies often miss: the contextual factors and practical adaptations that determine programme success or failure in real-world settings.
When implementers report across different contexts that tribal communities show less vaccine hesitancy than urban areas, or that teachers emerge as more influential than health workers in specific settings, these patterns represent valuable implementation intelligence.
Such insights also help explain why interventions that appear effective in controlled studies often fail to deliver similar results when implemented at scale.
In fact, these findings address precisely what quantitative studies struggle to capture: why education level does not reliably predict vaccine acceptance; why some resource-constrained settings outperform better-resourced ones; how informal networks frequently prove more effective than formal structures; and which communication approaches actually drive behavior change in specific populations.
For programme planners, this knowledge bridges the gap between general guidance (“engage community leaders”) and actionable specifics (“male community leaders became particularly effective advocates when engaged through these specific approaches”).
Accelerating HPV vaccination progress
To make significant progress on HPV vaccination as part of the Immunization Agenda 2030’s Strategic Priority 4 (life-course and integration), we encourage global health stakeholders to:
- Rethink how we learn
- Question how we engage with families and communities
- Focus on trust
By combining expert knowledge with the practical wisdom of thousands of implementers, we can develop more effective strategies for HPV vaccination that bridge the gap between planning and execution.
This peer learning network approach does not replace expertise—it enhances and grounds it in the realities of implementation.
It recognizes that the frontline health worker in a remote village may hold insights just as valuable as those of a technical expert in a capital city.
By creating structures that enable these insights to emerge and connect, we can accelerate progress on HPV vaccination and other public health challenges.
References
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