# Promoting health education through immunology: An analysis of socio-cultural and pedagogical challenges

Abdelkader Ouhtit, Rajae Zerhane, Rachid Janati-Idrissi

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Abdelkader Ouhtit, Rajae Zerhane, Rachid Janati-Idrissi. Promoting health education through immunology: An analysis of socio-cultural and pedagogical challenges. Advances in Medicine, Psychology, and Public Health, 2025, 2 (4), pp.225-237. 10.5281/zenodo.14176507. hal-04859295

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Original Article in Public Health

# Promoting health education through immunology: An analysis of socio-cultural and pedagogical challenges

Abdelkader OUHTIT<fnref n="1" />*, Rajae ZERHANE<fnref n="2" />, Rachid JANATI-IDRISSI<fnref n="3" />

**Cite this paper as:** Ouhtit A, Zerhane R, Janati-Idrissi R. Promoting health education through immunology: An analysis of socio-cultural and pedagogical challenges. Adv Med Psychol Public Health. 2025;2(4):225-237.

Doi:10.5281/zenodo.14176507

Received: 18 August 2024

Revised: 28 October 2024

Accepted: 15 November 2024

Published Online: 17 November 2024

## Abstract

**Introduction:** Health education in Morocco, integrated into school programs since 1971, promotes personal development, autonomy, and respect for others. While immunology can serve as a vehicle for this education, official texts and political will alone are insufficient to fully engage all stakeholders in the national education system.

**Methods:** This study aims to examine these challenges through two studies: a quantitative one targeting a sample of 103 teachers and the other qualitative, analysing the presence of health education in the immunology curriculum across three official textbooks. Excel and SPSS software were applied for descriptive statistics and comparative analyses.

**Results:** Findings revealed a reluctance among teachers to engage in activities aimed at promoting health education. Furthermore, school textbooks offer little space for health education.

**Conclusions:** The implementation of this education in Moroccan schools faces socio-cultural obstacles. This limits students' ability to develop a critical understanding of their health (psychological, sexual, and emotional), thereby contributing to an environment where ignorance and misinformation prevail.

**Take-home message:** Immunology can promote health education but integrating it into school curricula without considering values and broader health principles may hinder students' skill development. This issue worsens when teachers view health education as unnecessary, focusing only on factual knowledge and neglecting behavioural and practical competencies.

**Keywords:** Challenges; immunology; health education; school textbook; teaching.

<footnote n="1">¹Faculty of Sciences, Tetouan City University of Abdelmalek Essaadi, Tetouan City, Morocco. E-mail: Abdelkader.ouhtit@etu.nae.ac.ma ORCID: 0009-0000-1051-4433</footnote>

<footnote n="2">²Faculty of Sciences, Tetouan City University of Abdelmalek Essaadi, Tetouan City, Morocco. E-mail: r.zerhane@uae.ac.ma ORCID: 0000-0002-7100-0273</footnote>

<footnote n="3">³Faculty of Sciences, Tetouan City University of Abdelmalek Essaadi, Tetouan City, Morocco. E-mail: r.janati@uae.ac.ma ORCID: 0000-0002-6058-4664</footnote>

<footnote>*Correspondence</footnote>
INTRODUCTION

Health is a resource that should be maintained and protected. According to the World Health Organisation (WHO), health is a state of complete physical, mental, and social well-being, and does not merely consist of the absence of disease or infirmity, entitling every human being to the highest attainable standard of health [1]. In this sense, the United Nations General Assembly adopted the Universal Declaration of Human Rights in December 1948, where, in articles 25 and 26, it recognises the right of every individual to an adequate standard of living for health and the right to education aimed at the full development of human personality and the strengthening of respect for human rights and fundamental freedoms [2]. In this perspective, the Ottawa Charter, issued during the first International Conference on Health Promotion on November 21, 1986, demonstrated that health ministries are not solely responsible for promoting health; rather, all institutions and regulations affecting the living conditions of populations must also take their share of responsibility [3]. Thus, education is a human right, just as the right to health is, granting health education the status of a human right. Indeed, health and education are closely linked; education contributes to maintaining health, and health provides the necessary conditions for learning. In Africa, the repercussions caused by various diseases, malnutrition, diarrhoea, sickle cell disease, tropical diseases in addition to HIV/AIDS, malaria, and tuberculosis primarily affect young people aged 0 to 19 [4]. Indeed, according to the report prepared by the WHO Regional Office for Africa (2021), the burden related to infections from HIV, tuberculosis, viral hepatitis, and sexually transmitted infections (STIs) remains heavy in the African region [5]. In this context, health education can play a key role in raising awareness among young people about the health challenges they face, particularly in an environment marked by the emergence of various pandemics. To address these challenges, several countries, including Morocco, have integrated health education into their school programmes.

In Morocco, health education presents itself at two levels. On one hand, it mainly appears in the life sciences school programmes in the form of topics related to reproduction, nutrition, and immunology [6]. On the other hand, it is integrated into extracurricular activities of the school health programme related to reproductive health education, sexual and reproductive health promotion, prevention of communicable diseases, and promotion of mental health [7]. In this context, immunology, as a discipline that serves as an interface between science and society, plays a crucial role. According to Pradeu (2005,2020), immunology constitutes an essential bridge between fundamental biology and medicine. It gained importance and influence throughout the 20th century, both in biology and society at large. Indeed, major current and future medical issues, such as AIDS and cancer treatment, are closely related to the challenges that immunology must address [8,9].

During the COVID-19 pandemic, there was a frequent use of immunological terms such as virus, vaccine, booster, herd immunity, lockdown, pandemic, etc., in national media [10], reflecting the crucial nature of immunological knowledge in understanding this pandemic. In fact, the significance of immunology as a science far exceeds purely scientific aspects, extending to notable social and economic repercussions. Socially, during COVID-19, we witnessed the adoption of new behaviours such as wearing masks, social distancing, and the expansion of vaccination and hygiene practices. In this sense, immunology can be a vehicle for health education through knowledge related to sexually transmitted infections, vaccination practices, and hygiene practices. Certainly, secondary school students are at a critical age (15 to 18) where they are perceived by adults as immature and incapable of acting responsibly, leading them to make choices harmful to their health [11]. Health education ultimately aims to develop the necessary skills for making free and responsible health choices [12]. However, it is important to mention that this health education depends on a set of factors that may impact its effectiveness. Thus, the transposition of knowledge conveying this education in textbooks, the teacher's perception of this education, and their involvement in extracurricular activities related to this education are all key elements to ensure its success. Indeed, the school textbook, as a multifaceted tool [13], serves as a vector for two distinct forms of curricula; the first is official, presented in the form of educational objectives
defined by the competent authorities (curricula directorate). The second is a latent curriculum that reflects the values and representations present within society. Hence, there is great interest in conducting an analytical study of textbooks to identify how health education is presented.

In relation to the Moroccan context, despite the recognition of health education as a fundamental human right, the integration of health education into Moroccan school programmes remains insufficient [14,15]. This situation raises three crucial questions: How do school textbooks, as key pedagogical tools from which teachers can draw inspiration to create their lessons [16], contribute to promoting health education? What are the perceptions of teachers regarding health education? Finally, what is the degree of involvement of life sciences teachers in extracurricular activities related to health education?

Thus, the objective of this study is to understand how school textbooks address health education through the theme of immunology. This involves analysing not only the coverage of immunology subjects related to health but also checking whether these contents meet educational standards and the current needs of students. Secondly, it aims to identify and conduct an analytical study of the perceptions of life sciences teachers regarding health education and finally determine the extent of their involvement in implementing health education.

## METHODS

### Research design

This study employed a mixed-methods approach, combining qualitative and quantitative methods. Two distinct studies were conducted: a questionnaire aimed at teachers and a content analysis of school textbooks.

### Research population

Teachers: the first study involved 103 life sciences teachers. Among them, 65.04% were women, and 63.10% had more than 12 years of teaching experience.

<table><caption>**Table 1.** Distribution of teachers by gender and years of teaching experience.</caption><thead><tr><th colspan="2">Gender</th><th colspan="3">Teaching experience (in years)</th></tr></thead><tbody><tr><td>♀</td><td>♂</td><td>[0 - 6]</td><td>[6 - 12]</td><td>>12</td></tr><tr><td>65.04</td><td>34.95</td><td>11.65</td><td>25.24</td><td>63.10</td></tr></tbody></table>

*Textbooks*: the second study focuses on the analysis of three life sciences textbooks used in high schools in Morocco: *Fi Rihab Oloum al Hayat wa al Ard*, *Al Jadid fi Oloum Albayat wa al Ard*, and *SVT Plus*.

### Study instruments

*Teacher Questionnaire*: An online questionnaire via Google form was designed to evaluate teachers' perceptions and the degree of their involvement in relation to health education. The questionnaire was based on a Likert scale and covered four areas: general information, perceptions of health education, opinions on the role of immunology in health education, and challenges to the implementation of health education.

*Textbook Analysis Grid*: To assess the presentation of health education in school textbooks, we conducted a qualitative study focused on content analysis. This analysis, as described by Wanlin (2007), consists of a set of methodological instruments applied to extremely diverse discourses, relying on deduction and inference [17]. Our analysis specifically concentrated on the pedagogical aspect of presenting health education through the chapter on immunology, excluding ergonomic and technical considerations. Therefore, we developed a simplified analysis grid, based on a model validated by Roegiers (2009), which was used to examine the textbooks [18]. The analysis focused on four criteria: the accuracy of immunological concepts, the link between immunology and health education, the prevention and promotion of health, and cultural and social sensitivity.
## Validity and reliability tests

*Teacher Questionnaire:* The questionnaire was peer-validated to assess its content. It was administered to a small sample of 7 teachers to evaluate the clarity and precision of the questions. Based on their feedback, some questions were reformulated. To assess the reliability (internal consistency) of the questionnaire, we turned to Cronbach's alpha test. According to the results obtained (calculation performed using SPSS software), the homogeneity of our data collection instrument appears to be satisfactory (α ≈ 0.74), indicating that the various items of the questionnaire are correlated.

*Textbook Analysis Grid:* To ensure a coherent analysis of the textbooks, we developed an analysis grid based on a model tested and validated by Roegiers.

## Data analysis

Quantitative and qualitative data were analysed descriptively according to the sections of the questionnaires or grid, taking into account two criteria: the frequency and specificity of responses. Data analysis was conducted using SPSS (IBM SPSS Statistics 28.0, Windows) and Excel (Microsoft Office Professional 2021, Windows).

## Ethical aspects

The data collected in this study were gathered with the consent of the participating teachers, who agreed to participate after being informed about the study's purpose and the anonymous use of the data. Participation in the questionnaire was entirely voluntary. Out of the 120 teachers contacted, only 103 completed the questionnaire. The teachers were informed of the study's objective and assured of the anonymity of their responses. We are committed to implementing all appropriate ethical measures to ensure the confidentiality of participants' data and to respect their right to privacy throughout the research process.

# RESULTS

## Life sciences teachers and health education

### General perceptions of health education

The data in Figure 1 reveal that 91% of teachers completely agree that health education is important within the framework of teaching life sciences. However, 51% of the same sample believe that this education is not sufficiently addressed in life sciences curricula. According to 74% of teachers, students are receptive to health-related teachings, whereas 26% think otherwise. In this sense, the Figure 2 shows that, according to our teachers, the most frequently addressed topics in class are the prevention of infectious diseases (93.88%), addiction prevention (81.63%), personal hygiene (79.59%), and diet and nutrition (66.33%). Conversely, the least covered topics are mental health (27.55%) and sexual education (12.24%).
<figure><img src="image_4.png" /><figcaption>**Figure 2.** Most important health topics to address in the classroom.</figcaption></figure>

<figure><img src="image_5.png" /></figure>

Teaching practices for health education

The data displayed in Figure 3 reveals that 94% of life sciences teachers integrate health education into their teaching practices, primarily without using specific resources for health education (93%). In fact, according to Figure 4, the most commonly used teaching material in health education is the textbook (86%).
<figure><img src="image_6.png" /><figcaption>**Figure 4.** Teaching materials used during health education.</figcaption></figure>

<figure><img src="image_7.png" /></figure>

*Immunology and health education*

According to Figure 5, 87% of teachers believe that teaching immunology plays a key role in raising students' awareness of disease prevention. However, 39% of them feel that this teaching is not sufficient to encourage students to adopt responsible health behaviours. In this regard, 96% of the sample confirms that immunology should occupy a more significant place in school curricula to strengthen health education.
<figure><img src="image_8.png" /><figcaption>**Figure 5.** The role of immunology in health education.</figcaption></figure>

*Challenges and obstacles to the implementation of health education*

According to Figure 6, nearly 80% of teachers believe that the lack of time in the curriculum, as well as the cultural sensitivity of certain subjects, such as sexual education, hinder the integration of health education. For 69% of them, the main obstacle is the lack of training in this field. Finally, almost 46% of our sample points to the lack of suitable teaching resources and the lack of student interest.

<figure><img src="image_9.png" /><figcaption>**Figure 6.** Main challenges to integrating health education into life sciences courses.</figcaption></figure>

*Teacher involvement in health education*

The results in Figure 7 show that 66% of teachers are satisfied with their involvement in health education, compared to 34% who are not. Moreover, 95% of teachers are interested in continuing education to improve their skills in health education. However, only 53% of them are willing to participate in specific initiatives or projects to promote health education in their school.
<figure><img src="image_10.png" /><figcaption>**Figure 7.** Teacher involvement in health education.</figcaption></figure>

## Health education in textbooks

As indicated in Table 2, the three textbooks focus on the purely biological aspects of immunology and show little interest in the role of immunology in promoting health education.

<table><caption>**Table 2.** Analysis of textbooks according to the criteria of the analysis grid.</caption><thead><tr><td>Criteria</td><td>Presentation of criteria in textbooks</td></tr></thead><tbody><tr><td>Accuracy of immunological concepts</td><td>The three textbooks adopt the same perspective in presenting immunology; thus, the same concepts are found, often using the same resources (images, diagrams). The immunological concepts are scientifically accurate, covering the fundamentals of immunology: innate response, adaptive response, B and T lymphocytes, phagocytosis, etc. However, there are gaps, as the immune response is presented merely as a reaction of the immune system to an antigen aimed at its elimination. The immune system is depicted as a mechanism responsible for defending the organism, yet the communication and regulation within the immune system are not well explained.</td></tr><tr><td>Link between immunology and health</td><td>The three textbooks address health aspects through concrete examples such as AIDS and the mechanisms of defence against viral infections (flu, HIV). Still, these textbooks do not emphasise health education sufficiently in daily life. For instance, although topics like AIDS are discussed from an immunological standpoint, there is a lack of information on real-life preventive measures (such as condom use, the importance of screening tests, and access to care). Additionally, while the textbooks cover immune response, they do not clearly explain how daily behaviours (hygiene, diet, sleep) influence immunity and health. To ensure comprehensive health education, these aspects should be addressed.</td></tr></tbody></table>
Prevention and
promotion of
health

Cultural and
social sensitivity

Although the textbooks explain the importance of vaccination and serotherapy as means to strengthen immunity, they do not directly mention hygiene or daily behaviours that favour immunity and thus health. Furthermore, they do not take into account the epidemiological aspects affecting large populations. Finally, these textbooks do not encourage sufficient reflection on public health issues, such as vaccination campaigns, protective measures, or the importance of awareness campaigns against STIs. While they discuss vaccination and the fight against certain diseases, there is a lack of discussions on individual and collective responsibility in protecting public health.

The textbooks do not address diversity in terms of gender, sexual orientation, or different socio-economic contexts, particularly in relation to diseases such as HIV/AIDS. Effective health education should include discussions on the impact of STIs (Sexually Transmitted Infections) in various population groups and take into account cultural sensitivities to better inform students.

## DISCUSSION

### Teachers' perceptions and their engagement in health education

Even though half of our sample believes that health education is not sufficiently addressed in life sciences curricula, no teacher doubts its importance within the teaching of life sciences. However, being convinced of the importance of something does not necessarily mean being actively engaged in it. Indeed, a teacher's involvement in promoting health education depends on their perception of it. In this regard, Deonna (2006) emphasises that a person's perception directly depends on the perceiver's perspective of their environment [19]. Thus, a teacher's perception of health education arises from their view of the role this education can play in the teaching-learning process. Furthermore, a teacher's perceptions will depend on their understandings of health education. In this view, Clément (2010) notes that an individual's conceptions stem from the interaction of their knowledge, personal value system, and professional, personal, and social practices [20]. In fact, regarding health education, some teachers hold a view that considers certain topics (such as sexuality) as taboo subjects that should not be addressed. This social representation translates into attitudes of silence, or even refusal, to teach certain psychosocial aspects of health, particularly outside the traditional framework.

For sure, the life sciences teachers in our sample are generally comfortable teaching the biological aspects of health (such as the prevention of infectious diseases, prevention of addictions, personal hygiene, and nutrition), but they are more reluctant when it comes to addressing the psychosocial aspects of health (such as mental health or sexual education). This reluctance can be explained by the values of the teachers, given that the respondents are of Muslim faith, their attitudes towards certain subjects of health education (notably sexuality) are influenced by religious and cultural values of modesty that associate aspects related to sexuality with a strict moral framework (marriage, abstinence), leading them to believe that health education should focus on these norms. In this perspective, a study conducted by Khzami (2010) revealed that HIV/AIDS is perceived by a majority of students as a symptom of transgressing cultural norms and values that emphasise fidelity within marriage and abstinence among youth [21]. By acting this way, teachers sometimes seem to overlook the necessity of preparing young people for the physical and psychological changes that accompany puberty. Thus, for health education to be effective, it must consider prevailing values while also addressing the needs and expectations of young people.

Moreover, even though 87% of teachers consider that the teaching of immunology plays a key role in raising students' awareness of disease prevention, 39% of teachers believe that the teaching of immunology alone is insufficient to encourage
students to adopt responsible health behaviours. Furthermore, the integration of health education during the teaching of immunology mainly occurs using the textbook as a didactic support (86%). However, the results of several studies on the learning of immunology in Morocco and in countries such as Lebanon and Tunisia have highlighted the presence of various types of inaccuracies and errors during the didactic transposition of immunological concepts in textbooks. Even if learners receive lessons on immunology, they do not mobilise immunological knowledge in acquiring health education [22-25]. In this sense, the lack of time and the cultural sensitivity of certain subjects, such as sexual education, are factors that hinder the implementation of health education. In a similar context, the results of a study conducted by Mérini (2010) revealed that while some teachers claim they are unable to implement health education due to time constraints and pressure from curricula, the study nonetheless showed that there is a real possibility to integrate activities related to health education, citizenship, and sustainable development into school activities [26].

Regarding teachers' involvement in promoting health education, it depends, according to Simar (2010), on the interest a teacher has in health education issues and the amount of training they have received [12]. In this perspective, even though 95% of teachers are interested in continuing education to improve their health education skills, only 53% of them are willing to engage in initiatives promoting health education in their schools. This result aligns with the fact that 34% of our teachers are not satisfied with their involvement in health education. In this sense, health education appears as a peripheral subject for which teachers' investment is closely linked to their interest and sense of competence [27].

## Health education through textbooks

While all educational reforms in Morocco—curriculum changes, integration of new teaching subjects, competency-based teaching—emphasises the importance of student involvement and autonomy in their learning process (constructivist approach). Moreover, the textbook plays a central role in teaching practices and is recognised as one of the most effective tools for improving the quality of education, particularly in countries where educational system resources are limited [28]. In this context, the textbook can play an important role in promoting health education. However, textbook authors often fail to implement this health education when translating expert knowledge into teachable content. In this sense, a study conducted by Selmaoui, which examined the educational approach adopted by textbook authors, concluded that an informative and dogmatic style predominates in parts of the textbooks where there should be teaching centred on student participation in constructing their knowledge [15]. In fact, the authors of the textbooks use participatory style very little in subjects related to health education, where participation and student autonomy are essential [21].

Furthermore, immunology as a science is distinguished by the complexity of its concepts [29], and this complexity is among the challenges that students must overcome to progress in their learning [30]. Even so, the three textbooks present immunology in an overly simplistic manner, focusing on the transmission of scientific knowledge related to the mechanisms of the immune response. By presenting immunology in fragmented and decontextualised activities, the three studied textbooks contribute very little in promoting health education and to the development of the scientific mindset of learners. In relation to cultural values, immunology could serve as a vector for a range of them; specifically, social values linked to hygiene, prevention, and individual and collective responsibility can be fostered in students through immunology. Nevertheless, the three textbooks place greater emphasis on the purely scientific aspect of immunology than on cultural and social values. For instance, HIV/AIDS is discussed without reference to health education, and various diseases presented in the textbooks are discussed without mentioning public health.

Yet, the context of COVID-19 has crucially highlighted the importance of epidemiological studies and the need to raise public awareness about health. Indeed, the pandemic has illuminated the interconnectedness of scientific research, public health, and the capacity of educational systems to play a key role in the prevention and management of health crises. In this sense, health education in schools has emerged as a fundamental pillar for preparing future generations to face such crises.
Integrating health education programmes from an early age enables the formation of informed citizens, capable of understanding health risks and practising barrier gestures and other preventive measures.

## CONCLUSION

The finding of this study revealed that despite the importance of education in training citizens to be aware of their role in protecting their own health and that of the community, not all teachers in our sample are engaged in promoting this education while teaching immunology. Even though textbooks are the most widely used teaching materials by educators, they are not very effective as didactic tools for promoting health education, and this is for several reasons:

* They are out of step with pedagogical orientations, particularly regarding the adoption of a competency-based approach.

* Immunology is developed following a content- and objective-focused approach.

* The textbooks, in their current design, often do not contribute sufficiently to promoting health education. While some health topics are covered in the curricula, they are often treated superficially, without a genuine emphasis on preventive practices and healthy behaviours to adopt. Furthermore, health is frequently presented in a theoretical manner, with no direct connection to contemporary issues such as pandemics, lifestyle hygiene, nutrition, or mental health.

Finally, in the Moroccan context, we believe that the challenge populations face in light of pandemics can be significantly mitigated by better integrating health education into educational system by considering the following points:

* Incorporate Health Education into teacher training programmes.

* Develop specific sections on the prevention of STIs, emphasising the importance of screening, protective methods (such as condoms), and discussions on responsible sexuality. This would enable students to better understand how to protect their health and that of others.

* Include health education in teaching practices by proposing debates or projects on dilemmas related to public health policies (mandatory vaccination, health measures during a pandemic, etc.), allowing students to critically reflect on their role as informed citizens in society.

* Develop Public Health Education in schools to encourage students to understand their role in disease prevention through discussions on public health issues, such as mass vaccination, epidemic prevention, and behaviours to adopt during health crises.

**Author Contributions:** Conceptualization: AO; methodology: RZ; software: RZ; validation: R J-I; formal analysis, AO, RZ; investigation: AO, RZ, R J-I; resources: R J-I; data curation: AO; writing—original draft preparation: AO; writing—review and editing: RZ, R J-I; visualization: AO; supervision: R J-I; project administration: R-J-I. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Acknowledgments:** None.

**Conflicts of Interest:** The authors declare no conflict of interest.

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