Designing and evaluating a Merrill model-based educational package to enhance midwives’ role in population rejuvenation

Abstract

Introduction

Global trends in population aging and declining fertility pose significant challenges to sustainable development. As frontline healthcare professionals, midwives play a pivotal role in addressing these issues through reproductive health education and advocacy. This study aimed to design, implement, and evaluate an educational package based on Merrill’s Instructional Design Model to enhance midwives’ competencies in promoting population rejuvenation strategies.

Methods

A cross-sectional study was conducted with 41 midwives from comprehensive health centers (2023). The Merrill-based educational intervention included four in-person sessions focused on demographic policies, counseling techniques, and family support frameworks. Data were collected via validated knowledge tests (pre-/post-intervention), satisfaction surveys, and demographic questionnaires. Statistical analyses (SPSS v.26) employed paired t-tests and Pearson’s correlation.

Results

Post-intervention knowledge scores (17.78 ± 1.89) showed a statistically significant improvement compared to pre-test scores (12.78 ± 2.05; p < 0.0001), with a large effect size (Cohen’s d = 2.536). All participants (100%) reported high satisfaction with the training (mean score: 222.5 ± 18.75). A strong positive correlation was observed between knowledge gains and satisfaction levels (r = 0.65, p < 0.001).

Conclusion

The Merrill Model-based educational package demonstrated effectiveness in improving knowledge and engagement among the 41 participating midwives in North Tehran. Its structured approach shows promise as a context-sensitive strategy for reproductive health training within similar settings, though further research is needed to evaluate its applicability in broader healthcare contexts.

Introduction

In recent decades, the global community has experienced two simultaneous yet contrasting trends: a marked decline in fertility rates and a rapid rise in the proportion of older adults. According to the United Nations, the average number of births per woman worldwide fell from 3.2 in the early 1990s to below 2.5 by 2020, while the share of people aged 65 and over increased from 5.5% to approximately 9% over the same period [1]. These demographic shifts have led to mounting pressures on social security systems, rising healthcare expenditures, and a shrinking productive workforce [2]. Iran is not immune to these challenges: its total fertility rate declined from 6.5 children per woman in the 1980s to 1.65 by 2020, and the proportion of those aged over 65 has surpassed 7% [3]. Such developments underscore the urgent need for interdisciplinary and cross-sectoral strategies to restore demographic equilibrium and secure the country’s sustainable development.

Globally, nations grappling with sub-replacement fertility rates—such as those in Europe—have implemented multifaceted incentive-based policies to counteract demographic decline. These include extended parental leave, subsidized childcare, financial grants, and healthcare support [4, 5]. Iran, too, has introduced pronatalist measures, such as extending maternity leave for working women and promoting marriage incentives [6]. However, the efficacy of such policies hinges not only on economic stimuli but also on cultural and educational interventions that address societal attitudes toward childbearing. Religious, cultural, and economic factors profoundly shape these attitudes, thus necessitating a holistic approach to foster a sustainable pronatalist culture [7].

Central to this effort is the role of healthcare providers, particularly midwives, who serve as frontline advocates for reproductive health and family planning. Midwives in Comprehensive Health Centers (CHCs) are uniquely positioned to influence young mothers’ decisions. They achieve this through education, counseling, and community engagement. Studies, including Rahmati et al. (2019), underscore their pivotal role in enhancing fertility awareness and shifting societal norms toward childbearing [8]. Yet, the effectiveness of these efforts depends on midwives’ own knowledge, attitudes, and training methodologies.

This study addresses a critical gap in current demographic strategies: the design, implementation, and evaluation of a structured educational program to equip midwives with the skills to advocate for family support and youth population sustainability. Grounded in Merrill’s Instructional Design Model—a cognitive framework renowned for its efficacy in organizing educational content and elevating learner performance—the research aims to develop a tailored training package for midwives in CHCs [9]. Merrill’s model emphasizes terminal performance outcomes, guiding learners from foundational knowledge to innovative application, making it ideal for translating complex demographic concepts into actionable practices [10–12].

The research questions driving this study are:

What constitutes an effective educational package, based on Merrill’s model, to enhance midwives’ awareness of family support and population rejuvenation?

To what extent can this model improve midwives’ knowledge and attitudes in Tehran’s North CHCs?

Conducted in 2023–2024, this cross-sectional study targets midwives in Tehran’s North CHCs, where demographic pressures are acutely felt. By integrating Merrill’s principles—such as problem-centered learning and phased skill development—the program seeks to empower midwives as agents of demographic change. Expected outcomes include improved counseling competencies, increased advocacy for healthy fertility practices, and measurable shifts in community-level childbearing behaviors.

In sum, this research contributes to both theoretical and practical dimensions of demographic policy. It not only tests the adaptability of Merrill’s model in public health contexts but also offers a replicable framework for nations facing similar demographic crises. By bridging the gap between policy design and grassroots implementation, the study underscores the indispensable role of healthcare professionals in sustaining demographic vitality.

Method

This cross-sectional study was conducted in 2023–2024 at Tehran’s North Comprehensive Health Centers (CHCs), affiliated with Shahid Beheshti University of Medical Sciences, Iran. The research aimed to design, implement, and evaluate an educational package based on Merrill’s Instructional Design Model to enhance midwives’ awareness of population rejuvenation and family support policies. This paper presents the methodology and findings of this intervention study.

Study population and sampling

The target population comprised midwives employed at Tehran’s North CHCs. A census sampling method was employed, inviting all eligible midwives via automated letters. Inclusion criteria required participants to hold a bachelor’s degree in midwifery and active employment at the CHCs. Exclusion criteria included incomplete participation in training sessions or withdrawal from the study.

Intervention design and implementation

The educational package was developed in alignment with Iran’s Ministry of Health guidelines on family support and youth population policies. Merrill’s model—a cognitive instructional framework emphasizing performance-driven learning—guided the curriculum design to ensure deep understanding and practical application.

The development process followed seven structured stages:

Learning Analysis: Pre-tests revealed significant knowledge gaps among midwives, particularly in interpreting dense legal and policy texts related to family support.

Content Classification: A panel of medical education and instructional design experts categorized the content into four domains: facts, concepts, procedures, and principles.

Performance Objectives: Learning outcomes were defined across three cognitive levels:

• Recall: Identification of key policy elements.

• Application: Use of legal frameworks in clinical scenarios.

• Discovery/Innovation: Designing context-sensitive support strategies.

Primary and Secondary Presentation: Instructional materials incorporated explanatory statements, generalizations, and illustrative examples. Case-based discussions and multimedia resources were used to enhance engagement and retention.

Instructional Sequencing: Sessions were logically ordered to scaffold knowledge acquisition, beginning with activation of prior knowledge and culminating in integration and reflection.

Design Principles: Four instructional rules—segmentation, variation, alignment, and complexity—were applied to optimize learner engagement and cognitive load management.

Training Delivery: The training was delivered over four structured sessions, each lasting approximately 90–100 min. Activities included concept mapping, multimedia presentations, role-play, and peer feedback. The sessions were designed to ensure both theoretical grounding and practical relevance in midwifery practice (Table 1).

Table 1.

Educational sessions structured by merrill’s model

Session	Instructional Phase	Topic	Duration	Activities	Assessment
1	Activation of Prior Knowledge	Population aging, fertility barriers, target groups of family support law	100 min	Group discussion, concept mapping, sharing prior experiences	Pre-test, oral Q&A
2	Demonstration of New Content	Legal support for pregnancy, childbirth, and families with multiple children	90 min	Multimedia presentation, legal document review, case study analysis	Quiz, role-play
3	Application of Knowledge	Support for employed/unemployed mothers, students, and seminary mothers	100 min	Scenario-based role-play, small group problem-solving, policy mapping	Case-based evaluation
4	Integration and Reflection	Abortion laws, public health education, reproductive services	100 min	Case discussion, independent summary, peer feedback	Oral presentation, final Q&A, Post-test

Data collection tools

Data collection was structured according to Kirkpatrick’s evaluation model, focusing on Level 1 (Reaction) and Level 2 (Learning):

1. Reaction (Level 1): Participant satisfaction was assessed post-intervention via the Course Experience Questionnaire (CEQ), a 50-item Likert-scale tool (1 = strongly disagree; 5 = strongly agree) designed to measure perceptions of teaching quality, clarity of objectives, content volume, available resources, and assessment methods. Scores were categorized as poor (< 80), satisfactory (80–160), or excellent (> 160). The CEQ has demonstrated high reliability in prior studies (Cronbach’s α = 0.85) [13–15]. In the present study, its internal consistency was confirmed with a Cronbach’s alpha of 0.85.

2. Learning (Level 2): Knowledge gains were evaluated using a 20-item multiple-choice test, developed and validated by a committee of midwifery specialists and medical educators. Content validity was confirmed through expert review. Reliability was established through pilot testing with 15 midwives from East Tehran Comprehensive Health Centers, which yielded a satisfactory Cronbach’s alpha of 0.80. Pre- and post-test scores were compared to quantify learning outcomes. These values confirm the reliability of the tools within the context of our study. The obtained alpha values for both instruments (0.85 for CEQ and 0.80 for the test) confirm their reliability for use in the context of this study.

Data analysis

Descriptive statistics (mean, standard deviation, frequency) summarized demographic data and satisfaction scores. A paired t-test analyzed pre- and post-test knowledge improvements. Pearson’s correlation coefficient examined associations between satisfaction and learning outcomes. ANOVA compared scores across subgroups, with significance set at p < 0.05. Analyses were performed using SPSS v.26.

Results

Study population

This cross-sectional study was conducted between 2023 and 2024 to evaluate the efficacy of a Merrill Model-based educational intervention aimed at enhancing midwives’ knowledge and satisfaction regarding population rejuvenation policies. The study was implemented across three North Comprehensive Health Centers (CHCs) in Tehran and included 41 midwives with a mean professional experience of 11 ± 3 years. The age distribution of participants was as follows: 17.1% (n = 7) were aged 20–30, 48.8% (n = 20) aged 30–40, and 34.1% (n = 14) aged 40–50 (Table 2).

Table 2.

Sociodemographic characteristics of participants (n = 41)

Variable	Category	Frequency (n)	Percentage (%)
Age Group (years)	20–30	7	17.1%
	30–40	20	48.8%
	40–50	14	34.1%
Professional Experience	Mean ± SD	—	11 ± 3 years
Educational Level	Bachelor’s Degree	41	100%
Marital Status	Single	10	24.4%
	Married	31	75.6%
Workplace Location	CHC 1 (Shahrara)	12	29.3%
	CHC 2 (Tajrish)	15	36.6%
	CHC 3 (Qeytarieh)	14	34.1%

Participant satisfaction (Kirkpatrick level 1)

Satisfaction was assessed using the 50-item Course Experience Questionnaire (CEQ), rated on a 5-point Likert scale. Scores were categorized as poor (< 80), satisfactory (80–160), or excellent (> 160). All participants (100%) scored within the exceptional range, with a mean score of 222.5 ± 18.75. The highest approval rates were observed in the domains of educational resources (82.69%) and teaching quality (75%), followed by learning objectives, assessment methods, and content volume (Table 3).

Table 3.

Participant satisfaction scores across domains

Domain	Approval Rate (%)
Teaching Quality	75.00
Educational Resources	82.69
Content Volume	68.50
Learning Objectives	73.20
Assessment Methods	70.10

The Merrill-based curriculum achieved exceptional satisfaction rates through its structured content and case-based discussions. These findings highlight the importance of learner-centered instructional design in demographic education.

Knowledge Improvement (Kirkpatrick Level 2).

Knowledge acquisition was evaluated using a 20-item multiple-choice test administered before and after the intervention. As shown in Fig. 1; Table 4, post-test scores demonstrated a significant improvement compared to pre-test scores, with a mean increase of 5.0 points (t = 16.03, p < 0.001). The computed Cohen’s d effect size was 2.536, indicating a very large magnitude of change. This improvement exceeded the minimum competency threshold of 4 points set by the Ministry of Health for clinical decision-making, confirming that the educational intervention resulted in both statistically significant and practically substantial improvements in participants’ applied knowledge of reproductive health policies.

Fig. 1.

Comparison of knowledge scores before and after the Merrill Model-based intervention

Table 4.

Pre-test and Post-test knowledge scores with effect size

Assessment Phase	Mean ± SD	Mean Difference	t-value	p-value	Cohen’s d	Interpretation
Pre-test	12.78 ± 2.05	5.00	16.03	< 0.001	2.536	Very large effect
Post-test	17.78 ± 1.89

Cohen’s d interpretation based on Sawilowsky (2009), where d > 0.8 indicates a large effect

Fig. 2.

Progressive improvement in knowledge assessment scores across the training timeline. Furthermore, to depict the trajectory of learning throughout the training sessions, the progressive enhancement of learning outcomes was tracked, (Fig. 2). This upward trend underscores the pedagogical strength of the Merrill Model in facilitating sustained knowledge acquisition

Correlation between satisfaction and knowledge

Pearson correlation analysis revealed a strong positive relationship between post-test scores and satisfaction levels (r = 0.65, p < 0.001) (Table 5; Fig. 3), indicating that participants who demonstrated greater knowledge gains also reported higher satisfaction. This correlation, visually represented in the scatter plot (Fig. 3), reinforces the pedagogical value of the Merrill Model, suggesting that effective instructional design enhances both cognitive and affective learning outcomes.

Table 5.

Pearson correlation analysis between Post-test knowledge scores and overall satisfaction scores

Variable	Mean ± SD	Correlation Coefficient (r)	p-value
Post-test Scores	15.28 ± 2.10	0.65	< 0.001
Satisfaction Scores	222.50 ± 18.75

Fig. 3.

Scatter plot demonstrating the positive correlation between post-intervention knowledge scores and overall satisfaction (r = 0.65, p < 0.001)

Discussion

This study offers compelling evidence that Merrill’s First Principles of Instruction serve as an effective pedagogical framework for enhancing midwives’ knowledge and satisfaction regarding Iran’s population rejuvenation policies. The educational intervention, conducted across North Tehran Comprehensive Health Centers (CHCs), led to a statistically significant improvement in post-test scores (mean difference = + 5.0; p < 0.001), underscoring the model’s ability to translate theoretical content into practical understanding. This outcome directly addresses midwives’ previously reported difficulties with dense textual materials and highlights the value of simplified, problem-centered instructional approaches tailored to their professional learning needs [11].

To ensure clarity and transparency, Table 6 presents the key quantitative findings, including pre- and post-test scores, satisfaction levels, and the correlation between cognitive gains and learner satisfaction.

Table 6.

Summary of midwives’ knowledge and satisfaction before and after the educational intervention

Variable	Pre-Test (Mean ± SD)	Post-Test (Mean ± SD)	Mean Difference	Statistical Test	p-value	Interpretation
Overall Satisfaction Score	–	222.5 ± 18.75	+ 5.0	Paired t-test	< 0.001	Significant improvement in satisfaction
Satisfaction with Educational Resources	–	82.69%	–	Descriptive analysis	–	High satisfaction with learning materials
Satisfaction with Teaching Quality	–	75.00%	–	Descriptive analysis	–	Positive reception of instructional design
Knowledge Score	12.78 ± 2.05	17.78 ± 1.89	+ 5.0	Paired t-test	< 0.001	Significant improvement in knowledge
Correlation: Knowledge & Satisfaction	–	r = 0.65	–

The strong correlation between knowledge acquisition and satisfaction (r = 0.65, p < 0.001) reinforces the effectiveness of learner-centered methodologies, particularly case-based discussions and interactive pedagogy. These results align with contemporary research in health professional education, which emphasizes that active learning strategies not only enhance retention but also foster motivation and engagement [16, 17].

From a broader perspective, the findings resonate with global evidence highlighting midwives’ pivotal role as frontline advocates for reproductive health and fertility promotion. In European countries grappling with demographic decline, educational interventions are often complemented by economic incentives—such as subsidized childcare and extended parental leave—to stabilize fertility rates [18]. In contrast, Iran’s socio-cultural landscape, shaped by religious values and economic constraints, necessitates localized strategies. Midwives, as trusted community figures, are uniquely positioned to act as culturally responsive agents of change [19, 20].

The high satisfaction ratings regarding educational resources (82.69%) and teaching quality (75%) reflect the program’s alignment with Kirkpatrick’s second evaluation level—Learning and Satisfaction. These outcomes not only affirm the cognitive effectiveness of the intervention but also its relevance and acceptability among learners, reinforcing its applicability in similar health education contexts [21–23].

Moreover, the integration of Merrill’s model—emphasizing problem-centered learning, phased skill development, and performance-based outcomes—proved instrumental in converting abstract policy concepts into actionable knowledge. The observed improvement in post-test scores is consistent with prior studies that underscore midwives’ influence in shaping societal attitudes toward childbearing through targeted counseling and education [18].

Despite its strengths, the study is subject to several limitations that warrant careful consideration. First, the absence of a control group limits the ability to establish causal relationships between the intervention and observed outcomes. While the statistically significant improvement in post-test scores suggests a positive effect, alternative explanations cannot be ruled out without a comparative design. Second, the short-term nature of the evaluation—conducted immediately after the intervention—precludes assessment of long-term knowledge retention and sustained behavioral change. Given the importance of durable learning in professional practice, future studies should incorporate longitudinal follow-up to determine whether the instructional gains persist over time. Third, satisfaction data were collected through self-reported measures, which may be subject to response bias, including social desirability effects. This could potentially inflate perceptions of program effectiveness. To mitigate this limitation, future research should triangulate self-report data with objective indicators such as performance assessments, observational metrics, or qualitative interviews. Finally, although census sampling ensured full participation within the selected CHCs, it restricts the generalizability of findings beyond North Tehran. Broader studies across diverse geographic and institutional settings are needed to validate the scalability and adaptability of Merrill’s framework in midwifery education. These limitations have been explicitly acknowledged in the manuscript to enhance transparency and guide future research directions.

Recommendations for Future Practice.

To broaden impact, several strategies are recommended:

• Program replication: Replicate the program in other Iranian healthcare centers, especially in low-fertility regions, to evaluate scalability [24].

• Curriculum integration: Integrate Merrill’s model into national midwifery curricula to standardize demographic training [25].

• Multi-faceted interventions: Pair educational initiatives with economic incentives (e.g., childcare subsidies) to address multi-faceted barriers to childbearing [26].

• Stakeholder collaboration: Foster collaboration among policymakers, educators, and healthcare providers to design culturally aligned interventions that address local demographic needs.

• Longitudinal research: Conduct longitudinal studies to assess long-term behavioral and fertility outcomes, while employing mixed-methods designs to reduce self-report bias.

• Technology integration: Utilize digital tools like e-learning modules to enhance accessibility and scalability in resource-constrained settings.

Conclusion

This study underscores Merrill’s Instructional Design Model as a promising framework for addressing Iran’s demographic challenges within the specific context of midwifery education. By equipping 41 midwives in North Tehran with the knowledge and motivation to advocate for population rejuvenation, the intervention demonstrated potential to bridge the gap between policy intent and grassroots implementation. While the findings are encouraging, they reflect outcomes within a localized setting and should be interpreted with caution regarding broader applicability.

As Iran continues to navigate its demographic transition, context-sensitive and evidence-based educational strategies—such as Merrill’s task-centered approach—can play a pivotal role in aligning national objectives with community-level action. Future studies across diverse regions and professional groups are recommended to further explore the replicability and scalability of this instructional model.

Author contributions

ZA, ET and MK were the major contributors to conceptualizing and formulating the research question and designing the study. MK was the leader of the research and project team. ZA, MZ collected and analyzed the data. The first draft of the manuscript was written by ZA, MZ, ET and MK critically studied and appraised the first draft. All authors commented on the modified draft and the final version of the manuscript was prepared. Finally, all authors approved the final manuscript.

Funding

The authors received no specific funding for this work.

Data availability

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Research Ethics Committee of Shahid Beheshti University (Code: IR.SBMU.SME.REC.1402.046). All participants provided written informed consent prior to enrollment. The study objectives, procedures, risks, and benefits were clearly explained. Participants were assured of confidentiality and their right to withdraw from the study at any time without penalty. All methods were performed in accordance with the ethical standards outlined in the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.