Wound management is essential in healthcare, particularly for complex cases like surgical and traumatic wounds, which can lead to severe complications if not adequately treated [1]. Antimicrobial calcium alginate dressings, known for absorbing exudate and offering hemostatic effects, have emerged as a widely used solution for such wounds [2]. These dressings are especially beneficial for managing infections in surgical wounds, maintaining a moist environment, and accelerating the healing process. Despite their clinical effectiveness, clinicians’ continuous usage intention (CUI) of these dressings could be more consistent in emerging markets such as Indonesia, where the healthcare infrastructure and access to such advanced products are still limited [3]. Therefore, a comprehensive understanding of clinicians’ role in decision-making regarding wound care products’ use is needed, as this would be related to the quality of medical care provided in hospitals.

Clinician experience (CEX) is derived from user experience, which is defined as the interaction between the user of a product and all touch points along the continuum of product usage, even if there are complaints. In the context of this study, CEX includes the experiences of physicians and other healthcare professionals who use the product directly while performing wound care. Clinicians often get involved in procurement activities by giving recommendations or suggestions to the decision-making management. Still, they can influence the decision to choose a certain wound care product for use through professional opinions and feedback either directly or through the medical committee and thus have a significant role in the continuous usage of medical products [4]. Exploring this relationship is crucial for optimizing communication between wound care product providers and decision-makers in hospitals or healthcare facilities in emerging economies, where product adoption often faces barriers related to different interests. Therefore, understanding clinicians’ perspective based on their experience and perceived value of medical products is crucial because in many cases clinicians are oriented toward the quality of service and represent patients’ benefits despite not always being in a position enabling them to actively promote products they want to use.

The role of clinicians, apart from treatment, has a broader contribution related to the structure of health services in developing countries where, in addition to public facilities, there are also many private hospital facilities whose patients are covered by a national health insurance system. In such situations, a clinician’s decision to use certain wound care products becomes important feedback for stakeholders of health services, as in an emerging economy like Indonesia, which currently has a population of around 270 million. This study, set in Indonesia, is expected to provide new insight for other countries with similar healthcare systems.

According to Basic Health Research, the prevalence of wounds in Indonesia increased from 8.2% to 9.2% [5]. The number of surgical procedures in Indonesia has also increased significantly since the 1970s, incorporating modern techniques and innovations [6]. The increase in the number of surgeons and operating theater (OT) facilities in hospitals correlates with the rising number of both major and minor procedures. This leads to an increase in the handling of acute post-operative wounds using wound dressings. CUI is fundamental in this context, as it subsequently affects the success of healthcare interventions and impacts patient outcomes and hospital resource management. CEX relates to various wound care products. Cases of hemostatic products such as calcium alginate which are widely known, but often not available in health facilities that have insufficient financial capacity, demonstrate the challenges in product selection and adoption. This research is both timely and relevant, as it addresses filling the gap indicated by the still limited empirical research from a clinician’s perspective related to clinicians’ desires in selecting and using wound care in the context of developing countries while contributing to better healthcare outcomes. From a clinician’s point of view, this research will extend the understanding of the contribution that can be made to the quality of care through interaction with stakeholders.

To that end, a survey was conducted with clinicians who handle acute wound care using modern wound dressings as respondents. The objective of this study was to test and analyze the relationship of factors related to intention value - brand benevolence and brand competence - to intention of use. This study is based on a hypothetico-deductive approach with a conceptual framework built on individual behavior, especially the theory of planned behavior [7]. This theory explains that individual intentions can be predicted by attitudes, subjective norms and perceived behavioral control, which, in this research context, are broken down into perceived value and experience variables.

The variables related to this study were Epistemic Value (EPV), Functional Value (FUV), Innovation Value (INV), Social Value (SOV), Economic Value (ECO), Clinician Experience (CEX), Brand Benevolence (BEN), Brand Competence (COM), and Continuous Usage Intention (CUI). The conceptual framework of the relationship between various values and CEX was developed from previous studies; the association between CEX and EPV was referred from Mazanderani et al. [8], FUV from Liu et al. [9], INV from Syeed et al. [10], SOV from Zhu et al. [11], and ECO from Al-Emran et al. [12]. These studies demonstrated that if the perception of a certain value increases, CEX will also increase. Therefore, in the context of the Indonesia wound care population, it can be hypothesized (H) as follows:

H1: EPV is positively associated with CEX

H2: FUV is positively associated with CEX

H3: INV is positively associated with CEX

H4: SOV is positively associated with CEX

H5: ECO is positively associated with CEX

The relationship between CEX and BEN is referred from Wang et al. [13], and that with COM is referred from Grundgeiger et al. [14]. Therefore, the following can be hypothesized in the context of wound care in Indonesia:

H6: CEX positively correlates with BEN

H7: CEX positively correlates with COM

The relationship between CEX, BEN, and COM plays a significant role in influencing CUI. When clinicians positively evaluate a product, they develop a stronger connection to it, which can lead to increased advocacy within their professional environment. By mentioning the product favorably, clinicians contribute to greater brand recognition through two key dimensions: brand benevolence and brand competence. A stronger perception of these brand attributes reinforces clinicians’ trust and engagement, ultimately driving CUI. The connection between CUI and CEX is referred from Kang and Hwang [15], BEN is referred from Chung et al. [16], and COM is referred from Wang et al. [17]. Therefore, in the context of Indonesian wound care, their influence can be hypothesized as follows:

H8: CEX is positively associated with CUI

H9: COM is positively associated with CUI

H10: BEN is positively associated with CUI

These associations are illustrated in Fig. 1, which shows the conceptual framework. Brand benevolence and brand competence in this study are used to accommodate the reality that the promotional activities of wound care product providers influence clinicians. Furthermore, the value or subjective benefits clinicians perceive about using modern wound dressings are independent variables.

This study employed a quantitative cross-sectional design with questionnaire instruments. It was conducted in seven private hospitals in Indonesia’s most prominent cities, Jakarta and Surabaya. The targeted population consisted of active users of modern wound dressings, including specialists such as general surgeons, plastic surgeons, and certified wound nurses. A purposive sampling method was deployed to collect data from clinicians with specific criteria who had specifically managed surgical wounds within the last 12 months. The exclusion criteria were users receiving sponsorship from particular brands within the sampling period. This approach was taken to prevent sampling bias.

Power analysis was used according to the recommendations for determining sample pada partial least square-structural equation modeling (PLS-SEM), as shown in Fig. 2 [18]. The required minimum sample size was calculated using G*power (version 3.1.9.7) with f square expected 0.15 alpha 0.05 and power 90% and a number of predictors 9. The determined minimum sample size for this investigation was 136.

The study used a structured questionnaire with closed questions that contained statements. Respondents were asked to express agreement using a data interval scale with 1–5 points, starting with 1=strongly disagree and 5=strongly agree. Likert quantified these studies indicator for variables measurement [18]. Items of the questionnaire that become indicators were adapted from previous scale development studies, CEX [19,20], BEN [21], COM [21], and CUI [22]. The items derived from the references were first translated from English to Indonesian by a professional translator. Then, this question item was tested for face validity using an expert panel of three academics with experience in survey research on health workers. After receiving input from the results of face validity, the questionnaire sheet was tested on a group of 10 respondents for a readability test. After improvements were made, the questionnaire sheet was distributed online. The questionnaire sheet also mentioned anonymous volunteers only for academic purposes. The question items tested for reliability and validity can be seen in Table 1.

A multivariate approach using PLS-SEM was applied for data analysis. SmartPLS version 4.1.0.2 was used for the PLS-SEM analysis due to the complexity of the model and explanatory and predictive oriented. The use of PLS-SEM with bootstrapping as a nonparametric approach was justified as the data were derived from respondents’ perceptions and were not normally distributed. In the PLS-SEM method, two mandatory stages are carried out [18]; the first is the outer model analysis to ensure the reliability and validity of the indicators, after which the inner model analysis is carried out. At this stage, there are two important steps to assess the quality of the model. The first step comes from the R², f², Q², and Cross-Validated Predictive Ability Test (CVPAT) values; the second step comes from structural relation analysis results based on significance and coefficients (95% confidence interval [CI] and P<0.005) [18].

For data analysis, 147 respondents were considered eligible, exceeding the minimum target required. Table 2 shows males representing 62.6% (n=92). Most respondents were between 31 and 40 years old (40.8%). Nurses dominated the sample at 64.6% (n=95), with doctor specialists comprising 35.4% (n=52). Most respondents worked in the OT (69.4%), including minor operating rooms. The findings reveal that 52% of cases demonstrated the primary outcome, indicating a majority trend in this category. Additionally, secondary outcomes show decreasing frequencies, with 28%, 11%, and 9% respectively, suggesting a notable divergence in response rates among clinical cases. With the diverse respondent base, primarily made up of mid-career professionals in clinical settings, this data was suitable for the purpose of the study.

Descriptive analysis shows that the data was not normally distributed, thus confirming the use of nonparametric multivariate statistics such as PLS-SEM. As displayed in Table 1, with an interval scale using a Likert scale point of 1–5 the mean value for the dependent value CUI was 4.213 (standard deviation [SD]=0.689). For the independent variables EPV, FUV, INV, SOV, and ECO, the lowest mean value was in INV with a value of 4.128 (SD=0.684) and the highest in SOV with a value of 4.252 (SD=0.555).

Data processing with PLS-SEM produces two stages of data analysis results [18]. The first is the outer model or measurement model to confirm the reliability and validity indicators in measuring the latent variables. In the outer model, four tests were carried out. In this test, it was found that there were 40 reliable indicator items with loading values above 0.7, as can be seen in Table 1. Then, all eight variables met the requirements of a reliable construct with a Cronbach alpha value, Rho_a above the threshold of 0.7 and Rho_c or composite reliability below the upper threshold of 0.95. The construct validity test found that all eight variables had an AVE (average variance extracted) value above 0.5 and were deemed valid.

The discriminant validity test with the heterotrait-monotrait ratio matrix (HTMT) showed that all HTMT values in Table 3 were below 0.9, so it was concluded that the indicator items were well-discriminated and could measure their respective constructs precisely. The standardized root mean square residual value was below 0.8 indicating a fit model. Overall, it can be concluded from the outer model that it has met the reliability and validity requirements. In the variance inflation factor test, a value below three was obtained, so it was said to be free from multicollinearity problems and does not indicate common method bias since it was less than 3.3 [18].

The determinant coefficient in R² data for CUI was 0.587, while CEX was 0.652. This study’s results focused on CUI, which can be explained by 58.7% of the variables in the model. The effect size was low to moderate for the value of f² of 5 independent variables. This shows that the role of independent variables is more prominent when appearing parallelly.

LS_predict might be used to assess a model’s overall prediction ability [18]. The CVPAT in Table 4 indicated that the model performs strong predictive validity with Q² 0.989 [18]. The research findings compare the indicator average (IA) and PLS-SEM. The linear model (LM) thus displays a negative value compared to IA, indicating a smaller error value in PLS-SEM. In contrast, a positive value for LM indicates that the model has adequate predictive power.

Based on the bootstrapping hypothesis testing findings in Table 5, ten relational hypotheses were supported with P-value <0.05 [10] and CI of 5% and 95% in the positive direction. In the second step of the analysis, the inner or structural model confirmed the relation between all variables in the model, as shown in Fig. 2.

This study aims to analyze the relationship between the perception of clinicians who use wound dressings from the perspective of perceived value and the intention to use calcium alginate products continuously. By focusing on evidence from clinicians in emerging countries, this study contributes to improving healthcare management in resource-limited settings through a clinician perspective. Feedback from clinicians is an important thing to understand for stakeholders, including regulators, and decision-makers in healthcare providing services, including persons in charge of procurement. This study’s results indicate that product selection based on CEX is important as input in improving the quality of service to patients in hospitals; the more clinicians have experience with a particular product, the more the clinicians will choose to use the product that is best for clinical interests and its stakeholders. This result is relevant since the experience of clinicians is associated with the selection of effective and efficient products, which subsequently relates to improvement of quality of care. This is consistent with the study by Pervaz Iqbal et al. [4], which stated that clinicians’ experience plays a significant role in the continuous usage of medical products, and this has a long-term impact including policy decisions which are associated with mutual benefits. The concept of CEX, which encompasses knowledge and practical skills acquired over time, can be critical in determining whether advanced wound dressings such as antimicrobial calcium alginate are consistently utilized in surgical wound care.

This study demonstrated a strong relationship between CEX and CUI. This confirms that the clinician’s perspective based on their experience and interactions while using calcium alginate products is a dominant factor in choosing hospital wound care products. This can be a consideration for procurement in hospitals to improve the quality of service.

This condition is in line with Vaidis’ cognitive dissonance theory (2014) [23], where expectations are built with intellectual abilities, but in reality, these expectations are not met according to cognitive expectations. Therefore, switching to the experience grip becomes empirical evidence for users.

The findings of this study indicate that five perceived values from the clinician’s perspective are positively and significantly related to CEX. Of the five independent variables, CEX has the strongest relationship with ECO (P=0.025; β=0.258), EPV (P=0.011; β=0.242), and FUV (P=0.049; β=0.200), while INV (P=0.036; β=0.171) and SOV had the weakest (P=0.027; β=0.127). Thus, it can be concluded that clinicians consider economic value as a priority when choosing wound care products in private hospitals in Indonesia. This finding is consistent with previous studies that state that economic factors are the primary consideration [12] This makes sense because Indonesians’ purchasing power, as citizens of an emerging country, is limited when it comes to buying relatively expensive imported wound care products. Therefore, a scheme that makes calcium alginate products more affordable for private patients is needed to accommodate clinicians’ aspirations. These findings reflect that clinicians are concerned about efficient treatment. This is relevant when there is much temptation to use more expensive products that have not been proven clinically. Here, it can describe the behavior of clinicians in Indonesia, where rational clinicians consider efficacy and efficiency as necessities in the context of a resource-constrained environment, so it is important to consider procurement.

Other findings show EPV as the second highest priority in the preference for using calcium alginate dressings (P=0.011; β=0.242); this finding aligns with previous findings [8,23]. This shows that clinicians must understand the features of hemostatic products, which can be rationalized, seen, and tested empirically during wound care. Therefore, information about the product must be delivered communicatively and clearly because clinicians will see it with a clinical and rational perspective over the claim. This fosters the practice of evidence-based medicine (EBM) with a systematic review, which will be mandatory in communicating the benefits of evitable wound care in the decision to use particular wound care products in a hospital. This finding supports previous research on the importance of EBM in wound care [24]. The weakest relationship was found in social value (β=0.103), which shows that these clinicians are not distracted by the influence of social affirmation. This means that these clinicians use wound care products not based on prevailing trends, but rather relying on rational bases. This finding is inconsistent with other findings that the use of wound care products is influenced by colleagues [25].

Furthermore, this experience can be significantly and positively related to the branding process conveyed by the wound care product provider. This finding aligns with previous research [14] that states the products must undergo branding to be more engaged with users, for example, through continuous medical education supported by the wound care product provider.

The interesting findings of this study indicate that clinicians prioritize COM (P=0.000; β=0.727) over BEN (P=0.000; β=0.281), although both paths were significant and positive. From a clinician’s perspective, a good brand can be a marker of product quality and an assurance that the product can deliver what it promises. This reveals that clinicians first see and remember a wound care product brand from its function and clinical outcome. Meanwhile, they also assess how the product can provide comfort or benefits that the patient can feel directly. It is also possible that BEN will be related to patient satisfaction where patients, due to their limited medical knowledge, can only assess what they feel or the improvement of complaints, not on clinical or lab parameters.

The findings of this study demonstrated that CUI can be explained adequately (R²=0.578) and with relevant predictive ability (Q²=0.989). R² shows that CUI is a determinant, and increasing it will have a direct impact. So, there must be an initiative to increase CUI, especially through information that the product is efficacious and efficient, either by the medical committee or senior KOL (Key Opinion Leader) at the hospital. This finding can also provide implications for persons in charge of procurement and decision-makers in hospitals, who must be open to input from clinicians who directly handle patient wounds. In Indonesian settings, decision-making from a clinical perspective also comes from the medical committee. Unlike other countries, the medical committee is an independent party in the hospital that directly provides clinical input and must be more proactive in asking for opinions. Moreover, the CVPAT method confirmed the model has strong predictive validity [18]. Therefore, the same model can be recommended in replication studies with different populations, especially in countries with health systems similar to that of Indonesia. Other studies with various demography also need to test the model to obtain external validity. Responder bias may have been a limitation of this survey study. Such bias may relate to the length of service and the number of practical experiences in handling complicated wound cases. These matters may raise data heterogeneity, especially between the nurses and specialist doctors. Further research should be carried out with multigroup analysis of distinct doctors and groups of nurses who may perform chronic wound care.