Limitations
Our findings should be interpreted with caution due to the following limitations. Because this was the first time such a study was done, we recruited educated participants who were able to read and write, perceived to have good recall ability and were able to comprehend things. Our study was only done in Lusaka province in facilities that were largely urban except for one facility which was periurban; hence, it is hard to generalise these findings. Another limitation in our approach is the one-time cross-sectional nature of our measurements among people in long-term HIV care. If more measures were collected from each TEC, we may well see them being activated in a way that results in an improvement in their experience based on the skills they develop to seek better care from providers which ultimately would improve their retention in care. Despite its limitations, the TEC method provides valuable information about healthcare quality, even though it is limited to situations where ‘walk-ins’ are permitted. Our approach only focused on real patients accessing care and we did not manipulate any patient files, so it is possible that some TECs were known to the facility as patients accessing chronic care. Our approach does require a trained interviewer to speak with TECs after their visits, but this is not any different to what already exists. In future, it may be worth using the domains in the national HIV guidelines as the gold standard, but we did not do this as our aim was to come up with a low-cost approach that can easily be rolled out. In addition, the concept of patient-centred care is still catching on in Zambia. Our TEC approach can be used to further the knowledge in provider attitudes to other relatively new approaches to delivering quality HIV care such as differentiated service delivery for stable patients by assessing whether HCWs follow guidelines when offering this.