This study represents the first application of the PEN-3 cultural model with malaria treatment practices in endemic countries. The findings indicate that appropriate treatment from the clinic coupled with physician's approach with child malaria diagnosis and treatment were important in generating positive maternal responses to treatment seeking for child febrile illness. In addition, beliefs related to teething patterns were critical in revealing existential decision-making towards treatment seeking for child febrile illness in this setting. For example, even though some mothers were of the opinion that their child's febrile illness was caused by teething, they still utilized health care facilities for diagnosing and appropriate case management of illness. The notion that teething is part of a child's development process is an existential belief held by mothers in this setting that has no harmful consequence particularly as it posed no threat to maternal treatment seeking for child febrile illness. Also, there are negative responses that should be taken into consideration in formulating malaria control strategies. Consistent with previous studies [1, 3, 25], the belief that febrile illness is not severe was a common perception shared by some mothers in this study. This perception often underestimates the potential harm of child febrile illness and may invariably contribute to the estimated increase in child morbidity and mortality rates due to malaria in many endemic countries. Ultimately, the decision to seek prompt diagnosis and effective treatment may be influenced by whether mothers perceived the illness to be mild or severe. In cases in which child febrile illness was perceived as mild, or not severe, it was not uncommon for mothers to delay seeking treatment. As signs and symptoms became more prominent, mothers then sought care from health care facilities for proper treatment of their children's illness.
Although it remains unclear why some mothers underestimate the potential severity of child febrile illness, one might expect that if mothers have the ability to recognize signs and symptoms of malaria, they will act accordingly by providing appropriate anti-malarial treatment or by seeking a health care facility for prompt clinical examination. This was generally not the case in this study, for even in situations in which mothers perceived that their children's illness was caused by mosquito bites, they also stated that the illness was not severe. These negative responses suggests that knowledge of the causes of malaria or even signs and symptoms alone may be insufficient if efforts are not equally made to address perceptions related to illness severity for some mothers. Thus, the assumption that changing knowledge may lead to behavior change may be severely limiting if it fails to also consider other factors, including positive or existential factors that might influence treatment-seeking behaviours for child malaria. The PEN-3 cultural model offers an opportunity to explore not only the responses that may serve as barriers to effective treatment of malaria, but also positive and existential responses that are critical in influencing mothers' management of malaria in their children. Also, the findings clearly illustrate the importance of highlighting responses that promote treatment-seeking behaviours as well as responses that have no harmful consequences prior to identifying responses that may have negative health consequences. In this way, rather than dismissing the values and practices that mothers may have towards malaria treatment strategies, the PEN-3 cultural model affirms the possibilities of their lived experiences by encouraging responses that are positive, acknowledging unique responses while discouraging responses known to be harmful to health.
The implications of these findings are important for malaria control strategies. Specifically, as mothers adapt to the new and expensive artemisinin-based combination therapies with their multiday/dosage regimes , attempts to conceptualize the positive, existential, and negative factors that influence patterns of treatment-seeking for child fever are critical to framing a comprehensive approach to malaria treatment in endemic regions. The findings from this study should be considered in light of several limitations. First, the in-depth interviews were conducted among mothers who were recruited from a health care facility and the information obtained was based on interview responses that may be prone to bias. Second, the findings cannot be generalized to other mothers as the sample for this study was not randomly selected. Indeed, the degree of representation is unknown, particularly as we did not conduct interviews with mothers who did not bring their children to the outpatient clinic. Despite these limitations, the findings provide a better understanding of the influence of cultural values and practices with malaria treatment strategies in that it illuminates maternal response to child febrile illness that are positive, existential, or negative. Although the potential for sampling bias exists in this study, the use of purposive sampling ensured that only mothers with child febrile illness diagnosed as malaria were interviewed. Also, the similarities between maternal responses from one in-depth interview to another, coupled with consistency of findings with published studies on maternal perceptions and treatment-seeking practices for malaria, permits confidence in the validity and analysis of the data . However, more research is necessary to assess other beliefs and values that influence decision-making for treatment seeking practices at clinic settings, the resources and institutional arrangements that promote or discourage prompt and effective treatment of malaria, coupled with the role of family, kin, and friends in influencing decisions related to patterns of treatment-seeking. These factors, which coincide with the relationship and expectations domain of the PEN-3 cultural model, should by explored further in order to achieve a deeper understanding of not only the social and cultural factors, but also the structural factors that might influence positive, unique, or negative responses to patterns of treatment-seeking for child febrile illness in malaria-endemic countries.