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Introduction: Breastfeeding intention is one of the strongest predictors of breastfeeding behavior and practice. The Theory of Planned Behavior (TPB), with its main construct, behavioral intention, is useful to predict actual behavior. While the literature has examined the implications of other theoretical notions such as self-identity, moral norm, descriptive norm, and socio-demographic variables, their roles remain unclear. Similarly, research on ethnic and low-income mothers is even insufficient. Therefore, given the original TPB constructs, our goal was to examine the role of extra theoretical constructs and specific demographic variables, and observe whether the original model would alter., Methods: A cross-sectional analytical study was carried out among 325 pregnant mothers in six purposively selected health care facilities of Kaski and Tanahu districts, using structured pro forma, from December 2018 to November 2019. We developed stepwise multivariate logistic regression from the entered and cleaned data, observed the effects on breastfeeding intention (BFI), and checked against multiple parameters. We interpreted the model with adjusted odds ratios and β coefficients, along with the variance explained., Results and Discussions: Out of 325 pregnant women, more than half (54.8%) were primiparous, and the mean age was 25.1±5 years. All three theoretical constructs of TPB regressed the BFI significantly, with 10.7%, the breastfeeding attitude dominating (β = 0.734, p = .003), and the other two constructs-perceived breastfeeding control (β = 0.659, p = .011) and breastfeeding subjective norm (β = 0.504, p = .045). Interestingly, breastfeeding self-identity added further variance of 5.2% (β = 0.955, p < .001), followed by income, with 3.2% (β = 0.856, p = .001), both of which also tallied large effect sizes. The model parameters showed consistency and robustness. We discuss the variables of the theoretical and extended model for BFI as well as the arguments for the explained variance., Conclusion: Self-identity is a strong and independent predictor of breastfeeding intention and, therefore, should be considered to better prepare for breastfeeding, especially among ethnic pregnant mothers. The direct and intermediate effects of self-concept and income need further study with more robust designs., Competing Interests: CA and RD are faculty members under SHAS. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Adhikari et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Community health workers (CHWs) are essential to primary health care systems and are a cost-effective strategy to achieve the Sustainable Development Goals (SDGs). Nepal is strongly committed to universal health coverage and the SDGs. In 2017, the Nepal Ministry of Health and Population partnered with the nongovernmental organization Nyaya Health Nepal to pilot a program aligned with the 2018 World Health Organization guidelines for CHWs. The program includes CHWs who: (1) receive regular financial compensation; (2) meet a minimum education level; (3) are well supervised; (4) are continuously trained; (5) are integrated into local primary health care systems; (6) use mobile health tools; (7) have consistent supply chain; (8) live in the communities they serve; and (9) provide service without point-of-care user fees. The pilot model has previously demonstrated improved institutional birth rate, antenatal care completion, and postpartum contraception utilization. Here, we performed a retrospective costing analysis from July 16, 2017 to July 15, 2018, in a catchment area population of 60,000. The average per capita annual cost is US$3.05 (range: US$1.94 to US$4.70 across 24 villages) of which 74% is personnel cost. Service delivery and administrative costs and per beneficiary costs for all services are also described. To address the current discourse among Nepali policy makers at the local and federal levels, we also present 3 alternative implementation scenarios that policy makers may consider. Given the Government of Nepal's commitment to increase health care spending (US$51.00 per capita) to 7.0% of the 2030 gross domestic product, paired with recent health care systems decentralization leading to expanded fiscal space in municipalities, this CHW program provides a feasible opportunity to make progress toward achieving universal health coverage and the health-related SDGs. This costing analysis offers insights and practical considerations for policy makers and locally elected officials for deploying a CHW cadre as a mechanism to achieve the SDG targets., (© Nepal et al.)