Promotora-delivered education to improve Metabolic Dysfunction-Associated Steatotic Liver Disease knowledge and engagement in noninvasive liver assessment in populations at risk for liver cancer: A mixed-methods study

Technical Summary: Promotora-Delivered Education for MASLD Knowledge and Engagement in Noninvasive Liver Assessment

Problem Statement
Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) is a rapidly growing risk factor for hepatocellular carcinoma (HCC), disproportionately affecting Latino/Hispanic populations due to higher prevalence, genetic susceptibility (e.g., PNPLA3 I148M variant), and metabolic comorbidities. Despite the availability of noninvasive liver assessment tools like transient elastography (TE) for early detection and risk stratification, utilization remains low. Barriers include a lack of standardized screening guidelines, limited provider awareness, and restricted access in safety-net settings. While Community Health Workers (promotoras) are established in cancer screening, their efficacy in delivering MASLD education to drive engagement in noninvasive liver assessment within Federally Qualified Health Centers (FQHCs) had not been extensively evaluated.

Methodology
The study employed an explanatory sequential mixed-methods feasibility design with a single-group pretest-posttest structure.

• Setting and Participants: The study was conducted at an FQHC in Los Angeles serving predominantly Latino communities. 100 Latino/Hispanic adults (mean age 52.8, 77.8% female) were recruited and enrolled.
• Intervention: Participants attended a promotora-led, Spanish-language educational session on MASLD.
• Quantitative Measures:
  • Knowledge: A 24-item survey assessed MASLD knowledge (prevalence, symptoms, risk factors, diagnosis, consequences, reversibility, and prevention) pre- and post-intervention.
  • Engagement: Participants reported intentions to undergo TE. TE was subsequently offered using Hepatoscope or Vibration-Controlled Transient Elastography (VCTE/Fibroscan). Completion rates were tracked.
  • Analysis: Descriptive statistics, Wilcoxon signed-rank tests, McNemar's tests, and logistic regression (univariate and multivariable) were used to identify predictors of TE completion.
• Qualitative Measures:
  • Two focus groups (one with completers, one with non-completers, n=6 each) and three semi-structured interviews with promotoras were conducted 8 weeks post-intervention.
  • Analysis: Direct content analysis guided by the Health Belief Model (HBM) was used to identify themes regarding barriers, facilitators, perceived susceptibility, severity, and self-efficacy.

Key Results

• Knowledge Gains: MASLD knowledge scores improved significantly from a mean of 9.59 to 14.45 (p < 0.001). Significant gains were observed in understanding metabolic risk factors, asymptomatic presentation, and the link to cirrhosis/HCC. However, misconceptions persisted; only 14% correctly identified that alcohol is not a defining cause of MASLD post-intervention, and knowledge regarding liver imaging as a diagnostic tool declined (75% to 5%).
• Engagement and Completion: Intentions to undergo TE increased from 76% to 81%. Of the 81 participants expressing post-intervention intent, 48 (59%) completed the assessment. Including those who completed without prior stated intent, the total completion rate was 56/100 (56%).
• Predictors of Completion:
  • Quantitative: In unadjusted models, older age, smaller household size, and employment status (homemakers had lower odds) predicted completion. Baseline and post-intervention intentions were also associated with completion. In multivariable analysis, older age remained the only independent predictor of completion (aOR 1.06, p=0.02). Knowledge scores were not associated with completion.
  • Qualitative: Structural barriers were primary determinants of non-completion, including transportation challenges, long travel distances, caregiving responsibilities, and inflexible work schedules. Emotional barriers included fear of an adverse diagnosis and hopelessness. Conversely, facilitators included encouragement from promotoras, a welcoming "family-like" environment, and family history of liver disease which heightened perceived susceptibility.
• Clinical Findings: Among the 56 participants who completed TE, 42.9% had severe steatosis (S3) and 12.5% had moderate-to-advanced fibrosis (F2-F4).

Significance and Claims
The paper claims that while promotora-delivered education is effective in significantly improving MASLD knowledge and awareness in high-risk Latino populations, knowledge alone does not translate into action (completion of noninvasive liver assessment).

The study highlights that the gap between intention and completion is driven by structural and contextual factors rather than a lack of understanding. Specifically:

1. Education is necessary but insufficient: Improving health literacy did not overcome logistical barriers (transportation, work, caregiving) or emotional barriers (fear of diagnosis).
2. Structural Support is Critical: The authors conclude that strategies to enhance early detection must extend beyond education to include supportive systems, such as on-site or flexible scheduling, transportation support, and addressing the "cold" nature of traditional healthcare systems in favor of community-based, welcoming environments.
3. Role of Promotoras: Promotoras successfully facilitated engagement and reduced hesitation through trust and cultural relevance, but their ability to ensure completion is limited by external structural constraints.

The study positions these findings as a call for integrated, system-level strategies in safety-net settings to support the early detection of liver disease and prevent progression to cirrhosis and HCC in vulnerable populations.