Produce prescriptions that provide vouchers to individuals to purchase fresh FVs at a specified retail outlet have the potential to positively impact food security status, diet, and chronic disease risk. However, maximizing program participation is vital to ensuring program success. This research describes motivators, barriers, and support for participation in a child produce prescription program among a population of Native Hawaiian and Other Pacific Islanders, who are underrepresented in this field of research. This qualitative grounded theory study was nestled within a quasi-experimental pilot intervention trial and included semi-structured interviews with pediatric program participants. Twenty-five interviews were conducted, which represented one-third of program participants. The top support factors for program participation included: ease of voucher use, program convenience, health center/pediatrician endorsement and positive communications with farmers’ market vendors. Key motivators for program participation were produce enjoyment, child support, financial support, and positive impacts on family. Three themes emerged consistently as barriers to participation amongst participants, (1) difficult use of vouchers, (2) conflicting schedules, and (3) online market concerns. (4) Conclusions: This research offers insight into policy implications as the number of produce prescription programs has grown. These findings suggest that key program design characteristics can enhance and support program participation. Clinical and community-based interventions to increase fruit and vegetable (FV) intake, while reducing food insecurity, in children have had limited success in improving diet ,2. A proMaximizing participation is an important first step in determining the effect of the FV voucher program for families. For example, in Arizona, a WIC program observed inconsistent redemption rates for WIC FV vouchers, so researchers sought to identify factors that influenced participation, barriers, and attitudes around redemption . The resThe KPRx program is the result of a collaboration between the Waianae Coast Comprehensive Health Center (WCCHC) Pediatric Department, WCCHC Health Promotion Department, and University of Hawai‘i at Mānoa researchers . KPRx waThe KPRx feasibility program provided $24 in vouchers to obtain FV each month for three months, but while parents expressed their excitement about and satisfaction with the program, only 23% of participants completed the program . As a reThe pilot study aimed to quantify the effect of the KPRx program on household food insecurity status and FV consumption, as well as identify mechanisms to improve program participation. The purpose of this qualitative research was to understand factors that KPRx participants perceive as motivators, barriers, and support for KPRx participation in a population of Native Hawaiian and Other Pacific Islanders, who are underrepresented in this field of research.This qualitative grounded theory study was nestled within the KPRx pilot intervention trial. Participants were referred to the KPRx pilot study by their WCCHC pediatrician. Pediatricians screened patients for food insecurity using a validated 2-question tool . PatientConsent and assent (children ≥ eight years of age) were obtained prior to participation in KPRx activities, this included consent to be interviewed. Parents/caregivers were invited to participate in the KPRx exit interview once their child had been enrolled in KPRx for at least six months. Parents/caregivers were offered a $25 gift card as a token of appreciation for participation. The research protocol was approved by the Institutional Review Board at the Waianae Coast Comprehensive Health Center (No. 00006399).The one-on-one interviews were conducted using open-ended questions developed in the feasibility evaluation  18]. Th. Th18]. Interviews were conducted between 2021 and 2022 via phone at time convenient to the participant. Participants completed a brief demographic questionnaire  at enrollment in the KPRx study. Interviews were conducted and recorded by the study principal investigator who had little interaction with participants throughout the duration of the pilot study, to limit bias in responses. The principal investigator has a good understanding of the community and Native Hawaiian and other Pacific Islander culture, having worked in the target community for over 10 years. Interviews lasted between 30 and 60 min. Audio recordings were transcribed verbatim using an audio transcription service. KPRx research staff reviewed transcripts for accuracy. As interviews were conducted, research staff performed reviews of data. Data collection was ceased when saturation was achieved .Two trained members of the research team analyzed the interview transcripts using a grounded theory approach . Each ren = 25). The average age of participating children was nine years (ranging from two to 18 years). Ninety-two percent (n = 31) of the child participants were of Native Hawaiian or Other Pacific Islander race. Over half of the interviewees received SNAP (food stamp) benefits (n = 18) and 68% (n = 17) had completed the KPRx program, defined as having redeemed vouchers for all six months of the program. A total of 95 KPRx study participants were eligible to complete an exit interview (enrolled for at least six months). Interviews were conducted with 25 parents/caregivers, representing 34 children who participated in the KPRx pilot study (nine interviewees had two children enrolled in the KPRx program). All parents/caregivers were women (The top support factors for program participation included: (1) ease of voucher use, (2) program convenience, (3) health center/pediatrician endorsement and (4) positive communications with farmers’ market vendors.n = 25). Specific examples of what made the vouchers easy to use included that they vouchers were treated as cash and were welcomed by all vendors. One participant shared, “Everybody in the marketplace accepted it. And they were happy and everybody treated you, you know, nicely. Just like as if you were giving them money.”All participants shared that the ease of use of the vouchers supported their program participation, this was mentioned 35 times across interviews , not having to wait in line at the farmers’ market to get the vouchers, and the ability to redeem at several different market vendors were some of the most convenient characteristics. One participant shared, “To me, it’s easy to access, or it’s easy to really just go in, and especially picking up the coupons…It’s not long line because every time I go, it’s already ready. By saying that, they are organized” and another shared: “Being able to just go to the market and pick it up, and then from whatever tent they were in, and then my kids could just go and use it on their own. It was just like money.”Ten of the twenty-five participants mentioned a support for program participation was through endorsement by the health center and the pediatrician specifically, mentioned 11 times. One participant shared, “The doctor recommended us and I was like why not. It helps me get vegetables, so I was like okay, why not, we’ll see what this program is about.” And another shared, “We actually was referred by my daughter’s doctor and that’s what got us involved in participating.”n = 8) mentioned specifically that the interactions with the vendors supported participation (cited nine times). Most of the comments in this theme were around vendors helping participants to utilize the full voucher benefit. For example, if the voucher value was five dollars and the participant selected four dollars in FV, the vendor would help the participant in identifying what they could get for one dollar to maximize their benefits. One participant shared, “The vendors, they were very helpful. If I didn’t, sometimes it was a specific thing, if it was too high, they would put something else they would add on top of, like a banana. And that’s how, because I couldn’t break the $5 [voucher], they would put on more stuff for me so I could use that certain amount up.”Participants  produce enjoyment, (2) child support, (3) financial support, and (4) positive familial effect.More than half (16 out of 25) interviewees mentioned produce enjoyment 18 times across the interviews. Participants enjoyed the process of purchasing and picking the produce as well as the availability and accessibility of the produce. Interviewees shared that children were excited to purchase FV. For example, a participant stated, “So, I know my son is very enthusiastic, every time I tell him it’s time to go pick up his vouchers, and he likes picking out the fruit and vegetables for us.” Participants enjoyed the availability and accessibility of produce at the farmers market, stating, “… it’s harder to get fruits and veggies with all the prices going up, or even just getting those type[s] of fruits and vegetables is more in the stores. Sometimes it’s limited, too. There’s none at the stores. So it’s easier to get at the market”.The second frequently cited motivator was the support provided to the child, which was mentioned 17 times by 15 participants. Some participants noted the program was “[a] great way of allowing [my daughter] to try different types of vegetables and fruits”. Parents also perceived increased FV consumption as “support[ing] a healthier lifestyle”. One user stated, “I chose to participate in the program so my son would eat healthier. He would have more options on vegetables, fruits, so he could learn more about the different types of vegetables and fruits that you guys offered in the program.”One participant was motivated to join the program to support their child’s community engagement. She, and another, mentioned, “I was just kind of curious to see what kind of resources they would have. And what kind of ways they would’ve had the community get engaged, especially with the younger kids.” Another shared, “I thought that it was a good program for the kids, just because it promoted eating healthier and that they got to try all different types of vegetables and fruits that they usually don’t try. And I like how the program, how they got those bags with the stuff inside to make the vegetables. I like those and the recipes that it came with, all the information. I thought that was cute.”Financial support was the third largest program motivator, mentioned 21 times by 12 people. Some users mentioned that it increased FV affordability, “Anytime we can get some fresh fruits and vegetables at a good cost, that’s free. Right? That’s awesome.” Others mentioned that the help purchasing food freed the financial burden to purchase other household necessities. For example, “It was easy and very helpful, because toward the end of the month, when you don’t have enough food, that helped out a lot. It helped out with just buying the necessities that we need, besides groceries, other things that it could help us with in the household.” One participant said it helped the family provide food with the financial burdens of the COVID-19 pandemic, “I know it would benefit us by helping, because it was kind of tight with the budget, especially dependent on the COVID and all that, and being out of work for certain people in our household. So that help food-wise, a whole bunch actually helps.”Twelve participants mentioned the positive family effect of the program, which came up 17 times across interviews. One person noted that they as a parent were also able to enjoy the benefits produce, saying, “I was able to eat with them [my family]”. Another person mentioned that it gave the family something to do together, “ … going to the farmer’s market actually gave us a reason to go out on Saturday and be a part of the community.”Three themes emerged consistently as barriers to participation amongst participants. In order of frequency, barriers were the (1) difficult use of vouchers, (2) conflicting schedules, and (3) online market concerns.Thirteen participants mentioned some difficulty in using the vouchers 30 times across the interviews. Factors that made the vouchers difficult to use as perceived by participants ranged. Some participants thought that the expiration dates complicated their use. Participants said, “I’d have to buy things that I wouldn’t want to buy before the thing [voucher] would expired.”. Another shared, “I was getting confused with the expiration date on the bottom. I thought when I could use it was the expiration date.”Although positive vendor communication did help, some participants found the need to use the whole voucher made the vouchers difficult to use. For example, “because the vouchers were in whole dollar increments, it made it a little difficult.” Other concerns included wanting to use the vouchers for products that were not FV.A conflicting schedule between participants and the market was mentioned by 9 participants and referenced 11 times. One participant stated, “just organizing our own schedule as a family was the issue”. Other participants mentioned that Saturdays were normally filled with obligations that could not be done during the work week. Some had other familial obligations, “Sometimes I really wanted to get the vegetables but I had to choose. Do I go to my son’s game or to this family event or do I pick up my vegetables.” Another shared, “It was just harder for me if we had appointments on Saturdays and we had to drive all the way to town, there was no way for us to be able to go to the farmer’s market. I mean, I don’t know if it is really, I mean, most people have time I am supposing on Saturday mornings, but for working parents during the week, it is just, Saturday is the only day for them to get stuff done.”The final and third most noted barrier to participation was online market concerns. Online market concerns were referenced 7 times by 6 participants. Common concerns with the online market included not getting to make produce selections, in terms of preference and quality selection, also noting that the online option had a smaller selection of produce, “there was not as much to choose from as if you went to the farmer’s market…” One person also mentioned, “But one sort of onion, which I know they have the purple and the regular onions, but we like the purple ones. They just dropped off like a gang load of the regular ones, And… just being able to choose what we like. I wouldn’t have chosen the oranges. I would’ve probably went with some green onions. So just being able to choose.”Participants offered some specific recommendations to improve the program for the future, these included adjusting the voucher values and increasing advertisement for the program.Most participants found the value of the vouchers value sufficient. One participant voiced, “I think that was a perfect amount. I’d be greedy if I asked for more”. Though sufficient, a consistent recommendation was to provide the voucher in smaller increments. Smaller values suggestions were referenced 5 times by 4 participants. Vouchers were available in five and ten-dollar increments. One participant mentioned failing to use the full voucher value, stating, “I guess when something was half of a dollar, then we had to give them the whole dollar. Or they didn’t give change back, that’s why. So we kind of lost out on that part of it.” Other participants also suggested smaller increment amounts, “maybe just being able to split it change-wise.”More advertisement on the program was referenced three times throughout participant exit interviews. One participant “never knew it existed”. Another expressed that they would share about the program with friends and family who did not know about it, “No, but I shared it with all my friends, and I think a lot of them would try and see if they could get into the program as well. As I shared with many of my friends, who were going through some difficulties as well with the pandemic and losing their job, they said, “Oh.” They didn’t know they had the program.”This qualitative research study gathered perspectives regarding supports, motivators, barriers, and recommendations for future program optimization from 25 parent/guardians who had a child enrolled in a Produce Rx program in Hawai‘i. The research findings suggest that the health center and pediatrician endorsement of the program as well as additional program design qualities made the program easy and convenient which inevitably supported program participation. Participants were particularly motivated by the positive effect that the program had both on the child and shared that the benefits were experienced by other family members, even though the program was really designed for just the participating child. This was similar to another pilot study which found that enhanced family bonding and positive experiences for children as a benefit of a Produce Rx program .Barriers to participation included scheduling time to attend the market to redeem the vouchers. Online prescription redemption with home delivery service was designed to address this barrier. However, this alternative did not appeal to many KPRx participants. Participants found the online market unappealing, citing the smaller variety of produce available online and the inability to hand pick the produce as reasons for not favoring this option. Contrary to our findings, previous research has found that delivery services enhanced participation in Produce Rx programs among low-income households in urban settings . In the Findings from this study suggest that several key program design qualities were beneficial to encouraging program participation. These included leveraging the trusted relationship between the health center, pediatrician, and participants, which is supported in the literature . The welMotivating factors were identified in this research, which can inform future recruitment and retention efforts. Parents and caregivers were motivated to support their child both in improving their health through diet and providing their child with the opportunity to try new FVs. This is key, as Native Hawaiian and Other Pacific Islander cultures place high value on family and collective good over individual benefits. While the KPRx program was designed to primarily benefit the child, parents/caregivers expressed the positive effect that the program had on the whole family. Future programs can leverage this motivating factor several ways; (1) expand definition of participant from child to family unit, (2) include outcome assessment and evaluation at the family or household level, and (3) consider expanding benefits to support the family/household unit.Participants experienced barriers related to scheduling to attend the farmers’ market, despite our program’s partnership with the local online food hub which offered participants the flexibility to select produce and have it delivered free of charge to their home. Several participants expressed the inability to hand pick produce on the online platform as a barrier to utilizing the option. The opportunity to choose and select foods has been cited as a best practice for increasing participant satisfaction and diet quality among other food assistance programs for individuals experiencing food insecurity  ,26,27. AThis novel study investigated motivators, barriers, and supports to participation in a pediatric Produce Rx program, by female parent/caregivers of children who were enrolled in the program. It is the first to do so in a primarily Native Hawaiian or Pacific Islander population. This qualitative study has addressed and met the 21 criteria of the Standards for Reporting Qualitative Research Guidelines . LimitatThis research has identified key themes related to the KPRx that can inform program optimization and testing. The program design led to well trained staff and vendors who then facilitated an engaging and convenient experience for program participants, ultimately supporting program participation. Despite having two venues to redeem vouchers, the online marketplace was not an adequate solution for some participants, which created a challenge for participants to schedule time to attend the market. The addition of a retail grocery store is a potential solution presented by participants to overcome this challenge and should be explored. Another strategy to be explored is the potential for an electronic system which could reduce challenges related to the paper vouchers. The KPRx program intends to ease financial barriers to accessing healthy food with the goal of improving the health of children. Interviewees reinforced the same motivation for participating. As such, this messaging can be leveraged to support program recruitment. These findings can ultimately lead to program improvements that will enhance program participation and subsequent impact on diet and health, an important next step to long term sustainability of Produce Rx programs.


Peer Mentors (PMs) are valuable health educators within food-insecure communities; however, little is known about PMs’ perspectives and experiences after serving in their peer mentor role. Therefore, this qualitative study explored PMs’ (n = 10) perceptions and analyzed data using thematic analysis based on descriptive phenomenology. Four themes emerged: (1) Successes and Struggles in Sharing Nutrition Knowledge; (2) Establishing a Conducive Learning Environment; (3) The Peer Mentor and Mentee Connection: Impact of Shared Experiences; (4) Empowerment of the Peer Mentor Experience. PMs have many advantages; however, more research is needed to evaluate the sustainability and efficacy of PMs within food-insecure communities. Recent estimates from 2021 indicate that 10.2% of Americans living in the United States were food insecure at least once during the last year, while 89.8% of U.S. households were food secure . Taking Food pantries (FPs) were initially designed as a supplemental food source, but presently are necessary for many families on an ongoing basis, to bridge the meal gap by providing supplemental food . Many foHealth promotion and nutrition education programming delivery by community members serving as peer mentors (PMs) is an innovative approach and documented strategy to reach low-income, minority, or socioeconomically disadvantaged populations ,16,17,18While using a PM model to facilitate health behavior changes and knowledge acquisition among community members has been established, PMs’ perceived benefits, feedback, and perspectives after delivering targeted programming, specifically within the FP setting, are yet to be fully established or explored. Using a focus group and interviews, this paper reports on perspectives, experiences, successes, and challenges of delivering an FP-based, parent-focused nutrition education program by a select group of PMs.This qualitative study was employed to explore the experiences and perspectives of PMs after they completed teaching a nutrition education series to a parenting group within a FP.Martha’s Choice Marketplace (MCM) is the largest FP in Montgomery County, a suburb in Southeastern Pennsylvania, and the site that supports this program . MCM proTen of the eleven PMs from the original Community Cooks program consented to continue to serve in their PM role in a parenting skills class featuring healthy eating and basic cooking skills ,18. PrioMCM hosted the four-week PM-led nutrition education program within parenting classes. Up to three PMs rotated weekly to deliver a 60 min nutrition education lesson, including an interactive activity and healthy recipe preparation. In preparation for each week, the selected PMs practiced delivering the content and were encouraged to prepare the recipes at home.A semi-structured one-hour focus group was conducted with the PMs at the end of the program, and the session was audio recorded. The focus group included questions about the PM’s self-efficacy, confidence as a mentor, and any barriers to serving in this role. PMs were also asked to report on observations of the program’s effectiveness within this community and the participants’ receptiveness to the lesson content.The focus group recording was professionally transcribed, and two research team members independently reviewed the transcripts to correct any errors. Data were analyzed using Colaizzi’s phenomenological approach to identify emerging patterns . InitialThe following four themes emerged: (1) Successes and Struggles in Sharing Nutrition Knowledge; (2) Establishing a Conducive Learning Environment; (3) The Peer Mentor and Mentee Connection: Impact of Shared Experiences; and (4) Empowerment of the Peer Mentor Experience. See The PMs felt successful in their ability to share nutrition information and recipe preparation tips with the program participants and felt confident and prepared to deliver the nutrition lessons they had been trained on in preparation for the series. However, regardless of how well versed the PMs were in the lesson content, some participants were eagerly engaged while others were not as seemingly receptive. The PMs met with some resistance and had to overcome challenges presented by participants who were hesitant to try different foods and recipes or rejected specific messaging based on their personal or cultural preferences. The PMs observed the varied interest and enthusiasm levels of participants and some described participants wanting them to hurry up and finish the lesson or the recipe preparation so they could taste the meal. In other cases, PMs felt a general resistance to trying the “healthy” recipes or new ingredients served and found that participants were more willing to try healthier versions of recipes only when familiar with them. Despite the resistance to trying “healthy” versions of recipes, PMs felt encouraged when participants tasted the meal, and were pleasantly surprised.PMs expressed frustration and challenges motivating and engaging some participants in an orderly setting. It was difficult to balance the roles of being friendly and of being someone in charge while maintaining a respectful classroom environment. Participants frequently engaged in side conversations or were visibly distracted, which presented unique challenges for the PMs. PMs had to navigate between establishing professional boundaries and a conducive learning environment and remaining approachable to fellow group members. In general, PMs felt frustrated with the lack of respect or attention from the program attendees and felt additional training could have better prepared the PMs for their role.Another important theme was the recognition among PMs that the value of their presence, encouragement, and the nutrition knowledge shared went beyond the classroom setting. PMs discussed how unique personal experiences enhanced the nutrition information from the lesson among the group members. The PMs cited several examples of discussions with or comments by participants that signified a real desire to improve their nutritional health.Finally, and likely the most salient theme and profound takeaway from their entire PM experience was the personal empowerment and confidence stemming from their role as a PM. The PMs discussed the positive dynamic and synergy created among their peers, which increased their self-confidence as competent leaders and enhanced their relatability to participants. PMs developed a personal sense of purpose and belonging through supportive relationships and the cohesive PM community they formed. Additionally, the PMs reflected on the program design, including aspects such as presenting as a team on specific topics which helped establish camaraderie and provided additional support and empowerment by having fellow PMs presenting together. The PMs also described a sense of personal relatability with the participants. PMs believed that the participants felt more comfortable learning from their peers rather than the research team from outside their community. They also perceived that having a shared background, similar story, and race/ethnicity enhanced this relatability and acceptance.Of additional importance, one PM described how peer-to-peer relatability enhanced the program. Some of the PMs were able to communicate with participants in different languages. For example, one PM was of Middle Eastern descent and could translate the lesson content and overcome language barriers to those participants who spoke Arabic. The value this PM brought to the group simply by translating information cannot be overlooked. Not only does this skill empower the PM, but it empowers the participant to properly comprehend the information.Food insecurity among American households remains one of the social and economic factors that the literature has linked with poorer health, increased rates of chronic disease, and higher healthcare costs . HealthyVery few published studies explore the perceptions of PMs after delivering a nutrition education program, none so within an FP setting. Typically, most PM research reports on the benefits to the recipients of the PM and community-based nutrition education, not the providers. The authors wanted to give a voice to the PMs so they could share and reflect upon their role and purpose as a PM. After delivering nutrition education sessions to an FP-based parenting group, the focus group questions were formulated to stimulate conversation regarding the PMs’ perspectives and provide overall program feedback. The themes reflect a variety of personal and group benefits in addition to challenges such as managing group dynamics and parent-participant engagement.It should be highlighted that this focus group revealed that PMs were instrumental in providing a bridge for delivering simple nutrition messages and skill-building sessions to fellow FP clients and offered a valuable community-facing option for nutrition education program delivery. These findings align with PM literature in that PM-led programs are noted to have sustainable and long-term impacts on participants as well as can enhance health education efforts ,21,22,23This project explored PMs’ unique perspectives after delivering a PM-led nutrition education program within a community with a high prevalence of food insecurity. These results contribute to the body of research on improving nutritional health in low-income communities and can inform the design of future programs utilizing PMs or community health educators ,21,22,23Peer mentor health educators in a community setting like an FP can inspire individuals and communities to make better health choices. Peer mentoring is an effective strategy to bridge the gap between information dissemination and information retention, and community programming is necessary to reach people outside the traditional health care setting ,16. HowePeer mentor-led nutrition education delivered in an FP setting targeting a low-income, food-insecure community can be considered an innovative and sustainable teaching approach. Additionally, based on PM qualitative feedback, the PMs may have also found the program to be an invaluable and empowering experience that may infuse benefits far beyond the program implementation, such as organizational skills, leadership, teaching, and public speaking for the PM participants. The PMs also offered tangible suggestions for training improvement that might best equip PMs for some of the challenges related to delivering educational programs in a group setting. Future research is needed to explore the sustainability efforts and potential health impacts and overall benefits on PMs, the patrons, community members, and parent participants, within the FP setting and beyond.


Statistical descriptions of earthquakes offer important probabilistic information, and newly emerging technologies of high-precision observations and machine learning collectively advance our knowledge regarding complex earthquake behaviors. Still, there remains a formidable knowledge gap for predicting individual large earthquakes’ locations and magnitudes. Here, this study shows that the individual large earthquakes may have unique signatures that can be represented by new high-dimensional features—Gauss curvature-based coordinates. Particularly, the observed earthquake catalog data are transformed into a number of pseudo physics quantities  which turn into smooth surface-like information via spatio-temporal convolution, giving rise to the new high-dimensional coordinates. Validations with 40-year earthquakes in the West U.S. region show that the new coordinates appear to hold uniqueness for individual large earthquakes ( Statistical and geophysical knowledge are embodied by earthquake forecasting methods such as9, holding practical and scientific importance15. Combining a number of mechanics-/physics-based rules, researchers can reproduce “virtual” earthquakes on computer18. The advent of new high-precision observation technologies provides a valuable top-down viewpoint to explaining the fault, fracture, and slip behaviors21. Recently, newly emerging machine learning (ML) methods gradually play an important role in searching for hidden complex patterns of earthquakes, e.g., deep neural networks23, convolutional networks24, the gradient boosted regression trees25 or the random forest26. Despite meaningful contributions of the aforementioned approaches, we have little understanding regarding the prediction of individual large earthquakes’ location and magnitude. Collective statistical and probabilistic approaches are not directly applicable to individual earthquake prediction whereas the ML-driven exploration of earthquakes is in its infancy since the so-called black-box nature of ML methods poses challenges to the interpretability and generality. How can we fill such a formidable knowledge gap? This study seeks to address the daunting question.By virtue of the immense efforts of scientists, the statistical and probabilistic description of collective earthquakes bears meaningful fruits in understanding earthquake behaviorsThis study hypothesizes that individual large earthquakes have unique signatures that can be represented by new high-dimensional features—Gauss curvature-based coordinates. In particular, this study proposes that the observed earthquake catalog data can be transformed into a number of pseudo physics quantities  which turn into smooth surface-like information via spatio-temporal convolution, giving rise to new high-dimensional coordinates. Validations with 40-year earthquakes catalog data show that the Gauss curvature-based coordinates appear to hold uniqueness for individual large earthquakes ) via spatio-temporal convolution processes, of which details and procedures are presented in “E, P, V and L stand for the pseudo released energy, the pseudo power, the pseudo vorticity’s first term, and the pseudo Laplacian’s first term, respectively. Eqs. 50–68 in29 explain the detailed calculation procedure of the Gauss curvatures using the pseudo physics quantities. Figure If there exists a unique signature before the onset of an individual large earthquake and also if the signature can be detectable and learnable, it can facilitate the prediction of an individual large event’s magnitude and location. This study seeks such unique signatures from the Gauss curvatures of the pseudo physics quantities. Since the spatio-temporal convolution process endows sufficient smoothness to the pseudo physics quantities , they can be regarded as a smooth surface at each depth. In lieu of simple values of the quantities, the Gauss curvature—maximum and minimum principal curvature , the prediction only with In hopes of being independent of any prior knowledge of existing magnitude prediction modelsmentclasspt{minimacity Eq. . From th24), being independent of the pseudo physics quantities used in the Gauss curvature-based coordinates; this study denotes the general predictions as the “unassociated” prediction models. In this context, the present one is “associated” prediction model. The best-so-far prediction model is applied to the large reference events \document6. While being unique from other earthquakes’ signatures, there appears to exist interesting temporal variations of the Gauss curvature-based signatures as shown in Fig. 36. For interested researchers, data sets of the refined epochs with one-day interval are shared on28.It is important to remark the two challenges—data scarcity and overfitting. To overcome the data scarcity, one immediate solution would be to release the non-overlapping definition of epochs and shorten the epoch-to-epoch interval to one day from a month. One epoch is still defined as 30-day time range. As explained in Fig. 37, which may facilitate ML-driven autonomous evolution.Next, since the extreme earthquakes are rare, the data-driven prediction model most likely suffers from the overfitting problem. A successful prediction model may not generalize to other future earthquakes. But this issue may be tackled by the separation of two tasks—classification of large earthquakes and improvement of data-driven prediction models. With new data accumulate, the unique Gauss curvature-based signatures of individual large earthquakes can help reveal the difference or similarity of large earthquakes by using unsupervised ML techniques. Since an earthquake prediction model is customized for individual event, the separate classification task may inform us which prediction model should be used. Thereby, a prediction model can continue improving as being specialized for a class of large earthquakes, and there can be many different customized prediction models, in lieu of a single model. Moreover, the separate tasks of classification and model improvement can be performed by a high-level ML method such as a reinforcement learning38 will positively influence the prediction accuracy. As long as the reliability and precision of the relevant data is ensured, further inclusion of more physics  into the present framework would lead to a positive improvement, which will be straightforward in view of clear interpretability and extensibility of the present framework. There is ample room for further sophistication. It would be beneficial to consider more flexible, versatile bases40 for LFs, an extensive library of possible mathematical expressions41, powerful symbolic regression methods42, or stochastic optimizer43. Consistent evolution or automated optimization of many hyper-parameters of the framework may be done by inheriting the reinforcement learning paradigm37. This study may spark new research directions for seismogenesis. The smooth surface-like convolved information may catalyze the image-based deep learning methods. Gauss curvature-based signatures of large earthquakes may be clustered by unsupervised ML methods for better prediction models tailored for each category. Unique classifications of individual large earthquakes may advance the existing earthquake forecasting methods31. In light of the multifaceted nature of earthquake phenomena, enabling imminent individual earthquake predictions will require comprehensible collaborations44, and the outcome of this study will promote such a broad endeavor.The ML-identified best-so-far prediction model is not the final version but an interim candidate, being subject to substantial improvement and evolution. Since it is purely data-driven, the improvement of the earthquake data setsIn essence, the primary novelty of this paper lies in the new feature generation processes, which first transform raw earthquake catalog data into spatio-temporal convolved information, then transform the convolved information into a number of pseudo physics-based features, and further transform the pseudo physics into smooth surface-like features using Gaussian curvatures. All these new features are then utilized by a transparent ML method  to help identify unique signatures and to unravel hidden rules for prediction of large individual earthquake’s magnitude and location. Thereby, this paper’s outcome adds a new data- and ML-oriented dimension to the existing research paradigm for seismogenesis as well as natural hazards science and engineering.jth reference volume’s domain (Within one epoch (1 month), the spatial coordinates of every earthquake hypocenter available on the catalog are checked to determine which reference volume  the earthquake event belongs to. In particular, this study assumes that the hypocenter’s spatial coordinates 27 are processed into a text-based matrix form of h is in [km], being positive above the ground datum. The magnitude 29). A point-wise information index (II) is denoted as “local” II, 27). For comparison, the raw recorded magnitudes of relatively quiet epoch (10470) and active epoch (10474) are compared in Fig. 2 with a core being surrounded by the damaged zone of which macro-fractures decay with distance from the core45. Thus, an individual earthquake’s impact may not be described by a point-wise index, requiring a comprehensive means to capture a spatial impact on the surrounding. Complex spatial influences of many earthquakes are accounted for by the spatial convolution presented herein. If convolution is done over a spatial domain, ML can better understand the interaction of spatially distributed information and hidden patterns while applied to the temporal domain, the interactions between past and present information may be elucidated. This study seeks to spatially integrate the local II over the 3D point cloud, i.e., myriad earthquake events in the lithosphere. The key difference from the deep learning is that this study “externalizes” the multi-layered convolutions by conducting multiple convolutions at the information level, not in the opaque network layers. Rather than a uniform integration, we adopt a weighted integration using the Gaussian weight function (denoted jth reference volume experiences earthquakes during one epoch (t) while the closer events the higher impact on the volume. The “reference volume” is defined as a discretized volume in the lithosphere with fixed spatial coordinate which is needed for spatial and temporal convolution (see details in “29). This study’s reference volume has dimensions of  due to the limit of computational resources. For a higher resolution, a finer reference volume may be adopted. If the earthquakes during the epoch took place nearby (i.e. within or close to the jth reference volume whereas earthquakes occurred at distance (i.e. much larger than jth reference volume via the t) and calculated asjth reference volume and 29. In Eq. . Amongst many possible combination operations : z = 12.5 km with respect to the geodetic coordinate system. By observing the transient change of the spatial gradient of the pseudo released energy, this study derives the pseudo “vorticity” 21) may justify the use of such a large time interval for the pseudo velocity.Other important physics quantities would be the spatial gradients of the pseudo released energy over the lithosphere and “power.” The time derivative of energy is physically related to the power. The calculation procedure of the time derivatives of the energy-related terms is presented inmentclasspt{minimamentclasspt{minimaT) is directly related to the temporal evolution of the internal heat energy, i.e., This study found that the higher-order gradient of the pseudo released energy also helps improve the prediction accuracy. In fact, such an important role of higher-order gradients can be easily found in many physics phenomena. For instance, in the heat transfer, the Laplacian of the externally observed temperature  stand for a physics quantity calculated at the depth h and the horizontal coordinates . Z can be any pseudo physics quantities such as the pseudo released energy, power, vorticity, and the Laplacian terms. Then, we can conceive a smooth surface h. According to geometry, we can call 47] that the  Gauss curvature K is defined with the principal curvatures 29. Using these Gauss curvature-based coordinates, the unique signature of individual large earthquake can be found by an exhaustive searching algorithm in Table By regarding the distribution of a physics quantity at a certain depth as a smooth surface, this study can calculate the Gauss curvature at the maximum earthquake events. At a fixed depth t), the first step is to read each hypocenter’s raw coordinate h in [km]. Here, h means the ellipsoidal height along its normal, being positive outward normal to the reference ellipsoid. Note the earthquake catalog data use the reversed sign convention of h. Transform them to the earth-centered 3D spatial coordinate 48Transform Raw Hypocenter Data to Geocentric Coordinates: At current epoch  by performing spatial and temporal convolutions, it is efficient to define a fixed location in the space and time, which is the central reason for adopting the Eulerian 3D grid system of reference volumes. Admittedly the Earth lithosphere is not a simple spherical structure, and the earthquake hypocenters are often recorded on longitude, latitude, and depth, C++ and OpenMPI. All other learning, evolutionary algorithm and Bayesian update scheme are implemented on the parallel program. The developed program is made available upon request to the author. Iowa State University’s high-performance computing facility, Condo cluster is used for this study.The spatio-temporal convolution of earthquake catalog data to generate the convolved II is computationally expensive. This study developed a parallelized Bayesian evolutionary algorithm framework with 49 or two-parameter based exponential LF with its simplicity. First, the CRS-based LF has a general form as 29. Next, the two-parameter exponential LF has a simpler form as 29).Placing top priority on the interpretability, this study proposes to adopt an expressive link function (LF) using transparent, flexible basis that can describe a mathematical expression between the convolved spatio-temporal II, see Fig.  in29.Supplementary Information.


Finding My Way, into open access (OA) after completion of the RCT, and compared uptake, usage, and psychosocial outcomes to the earlier RCT.Few digital psycho-oncology programs have been adopted into routine practice; how these programs are used after trial completion remains unexplored. To address this, the present study transitioned our evidence-based 6-module CBT-based program, Recruitment was passive, via promotion through (1) media and social media releases, (2) public lectures, (3) radio interviews and podcasts, and (4) clinician-initiated referral. Measures included number of enrolled users, number of modules completed, and pre- and optional post-measures of distress and quality of life (QOL).n = 120; 63% of RCT). Usage was markedly lower: 1.5 modules were completed on average (vs 3.7 in RCT), and only 13% completed a ‘therapeutic dose’ of 4 + modules (vs. 50% in RCT). Research attrition was high; n = 13 completed post-measures. OA users were more sociodemographically and clinically diverse than RCT users, had higher baseline distress , and reported larger pre-post reductions than their RCT counterparts . Moderate improvements in mental QOL occurred during OA , broadly replicating RCT findings.Uptake was lower in OA (Findings that OA users were more medically and sociodemographically diverse and distressed at baseline than their RCT counterparts, and — despite having lower usage of the program — achieved larger changes from baseline to post-program, will help to shape future intervention design, tailoring, and dissemination. While the empirical evidence base for digitally delivered psychosocial programs for those affected by cancer is rapidly growing –7, a resTwo recent systematic reviews explored facilitators and barriers to implementing web-based therapy and digital health tools, from the perspectives of (a) researchers/program developers  and (b) are available. However, should these barriers be overcome, a third challenge exists that has remained relatively unexplored and unreported: of those programs that have been disseminated to end users after clinical trial completion, to what extent are they adopted and used by end-users ? This information is key to informing whether digital mental health programs are worth the substantial resource and training investments that are required to develop, test, and disseminate these interventions. Only one study to date has reported on the clinical practice implementation of their online transdiagnostic clinician-monitored CBT program for cancer-related depression and anxiety [iCanAdapt program by clinicians, only 25 patients self-referred over the 12 month recruitment window, and only 44% completed 1 or more modules. However, as iCanAdapt was offered as a component of a broader clinical treatment pathway, rather than as a standalone program, how well these findings translate to uptake and usage when offered/promoted in isolation remains unknown.These findings suggest that there are barriers to both (i) making programs available post-RCT, and (ii) encouraging HCPs to refer to programs where they  anxiety , findingFinding My Way — which found improved emotional quality of life and reduced health service usage over time for intervention users compared to a psychoeducational control group [Following the successful completion of the RCT of our digital psycho-oncology program, ol group  — our grFinding My Way (FMW) clinical trial protocol has been published elsewhere [www.findingmyway.org.au. Ethics approval was obtained from the Southern Adelaide Clinical Human Research Ethics Committee (476.16).The lsewhere . The preFMW is aimed at adult (aged over 18 years) acute cancer survivors, defined as those diagnosed in the past 6 months with any cancer treated with curative intent and currently receiving anti-cancer treatment. Participants had to have sufficient English proficiency to be able to register/consent for, and utilise, the program, and have access to the internet and an active email address. During open access, as recruitment occurred via self-selection, eligibility required self-screening and self-selecting.Participants in the current study were recruited over a 2-year window (16/2/2017–14/2/2019) to match the RCT’s 2-year recruitment timeframe. Recruitment methods were passive, including media releases, social media advertising through professional networks ; radio interviews; podcasts; and clinician-initiated referral. Given there were no study coordinators or direct approach within clinics, nor recruitment reminders to referrers, any referrals were due to clinicians’ own awareness of the program, and desire to refer to it.Eligible participants completed an initial online registration, where they created their username and password, followed by a brief demographic and psychosocial questionnaire. Following this, they were directed to a tutorial on their personalised user homepage instructing them how to use the program. Six weeks later, participants received an email link to complete an optional follow-up assessment post-intervention, with an automated email reminder 1 and 2 weeks later.FMW has been described in detail elsewhere [diagnosis, starting treatment and communicating with the treatment team; (b) coping with physical symptoms and side effects; (c) managing emotional distress; (d) coping with changes in how you see yourself ; (e) concerns with your family and friends, and (f) issues arising as participants contemplate completing treatment and transitioning to post-treatment survivorship. Upon first access to the program, participants could self-tailor/rearrange the order of modules. A booster module, summarising key program strategies, became accessible one month after program completion. Participants had ongoing access to all program materials after all modules and assessments were released.lsewhere , 12. TheCharacteristics recorded at baseline included sex, age, marital status, employment status, level of educational attainment, annual gross income, cultural affiliation, cancer type, date of diagnosis, and treatments received . One item ‘in what capacity are you using the program’ was added to the open access survey mid-way through data-collection, when it became clear that users without cancer were enrolling into the program .Uptake was assessed via number enrolled participants within a matched recruitment timeframe to the RCT, and engagement/usage was assessed via number of modules completed (range 0–6).distress and quality of life. Distress was measured using the Depression, Anxiety, Stress-21 scale [Quality of Life was assessed with differing measures in open access and the RCT. In open access, the briefer Medical Outcomes Study Short-Form-12 version 2 [SF-12v2; emotional functioning and physical functioning subscales were selected.Intervention effectiveness was assessed across measures of 21 scale , which pSF-12v2; , 15 was SF-12v2; , 17 geneSF-12v2; , 15. ScoSF-12v2; , 15. In SF-12v2; , a 30-itt-tests to compare the change over time from baseline to post-intervention in the OA group. However, given the small sample size post-intervention, inferential statistics were deemed inappropriate; thus, descriptive statistics  were conducted.Descriptive statistics were conducted to summarise the sociodemographic and clinical characteristics of the sample, and to summarise the primary outcomes of uptake and engagement. For secondary outcomes, given the single group repeated measures design, planned analyses included repeated measures n = 120), with the baseline characteristics of the RCT intervention group (n = 78) provided as a reference. Of note, 42.5% of participants had missing data for the item ‘in what capacity are you using FMW’ as this was added mid-way through data collection. Of the remainder, most participants identified as a ‘person with cancer’ (43.4%), 5.8% were using the program as family members, and 7.5% were health care professionals. Participants were on average aged 55 years , 78% were female, 71% identified as Australian ethnicity, 67% were partnered, 82% were tertiary educated, and 67% were employed. Most cancer participants had breast cancer (50%), with cancers of the prostate (4.2%), lung (4.2%), bowel (3.3%), melanoma (3.3%), and leukaemia (3.3%) also represented.A total of 120 participants registered for the program. Table n = 120) equated to 62.8% of uptake of the RCT (n = 191) in the matched recruitment timeframe. Overall, adherence was low, with an average of 1.5 modules completed per participant, and only 13% of participants completing an a priori defined therapeutic dose of 4 or more modules. More specifically, as Fig. diagnosis/communicating with your team), and module 3  being the second most accessed (40%). Thereafter, a linear drop in use occurred for modules 2, 4, 5, and 6.Uptake during OA n = 20 equateTable Mpre = 36.7; SD = 26.5) to post-intervention . When looking at the DASS domains separately, there were consistent patterns of reductions from pre- to post-intervention in all three domains of depression, anxiety and stress  and MCS12  were over a standard deviation below the scoring normed average of 50. While only a 2-point average improvement from pre- to post-intervention was observed for the PCS12, a 7-point improvement in the MCS12 was observed over time. This pattern of findings was highly comparable to the EORTC QLQ-C30 EF and PF in the RCT.In the OA phase, baseline scores in the PCS12  occurred. While few open access studies have been reported in cancer, our engagement and retention findings are comparable to those observed by Davies et al. in their implementation of iCanAdapt, an online transdiagnostic clinician-monitored psychological therapy when offered as part of a clinical pathway for the management of early-stage cancer-related anxiety and depression ; their siCanAdapt as a component of a clinical pathway; the majority of self-referred participants were below the recommended distress threshold for using the program. However, we would argue that higher distress is somewhat to be expected, as RCTs employ strict eligibility criteria which may exclude those with advanced cancer and severe/psychiatric comorbidities, whereas in open access, while we sought to be clear who the program was designed for, anyone could (and did) sign up. Furthermore, motivations for signing up to the program likely differ from clinical trial  to open access  [Finally, in terms of psychosocial outcomes, the present study found that OA users had (a) consistently and markedly higher baseline distress and impaired QOL and (b) larger changes from pre- to post-intervention, compared to their clinical trial counterparts. This is an important finding and again speaks to the importance of open access dissemination studies to evaluate intervention impact among more diverse and distressed populations. Our findings differed from those of Davies et al. : when thtration) . This tetration) , particuadding human interaction via guidance, such as ‘coaches’; (2) enhance the computer tailoring of program content, such as by stratifying the content to the user’s cancer type, gender, age, sexual orientation, whether they have a partner or dependent-children, and (3) removal of tunnelling — to mimic traditional face-to-face therapeutic delivery, modules were released in a tunnelled format, once per week. However, adult learning literature [This study provides valuable insights into ‘real-world’ uptake, usage, and outcomes of digital psycho-oncology programs, which has important implications for two key areas of future research: evaluating methods of enhancing engagement, and testing the minimal engagement required to achieve effect. With respect to enhancing engagement, three options for this could include (1) terature  indicateterature . Whetherimprove engagement, one could focus on mapping intervention design around the engagement level we currently have. Indeed, recent studies suggest that it is not the amount of an intervention accessed that yields outcomes, but the self-selection of activities of relevance [micro-interventions for participants that only include a maximum of two modules, given that is the number of modules the data indicates users will complete. Micro-digital-health interventions are increasingly explored in other clinical populations, including body dissatisfaction [The second avenue for future research is that instead of focusing on how to elevance . Even sielevance , 25, whielevance , 27. Thusfaction  and moodsfaction –31. ArisWhile digital mental health interventions are often hailed as a cost-effective method of delivering care, there are still a range of resource costs incurred including annual website hosting and maintenance costs, and time/staffing costs to address content updates. The present findings could therefore raise sustainability concerns, that the costs incurred outweigh the benefits provided. However, our group would argue that these concerns are premature, given that of the multiple indicators of impact, only user-engagement was potentially concerning, whereas uptake and psychosocial outcomes were promising. Indeed, in the current COVID-19 climate where access to traditional face-to-face care has been further restricted –35, digiFinding My Way. Findings that OA users were more medically and sociodemographically diverse and more distressed at baseline than their RCT counterparts, and — despite having lower usage of the program — achieved larger changes from baseline to post-program, will help to shape the way that future interventions are designed, tailored, and disseminated.Despite the limitations discussed, this open access study provides important data on the profile, usage, and outcomes achieved by community users of our digital psycho-oncology program