***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Counselor behaviors that mediate the efficacy of  motivational interviewing ( MI ) are not well understood , especially when applied to health behavior promotion . We hypothesized that client change talk mediates the relationship between counselor variables and subsequent client behavior change . Methods Purpose ful sampling identified individuals from a prospect i ve r and omized worksite trial using an MI intervention to promote firefighters ’ healthy diet and regular exercise that increased dietary intake of fruits and vegetables ( n = 21 ) or did not increase intake of fruits and vegetables ( n = 22 ) . MI interactions were coded using the Motivational Interviewing Skill Code ( MISC 2.1 ) to categorize counselor and firefighter verbal utterances . Both Bayesian and frequentist mediation analyses were used to investigate whether client change talk mediated the relationship between counselor skills and behavior change . Results Counselors ’ global spirit , empathy , and direction and MI-consistent behavioral counts ( e.g. , reflections , open questions , affirmations , emphasize control ) significantly correlated with firefighters ’ total client change talk utterances ( rs = 0.42 , 0.40 , 0.30 , and 0.61 , respectively ) , which correlated significantly with their fruit and vegetable intake increase ( r = 0.33 ) . Both Bayesian and frequentist mediation analyses demonstrated that findings were consistent with hypotheses , such that total client change talk mediated the relationship between counselor ’s skills — MI-consistent behaviors [ Bayesian mediated effect : αβ = .06 ( .03 ) , 95 % CI = .02 , .12 ] and MI spirit [ Bayesian mediated effect : αβ = .06 ( .03 ) , 95 % CI = .01 , .13]— and increased fruit and vegetable consumption . Conclusion Motivational interviewing is a re source - and time-intensive intervention , and is currently being applied in many arenas . Previous research has identified the importance of counselor behaviors and client change talk in the treatment of substance use disorders . Our results indicate that similar mechanisms may underlie the effects of MI for dietary change . These results inform MI training and application by identifying those processes critical for MI success in health promotion domains OBJECTIVE While research has documented heavy drinking practice s and associated negative consequences of college students turning 21 , few studies have examined prevention efforts aim ed at reducing high-risk drinking during 21st birthday celebrations . The present study evaluated the comparative efficacy of a general prevention effort ( i.e. , Brief Alcohol Screening and Intervention for College Students , or BASICS ) and event-specific prevention in reducing 21st birthday drinking and related negative consequences . Furthermore , this study evaluated inclusion of peers in interventions and mode of intervention delivery ( i.e. , in-person vs. via the Web ) . METHOD Participants included 599 college students ( 46 % male ) : men who intended to consume at least 5 drinks and women who intended to consume at least 4 drinks on their 21st birthday . After completing a screening/baseline assessment approximately 1 week before turning 21 , participants were r and omly assigned to 1 of 6 conditions : 21st birthday in-person BASICS , 21st birthday web BASICS , 21st birthday in-person BASICS plus friend intervention , 21st birthday web BASICS plus friend intervention , BASICS , or an attention control . A follow-up assessment was completed approximately 1 week after students ' birthdays . RESULTS Results indicated a significant intervention effect for BASICS in reducing blood alcohol content reached and number of negative consequences experienced . All 3 in-person interventions reduced negative consequences experienced . Results for the web-based interventions varied by drinking outcome and whether a friend was included . CONCLUSIONS Overall , results provide support for both general intervention and ESP approaches across modalities for reducing extreme drinking and negative consequences associated with turning 21 . These results suggest there are several promising options for campuses seeking to reduce both use and negative consequences associated with 21st birthday celebrations Few studies have investigated the impact of  adolescent change language on substance use treatment outcomes and even fewer have examined how adolescents respond to normative feedback . The purpose of this study was to underst and the influence normative feedback has on adolescent  change language and subsequent alcohol and cannabis use 3months later . We examined how percent change talk ( PCT ) was associated with subsequent alcohol and drug use outcomes . Adolescents ( N=48 ) were r and omly assigned to receive brief motivational interviewing ( MI ) or MI plus normative feedback ( NF ) . Audio recordings were coded with high interrater reliability . Adolescents with high PCT who received MI+NF had significantly fewer days of alcohol and binge drinking at follow up . There were no differences between groups on cannabis use or treatment engagement . Findings indicate that NF may be useful for adolescents with higher amount of change talk during sessions and may be detrimental for individuals with higher sustain talk BACKGROUND Client language is hypothesized to be a mechanism of action in motivational interviewing ( MI ) . Despite the association of change and sustain talk with substance treatment outcomes , it not known whether providers can intentionally influence this language as hypothesized . OBJECTIVE This is a r and omized controlled trial to investigate whether substance use providers can be trained to influence client language . METHODS Treatment providers specializing in substance use disorders ( n=190 ) were r and omly assigned to st and ard training in MI ( MI-AU ) or training emphasizing an influence of client language ( MI-LEAF ) . Treatment sessions with actual clients were evaluated 3 , 6 and 12 months after training by masked raters . Frequencies of client change and sustain talk were the outcome variables . RESULTS Sustain talk , but not change talk , was significantly lower in clients whose providers had received the specialized training ( b=-0.175 , SE=0.087 , p=0.046 , CI[-0.348 to 0.002 ] , d=-0.325 ) . Mediation analyses supported a causal chain between a ) training , b ) providers ' attempts to minimize sustain talk in treatment sessions via directive reflective listening and c ) client sustain talk in the treatment session ( κ2=0.0833 , bootstrap SE=0.0394 , 95 % CI [ 0.0148 , 0.1691 ] ) . CONCLUSIONS With specialized training , providers can reduce the amount of opposition language their clients offer when considering a change in their substance use . Demonstrating that client language is under partial control of the provider supports the feasibility of clinical trials to investigate the impact of shaping client language on treatment outcomes BACKGROUND Questions remain about how brief motivational interventions ( BMI s ) for unhealthy alcohol use work , and addressing these questions may be important for improving their efficacy . Therefore , we assessed the effects of various characteristics of BMI s on drinking outcomes across 3 r and omized controlled trials ( RCTs ) . METHODS Audio recordings of 314 BMI s were coded . We used the global rating scales of the Motivational Interviewing Skills Code ( MISC ) 2.1 : counselor 's acceptance , empathy , and motivational interviewing ( MI ) spirit , and patient 's self-exploration were rated . MI proficiency was defined as counselor 's rating scale scores ≥5 . We also used the structure , confrontation , and advice subscale scores of the Therapy Process Rating Scale and the Working Alliance Inventory . We examined these process characteristics in interventions across 1 U.S. RCT of middle-aged medical in patients with unhealthy alcohol use ( n = 124 ) and 2 Swiss RCTs of young men with binge drinking in a non clinical setting : Swiss-one ( n = 62 ) and Swiss-two ( n = 128 ) . We assessed the associations between these characteristics and drinks/d reported by participants 3 to 6 months after study entry . RESULTS In all 3 RCTs , mean MISC counselor 's rating scales scores were consistent with MI proficiency . In overdispersed Poisson regression models , most BMI characteristics were not significantly associated with drinks/d in follow-up . In the U.S. RCT , confrontation and self-exploration were associated with more drinking . Giving advice was significantly associated with less drinking in the Swiss-one RCT . Contrary to expectations , MI spirit was not consistently associated with drinking across studies . CONCLUSIONS Across different population s and setting s , intervention characteristics viewed as central to efficacious BMI s were neither robust nor consistent predictors of drinking outcome . Although there may be alternative reasons why the level of MI processes was not predictive of outcomes in these studies ( limited variability in scores ) , efforts to underst and what makes BMI s efficacious may require attention to factors beyond intervention process characteristics typically examined Context Brief interventions reduce alcohol use in out patients who drink unhealthy amounts but are not alcohol-dependent . Their effect in medical in patients is unknown . Contribution The authors screened all adult medical in patients at an urban teaching hospital and r and omly assigned 341 risky drinkers to a 30-minute motivational counseling intervention followed gy treatment planning or to usual care . By 3 months , the same proportion of patients from both groups had received alcohol assistance , and both groups had reduced their drinking to the same degree . Caution s Three quarters of the participants met Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition , criteria for alcohol dependence . Implication s In this well-done study , brief intervention did not affect alcohol-related outcomes in persons who drank unhealthy amounts . The Editors Professional organizations recommend that clinicians screen their patients for unhealthy alcohol use ( that is , the spectrum from drinking risky amounts to dependence ) and conduct a brief intervention when indicated ( 1 , 2 ) . Despite this recommendation and the existence of brief , valid screening tools ( 35 ) , patients with unhealthy alcohol use often are not identified and do not receive timely care . Although widely recommended , brief intervention has proven efficacy in decreasing alcohol consumption and related consequences only in unhealthy drinkers without alcohol dependence and in outpatient setting s ( 6 ) . Its efficacy among other population s ( for example , persons with alcohol dependence ) and in inpatient setting s remains unclear ( 7 ) . Evidence suggests , however , that medical in patients a group with a high prevalence of alcohol-related problemsmay benefit from brief intervention . Some studies have demonstrated the efficacy of brief intervention in setting s similar to medical services in which alcohol-related problems are common and their related consequences are severe ( 8 , 9 ) . Further , brief interventions are well suited to medical services . Patients who otherwise might not seek care are accessible and have time for an intervention . Persons admitted because of an alcohol-related problem may recognize the link between drinking and hospitalization , thus providing a teachable moment ( 10 ) . Also , busy staff might implement a brief intervention because of its brevity and flexibility . The unmet need for alcohol screening and intervention and opportunities for implementation underscore the importance of determining the efficacy of brief intervention in medical in patients with unhealthy alcohol use . In addition , evaluating its effectiveness and practicality in real-world setting s is critical to help clinicians make informed decisions when treating their patients ( 11 ) . Therefore , we conducted a r and omized , controlled trial to examine whether screening followed by brief intervention would improve alcohol-related outcomes in typical medical in patients ( that is , a racially diverse group with a range of unhealthy alcohol use , comorbid conditions , and readiness to change ) . We hypothesized that screening and brief intervention would lead to the following : receipt of alcohol assistance ( for example , specialty treatment ) among persons with alcohol dependence and , among all persons decreased alcohol consumption , alcohol-related problems , and health care utilization and improved readiness to change and health-related quality of life . Methods Patients As previously described , we recruited patients from the inpatient medical service of a large , urban teaching hospital ( 12 ) . Trained research associates approached all patients who were age 18 years or older and whose physicians did not decline patient contact . Patients fluent in English or Spanish who gave verbal consent were asked to complete a screening interview to determine eligibility : currently ( past month ) drinking risky amounts ( defined for eligibility as > 14 st and ard drinks/wk or 5 drinks/occasion for men and > 11 drinks/wk or 4 drinks/occasion for women and persons 66 years ) ; 2 contacts to assist with follow-up ; no plans to move from the area in the next year ; and a Mini-Mental State Examination score of 21 or greater ( 13 , 14 ) . Research associates assessed demographic characteristics and administered the  Alcohol Use Disorders Identification Test ( AUDIT )  ( 15 ) by interview . To better characterize current alcohol use , they assessed the average numbers of drinking-days per week and drinks consumed on a typical day , and the maximum number of drinks consumed per occasion ( 16 , 17 ) . For the first 7 months of the study , research associates asked these additional questions only to patients with an AUDIT score of 8 or greater ( a recommended cutoff for screening ) ( 18 ) . For the remaining 22 months , research associates asked the additional questions to anyone who drank in the past 12 months to maximize identification of drinkers of risky amounts . Lastly , the research associates asked all patients who were drinking risky amounts to describe their readiness to change by using a visual analog scale ranging from 0 to 10 ( 19 ) . Enrolled patients provided written informed consent and were compensated for each completed interview . The institutional review board at Boston University Medical Center approved this study . We secured additional privacy protection with a certificate of confidentiality from the National Institute on Alcohol Abuse and Alcoholism . Assessment at Enrollment Research associates interviewed patients before r and omization to assess the characteristics shown in Table 1 . One author review ed the medical records to determine medical diagnoses ( 29 ) . Diagnoses of alcohol use disorders were based on the Diagnostic 
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Finally , the relational hypothesis was not supported , but heterogeneity in technical hypothesis path effect sizes was partially explained by inter- and intrapersonal moderators .