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�CorrespondenceYork, NY 10003.

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Behavioral approaches to headache: A practical guide fornon-mental health providers

Madeline Gittleman, PsyD, MSED�

Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York

a r t i c l e i n f o

Keywords:

Behavioral approaches

Headache

Relaxation training

Biofeedback

Cognitive behavior therapy

Communication

Four Habits Model

Empathy

Education

ont matter Published by.1053/j.trap.2012.11.009

author at: Department o

mgittleman@chpnet.org

a b s t r a c t

Behavioral treatments such as relaxation training, biofeedback, and cognitive behavioral

therapy have repeatedly demonstrated significant efficacy for the treatment of migraine-

and tension-type headache. Behavioral treatments and pharmacologic treatments

together also have an additive effect such that the combination of the 2 treatments is

more effective than either treatment alone. The action mechanisms of behavioral

approaches revolve around the following constructs: (1) self-efficacy; (2) internal vs

external locus of control; (3) stress management skills; and (4) pain-coping skills. As these

constructs can remain relatively stable over time, behavioral treatments offer lasting

results for the management of pain. Despite the aforementioned clinical insights, financial

constraints and limited access to behavioral health experts make it difficult to fully

integrate behavioral approaches into treatment. As such, this article serves as a guide for

medical doctors and clinicians of various disciplines to gain awareness of and integrate

these approaches into their headache armamentarium. We present approaches to

maximize patients’ openness to a multimodal model and keys to distinguish patients

who require specialist-level care. We close with a call for greater inclusion of behavioral

medicine in graduate level medical training.

Published by Elsevier Inc.

Introduction

The biopsychosocial model of headache posits that pain is

triggered, exacerbated, maintained, and alleviated through

the interplay of physical, psychological, social, and environ-

mental factors.1 Successful treatment of headache therefore

calls for a comprehensive multimodal approach.

Much research has focused on the constantly evolving

pharmacologic and procedural (surgical) approaches to head-

ache. However, with greater acceptance of the mind/body

connection, research over the past 3 decades has also

Elsevier Inc.

f Pain Medicine and Pallia

focused on behavioral treatments.2,3 Interestingly, findings

have demonstrated that behavioral interventions are not

only effective in reducing frequency and intensity of head-

ache and improving quality of life, but they are also effective

in more generally improving pain treatment adherence and

treatment outcomes.4,5

Although many headache centers have incorporated psy-

chologists as part of their interdisciplinary pain teams,

physicians have the unique opportunity to directly integrate

behavioral strategies into their clinical work.5 As active

collaborators with their patients, physicians’ awareness of

tive Care, Beth Israel Medical Center, 16th Street, 1st Avenue, New

T E C H N I Q U E S I N R E G I O N A L A N E S T H E S I A A N D P A I N M A N A G E M E N T 1 6 ( 2 0 1 2 ) 6 9 – 7 570

and ability to address the emotional, cognitive, behavioral,

and social aspects of pain can be invaluable. Adding beha-

vioral approaches to one’s clinical tool kit also allows the

physician to view the patient from multiple perspectives,

thereby avoiding the old adage—if one’s only tool is a

hammer, every problem looks like a nail. Headache sufferers

are a heterogeneous group with multidimensional presenta-

tions. Therefore, they fare best with individualized multi-

faceted treatment plans. This paper seeks to provide non-

mental health providers with an overview of behavioral

approaches and a guide for how to incorporate these

approaches into daily headache treatment. The paper also

seeks to briefly present specific scenarios that call for more

in-depth behavioral treatment thus require referral for

specialist-level care.

Engaging the patient

The sine qua non of incorporating into treatment the tech-

niques described below is the task of engaging the patient as

an open, an active, and a cooperative collaborator in the

treatment plan. As engaging the patient is the critical first

step in all behavioral treatments, it is presented first.

Initial encounter

With the advances of the 21st century and the fast pace of

society, people have lost patience for the process of progress

and have come to depend on quick fixes.6 As such, when

people seek medical attention they expect immediate relief.

Their locus of control is completely external to themselves,

centered on the doctor with whom they feel no partnership.

That is, they expect something ‘‘medical’’ will be done to

them, not with them. Chronic illness and pain disorders pose

an even greater problem for patients in that they require long-

term management as opposed to acute management, thus

resulting in patient frustration. Chronic headache sufferers

also often enter into treatment with an array of worries and a

sense of desperation after seeing multiple specialists, endur-

ing tests, and attempting remedies to little or no avail.

In order to engage these patients, Nicholson et al. recom-

mend that clinicians approach the intake in a directive yet

flexible manner. They suggest clinicians maintain a mental

outline of the information they would like to obtain while

eliciting the information through open-ended questions. This

establishes the development of a collaborative clinician-

patient relationship as opposed to a one-time solution-focused

Table 1 – Sample questions for the initial encounter.

Open-ended questions

‘‘What brings you here today?’’

‘‘How do you understand your headache symptoms?’’

‘‘What alleviates/worsens your headache?

‘‘How do your headaches affect you (physically and emotionally)?’’

‘‘How do you deal with your headaches?’’

‘‘Who interacts with you around your headaches?’’

‘‘What is most bothersome/most important to you?’’

‘‘What are you hoping for with headache management?’’

consultation.7 Contrary to popular belief, research has also

shown that engaging patients in this way generates a greater

depth of relevant information in a shorter period of time8 (see

Table 1 for a list of open-ended questions for initial visits).

Communication

As medical treatment is often dependent on the collaborative

relationship between patient and clinician, communication

is key to building successful outcomes.9 Frankel and Stein

utilized the existing research on effective clinical interviews

and created ‘‘The Four Habits Model’’, a practical guide for

clinicians to communicate in meaningful ways with patients.

Based on this model clinicians are encouraged to organize

their behavior around the following: (1) investing in the

beginning—establishing a rapport; (2) eliciting the patient’s

perspective or obtaining relevant information; (3) demon-

strating empathy; and (4) investing in the end—motivating

patient towards treatment adherence. The model (Table 2)

specifies techniques that pertain to each habit with examples

of beneficial outcomes.10

Empathy is often conceptualized as a trait that cannot be

learned. Indeed, it is likely that there are people who are

more naturally empathic; however, it is a trait that can be

acquired with training and practice. Cohen-Cole and Bird

identified 5 ways in which clinicians can emotionally join

with patients: (1) reflection—‘‘I can see that you arey’’; (2)

legitimation—‘‘I can understand why you feely’’; (3) sup-

port—‘‘I want to helpy’’; (4) partnership—‘‘Let’s work togeth-

ery’’; (5) respect—‘‘You’re doing great’’.11 As is the case with

generally good communication, use of empathy in clinical

interactions leads to greater patient engagement and

satisfaction.

Education

In addition to communicating effectively and connecting to

the patient, education is a crucial component for headache

treatment. For patients, education serves as a key to self-

management, a motivating force for adherence to treatment

and a foundation for building self-efficacy. Due to the

complex biopsychosocial nature of headache, education as

a treatment in itself has been shown to decrease headache

pain and its frequency, improve quality of life and reduce

utilization of healthcare resources.12 To achieve these posi-

tive outcomes, instructions to the patients should focus on

etiology and pathology of headache; monitoring of headache;

Information elicited

History of present illness

Insight into condition; core beliefs; attribution of meaning

Awareness of triggers; capacity for self-management

Physical functional status; emotional functioning

Pain coping abilities

Support system

Treatment goals

Treatment expectations

Table 2 – Approach to effective clinical communication.

Habit Skills Techniques and examples Payoff

Invest in the

beginning

Create rapport

quickly

� Introduce self to everyone in the room

� Acknowledge the wait

� Convey knowledge of patient’s history by

commenting on prior visit or problem

� Attend to patient’s comfort

� Make a social comment or ask a

nonmedical question to put patient

at ease

� Adapt own language, pace, and posture

in response to patient

� Establishes a welcoming atmosphere

� Allows faster access to real reason for visit

� Increases diagnostic accuracy

� Requires less work

� Minimizes ‘‘Oh, by the way...’’ at the end

of visit

� Facilitates negotiating an agenda

� Decreases potential for conflict

Elicit patient’s

concerns

Start with open-ended questions:

� ‘‘What would you like help with

today?’’ OR,

� ‘‘I understand that you’re here for...

Could you tell me more about that?’’

� ‘‘What else?’’

� Speak directly with patient when using

an interpreterPlan the visit with

the patient

� Repeat concerns back to check

understanding

� Let patient know what to expect: ‘‘How

about if we start with talking more

about..., then I’ll do an exam, and then

we’ll go over possible tests/ways to treat

this? Sound OK?’’

� Prioritize when necessary: ‘‘Let’s make

sure we talk about X and Y. It sounds like

you also want to make sure we cover Z.

If we can’t get to the other concerns,

let’s...’’

Elicit the patient’s

perspective

Ask for patient’s

ideas

Assess patient’s point of view:

� ‘‘What do you think is causing your

symptoms?’’

� ‘‘What worries you most about this

problem?’’ Ask about ideas from

significant others

� Respects diversity

� Allows patient to provide important

diagnostic clues

� Uncovers hidden concerns

� Reveals use of alternative treatments or

requests for tests

� Improves diagnosis of depression and

anxietyElicit specific

requests

Determine patient’s goal in seeking care:

‘‘When you’ve been thinking about

this visit, how were you hoping I could

help?’’

Explore the

impact on the

patient’s life

Check context: ‘‘How has the illness

affected your daily activities/work/

family?’’

Demonstrate

empathy

Be open to

patient’s

emotions

� Assess changes in body language and

voice tone

� Look for opportunities to use brief

empathetic comments or gestures

� Adds depth and meaning to the visit

� Builds trust, leading to better diagnostic

information, adherence, and outcomes

� Makes limit—setting or saying ‘‘no’’ easier

Make at least one

empathetic

statement

� Name a likely emotion: ‘‘That sounds

really upsetting’’

� Compliment patient on efforts to

address problemConvey empathy

nonverbally

Use a pause, touch, or facial expression

Be aware of your

own reactions

� Use own emotional response as a clue to

what patient might be feeling

� Take a brief break if necessary

Invest in the end Deliver diagnostic

information

� Frame diagnosis in terms of patient’s

original concerns

� Test patient’s comprehension

� Increases potential for collaboration

� Influences health outcomes

� Improves adherence

� Reduces return calls and visits

� Encourages self-care

(continued on next page)

T E C H N I Q U E S I N R E G I O N A L A N E S T H E S I A A N D P A I N M A N A G E M E N T 1 6 ( 2 0 1 2 ) 6 9 – 7 5 71

Table 2 (continued) )

Habit Skills Techniques and examples Payoff

Provide education � Explain rationale for tests and

treatments

� Review possible side effects and

expected course of recovery

� Recommend lifestyle changes

� Provide written materials and refer to

other sources

Involve patient in

making

decisions

� Discuss treatment goals

� Explore options, listening for the

patient’s preferences

� Set limits respectfully: ‘‘I can understand

how getting that test makes sense to

you. From my point of view, since the

results won’t help us diagnose or treat

your symptoms, I suggest we consider

this instead’’

� Assess patient’s ability and motivation

to carry out the plan

Complete the visit � Ask for additional questions: ‘‘What

questions do you have?’’

� Assess satisfaction: ‘‘Did you get what

you needed?’’

� Reassure patient of ongoing care

Reproduced with permission from Frankel, RM, Stein, T. Getting the most out of the clinical encounter: The Four Habits Model. J Med Pract

Manage 2001; 16: 184. Copyright 2001. Greenbranch Publishing.

T E C H N I Q U E S I N R E G I O N A L A N E S T H E S I A A N D P A I N M A N A G E M E N T 1 6 ( 2 0 1 2 ) 6 9 – 7 572

headache triggers; the role of stress and stress management;

the role of lifestyle choices (eg, diet and activity level, and

sleep); activity pacing; and medication (use, side effects, and

potential overuse).1 Instructions should be carried out so as

to maximize the likelihood of comprehending, personalizing,

internalizing, retaining the information, and buying into the

collaborative treatment plan. Rains et al. note that clinicians

should: (1) limit information to a few key points; (2) use

language at elementary reading level; (3) provide both oral

and written instructions; (4) if appropriate, include family

members in the treatment plan; (5) ask patients to restate

recommendations; and (6) repeat and reinforce instructions.6,1

Behavioral approaches

Once the patient is engaged in a manner that allows for

openness to multimodal treatment, various behavioral inter-

ventions can be introduced. Generally speaking, behavioral

interventions seek to increase people’s awareness of internal

processes (ie, thoughts, feelings, and physiological arousal)

and external processes (ie, behavior and social functioning),

and to assist people in regulating these processes. Typically,

we can introduce behavioral interventions by inquiring as to

whether a patient has noticed that on ‘‘bad days’’ (eg, their

car breaks down, they are running late, and their boss is in a

bad mood), their headache tends to be more bothersome. We

note that while it is impossible to prevent or predict all

stressors, it is quite possible to control the way in which we

respond to stress. One can gain control over the way in which

one responds. The primary ways in which we assert this

control are described below: relaxation, biofeedback, and

cognitive behavioral therapy.

Relaxation

Humans are adaptive beings with certain innate qualities

that perpetuate their existence. The fight or flight response is

one such adaptive mechanism that in truly dangerous situa-

tions allows us the greatest opportunity for survival. How-

ever, in today’s society the fight or flight response tends to

kick in with perceived threat as opposed to actual threat.

With the high degree of stress commonly experienced by

individuals in western society it is nearly impossible to

prevent the many external pressures from activating these

systems. It is even harder to avoid the hyperaroused state

when fighting the constant threat posed by chronic illness.

The technique of relaxation aims to decrease hyperarousal,

thus improving stress coping capacity and preventing stress-

related headache.

The literature most often cites the following forms of

relaxation: progressive muscle relaxation (patients gradually

tense and release each muscle, working either from their

head down to their toes or vice versa); autogenic training

(using a series of self-instructions to generate specific sensa-

tions of warmth or heaviness); meditation (specifically direct-

ing focus toward the identified targets or allowing for more

general awareness of the here and now, or both); and

hypnosis (utilizing focus to access the unconscious or to

allow for more openness to suggestions around calming the

system or both).13,14 Overall studies show that 43%-55% of

headache sufferers experience 50% or greater reduction in

the frequency of headache with these techniques.2,8 Buse

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and Andrasik1 also point out that alternative techniques (eg,

yoga, imagery, and music, prayer) that elicit a sense of calm

in the patient should also be encouraged, as they are likely to

serve the same function. It is noted that the efficacy of

relaxation exercises is highly dependent on the patient’s

commitment to practicing them. Ideally, over time, patients

develop a relaxation response pattern that is almost as

automatic as the fight or flight response. The acquisition of

these skills feeds into the patients’ self-efficacy and sense of

control over their condition.

While non-mental health providers may not have received

formal training on administering relaxation exercises to

patients, they can either seek out training opportunities or

introduce this modality through less formal means. More

specifically, providers can access an array of resources from

the internet (eg, relaxation scripts, relaxation audio down-

loads, and relaxation videos) either to use directly with the

patient or to suggest for patient use at home. This modality

also provides a unique opportunity for the provider to engage

family members or members of the patient’s support net-

work in the plan of care.

Biofeedback

Biofeedback is a treatment modality, whereby we bring

conscious awareness to physiological processes formerly

considered to be involuntary (ie, breathing rate, muscle

tension, blood pressure, and temperature) and thus allowing

us to bring these processes under voluntary control.15 This is

feasible through the use of equipment that converts certain

physiological processes into signals that can be seen, heard

or both. It is also often only feasible when used in conjunc-

tion with relaxation and patient education regarding auto-

nomic nervous system functioning and stress response.

The following are different forms of biofeedback that target

various physiological processes: (1) Thermal biofeedback

measures distal (finger) temperature or degree of vasocon-

striction vs vasodilatation; (2) Electromyelograph biofeedback

measures electrical activity of muscles (muscle tension); (3)

Blood Volume Pulse biofeedback measures the degree to

which blood flow in the temporal artery is constricted; and

(4) Galvanic Skin Response biofeedback measures electrical

conductance of skin through moisture. As we assist patients

in gaining control of these processes, the goal is always to

reduce system distress/sympathetic arousal. Thus, the goal

for muscle tension, temporal artery constriction, and moist-

ure skin conductance is to decrease the signal; the goal for

distal temperature to increase the signal (signifying greater

degrees of vasodilatation). Biofeedback as a behavioral treat-

ment works through an operant conditioning paradigm,

whereby the signals of the physiological functions serve as

external reinforcers for the desired behaviors of decreasing

arousal and coping adaptively with stress. Over time and

with practice, the reward becomes intrinsic and the need for

the external cues dissipates, thus allowing the patient to

generalize the skills apart from the biofeedback equipment.

The effectiveness of biofeedback in treating both migraine-

and tension-type headache is strongly supported by a great

deal of research.16,17 Nestoriuc et al. conducted a recent

meta-analysis evaluating the efficacy of biofeedback. They

compared various forms of biofeedback in relation to the

improvement in duration, frequency, and intensity of head-

ache; and in relation to improvement in emotional well-being

through psychological constructs of anxiety, depression, and

self-efficacy. Results indicated medium to large effect sizes

for all forms of biofeedback with pretreatment vs posttreat-

ment data revealing significant symptom improvement.

When compared to participants in the no-treatment group

and participants in the placebo control group, participants

who underwent biofeedback evidenced medium and small-

medium effect sizes respectively. It is noted that while the

average biofeedback treatment length was 11 sessions,

follow-up evaluations revealed that positive treatment out-

comes/symptom improvement persisted for years after treat-

ment termination.18

As with relaxation, biofeedback is not necessarily a mod-

ality in which medical providers receive training. The cost of

biofeedback equipment is often a burden that clinics cannot

bear. As such, patients are often referred to biofeedback

specialists. Although referral can be helpful, particularly for

patients who may benefit from multiple biofeedback training

modalities, less formal biofeedback is available for clinicians

to utilize in their clinical visits or for patients to utilize at

home, or both. One of the most commonly used biofeedback

tools is a hand-held alcohol-based distal thermometer.

Patients can carry these in a pocket and measure vasocon-

striction at any point in time.

Cognitive behavioral therapy (CBT)

CBT is a psychotherapeutic model based on the premise that

our thoughts, emotions, and behaviors are all interrelated,

such that shifting the way we think can alter the way we feel

and the way we act. CBT further theorizes that people tend to

develop certain automatic thoughts based on core beliefs

derived from early experiences, values, and predispositions.

In this way, our beliefs serve as a lens through which we tend

to view the world. As in the common saying ‘‘looking at the

world through rose-colored glasses’’, the lens can shift our

perception of reality to alter our mood for the better (or

perhaps for the worse).

Burns generated a list of 10 lenses or cognitive distortions

that people commonly employ: (1) all-or-nothing thinking; (2)

overgeneralization; (3) mental filter; (4) disqualifying the

positive; (5) jumping to conclusions; (6) magnification/mini-

mization; (7) emotional reasoning; (8) shoulding; (9) labeling/

mislabeling; and (10) personalization and blame.19 Burns

suggests that these thought processes often lead to greater

emotional suffering than the problematic situations which

trigger them.

Several years ago, Salovey and Birnbaum demonstrated

that emotions have a direct influence on pain tolerance.

Negative, neutral, or positive mood was induced by reading

samples that had depressive, neutral, or euphoric tones.

Results demonstrated that those with negative mood had

significantly lower pain tolerance for cold-pressors whereas

those in the positive mood group had significantly higher

pain tolerance.20

If thoughts directly affect mood states and mood directly

affects pain then we can infer that people’s thoughts can

T E C H N I Q U E S I N R E G I O N A L A N E S T H E S I A A N D P A I N M A N A G E M E N T 1 6 ( 2 0 1 2 ) 6 9 – 7 574

directly affect their experience of headache. Research has

also shown that the way in which people think about their

pain (be it headache or other pain) influences the outcomes,

such as functional status; disability; mood and quality of life.

One such example is pain catastrophization or excessive

focus on and fear of worst-case scenarios related to pain.

This thinking pattern has been widely shown to lead to

greater degrees of pain-related disability and poorer quality

of life.21

CBT aims to restructure patients’ thoughts about pain to

allow for adaptive functioning. Homework assignments and

thought logs bring patients’ awareness to distorted thought

patterns and provide a forum for challenging such distor-

tions. Patients are also taught skills such as problem solving,

goal setting, and pacing to allow them to behave in a way

that allows for life fulfillment while respecting their pain

limitations.

As non-mental health clinicians will neither have the time

nor the training to engage patients in all of the CBT compo-

nents described above, they can utilize this information to

observe patients’ thought patterns during clinical encoun-

ters. As patients reveal cognitive distortions that seem to be

interfering with their treatment, physical, or emotional well-

being, clinicians can share their observation then challenge

the distortion through one of these means: (1) ask the patient

what evidence supports their thought; (2) provide evidence to

support the contrary; (3) take their thought at face value but

help them problem solve or develop a plan of action based on

that thought, or both; (4) ask them to imagine a loved one or

friend having that thought and inquire as to how they would

respond; (5) ask them to place their thought on a spectrum of

0-100, 0 signifying that the thought has no affect on their life

and 100 signifying that the thought completely disrupts their

life; and (6) utilize humor (carefully and tactfully) to point out

the improbability or absurdity of thought.

Internet-based intervention

With technological advances predominating in so many

domains of life, it is inevitable that the behavioral health

field has begun to utilize internet-based interventions for

various conditions. In the case of chronic headache or

migraine or both, internet-based approaches have particular

benefits in their accessibility and low cost. Strom

et al.evaluated the effects of an internet-based behavioral

program incorporating relaxation and problem solving in the

treatment of chronic headache. The treatment lasted 6 weeks

and involved use of internet-based self-help instructions, as

well as email reminders. Results at the conclusion of the

study revealed significant decreases in headache frequency.22

In an effort to focus specifically on migraine headache,

Hedborg and Muhr evaluated an internet-administered mul-

timodal-behavioral treatment program in Sweden. The pro-

gram sought to increase participants’ insights into daily

factors that affected their pain and was comprised of online

lessons with recommendations, daily journal, hand massage

for some participants, follow-up questionnaires, and brief

face-to-face encounters with investigators. The results

remained consistent. The MBT group had a greater reduction

in the frequency of headache than the control group.23

In their systematic review of the literature, Cuijpers et al.24

found that internet-based interventions show promising

efficacy in the treatment of health problems—specifically

pain and headache. To date, little evidence has compared

internet-based behavioral interventions to face-to-face inter-

ventions. However, the logistical advantages of this treat-

ment modality make it a viable option. Additionally, it is

noted that aside from formal online behavioral protocols, the

internet has a wealth of resources for headache sufferers.

Integration vs referral

It is noted that while this article calls for non-mental health

professionals to integrate behavioral interventions into head-

ache treatment, there are specific patients for which referral

to a behavioral specialist or psychologist, or both, is

necessary. Nicholson25 specifies these situations as follows:

(1) patient presents with psychiatric comorbidities, active

psychiatric issues or both; (2) patient presents with mala-

daptive coping patterns which inhibit progress (eg, patients

who engage in pain catastrophization to the extent that they

avoid engagement in activities for fear of exacerbating pain);

and (3) patient presents with premorbid or comorbid sleep

problems. Experts in behavioral health can utilize their

psychodiagnostic, assessment, and interventional skills to

work with these more psychologically complex cases.

Conclusion

In an ideal world, standard headache treatment would

always involve multidisciplinary treatment; however, finan-

cial limitations, time constraints, and barriers to access make

this more of the exception than the rule. As such, it is crucial

for physicians and other treating clinicians to become famil-

iar with and utilize (1) techniques to engage the patient as

active collaborator in his treatment and (2) behavioral

approaches to headache management. Of course, there will

be many situations that require referral for specialist-level

behavioral interventions. However, it is hoped that non-

mental health providers will incorporate the practical steps

presented to engage patients as partners in behavioral inter-

ventions. Building rapport, effective communication, empa-

thy, and education serve as the cornerstones for developing a

treatment plan that incorporates relaxation, biofeedback and

CBT. While pharmacologic interventions play an important

role in headache management, these behavioral techniques

foster the development of internal resources, thus empower-

ing patients, encouraging independent management of pain,

and building confidence in ones’s ability to cope. Behavioral

approaches also allow for internet-based home formats

which open up treatment options for patients who may not

have otherwise received any treatment. Given these clear

benefits we close with a call for greater awareness of and

commitment to integration of these approaches. It is also

hoped that efforts are made to incorporate more formal

behavioral instruction into medical training programs.

T E C H N I Q U E S I N R E G I O N A L A N E S T H E S I A A N D P A I N M A N A G E M E N T 1 6 ( 2 0 1 2 ) 6 9 – 7 5 75

Acknowledgments

The author would like to thank Dr. Richard M. Frankel and

Dr. Terry Stein for developing ‘‘The Four Habits Model’’ and

granting permission for its use in this manuscript.

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