Digital empathy: A new concept for health coaching

Elena Rey Velasco is a dietitian and nutritionist. She is currently undertaking an Industrial PhD with Liva Healthcare and the University of Copenhagen, in partnership with the Impact Diabetes Bump2Baby project and the Bump2Baby and Me study. Her PhD project work explores how to improve text-based communication in digital health coaching interventions, with a focus on type 2 and gestational diabetes prevention and lifestyle behaviour change.

In recent years, telehealth gained popularity as a convenient and cost-effective method of delivering healthcare using digital infrastructures. The large numbers of people across the world who were already receiving support remotely, thanks to these alternatives to traditional healthcare, significantly increased during the COVID-19 pandemic. Most health-related consultations, including with general practitioners (GPs), psychological therapy, and health coaching, can easily be undertaken using telehealth solutions. As long as a physical examination is not necessary, telehealth is just as effective as in-person treatments.1 The Bump2Baby and Me study is trialling a novel telehealth intervention which provides women at risk of developing gestational diabetes with personalised, evidence-based, healthy eating and exercise information. This information is provided via a smartphone app and a dedicated health coach during pregnancy and for the first 12 months after birth.

The digital relationship

The way we build human relationships digitally is different from the way we do it face-to-face, simply because the communication is different. Telehealth can take different forms, including voice or video conversations, text messaging or emails. Equally these communications can be synchronous (in real time) or asynchronous (not in real time). Video calls are a good example of synchronous communications, while non-instant text messaging, where we are not expected to answer right away, is an example of asynchronous communications.

The combination of both synchronous and asynchronous is more successful for behaviour change2 because it strengthens the relationship built between the health coach and their patient/client – which is essential in coaching.3 The relationship is developed by the coach getting to know their patient/client, listening to them and accounting for their perspective and needs. The trust placed in a coach and the feeling of being supported is the key to making successful lifestyle change.

The fact that the number of technologies are expanding does not necessarily mean that everyone is satisfied with the interaction. Some people experience a greater sense of distance and separation speaking on the phone or via a computer rather than a genuine personal connection.4 In health coaching, putting extra work into forging a strong relationship may shorten this distance. The Liva coaching model that we are using in the Bump2Baby and Me study consists of both theoretical and practical components necessary to promote this connection, such as integrative health coaching,5 self-determination theory,6 patient centred communication (PCC),7 and behaviour change techniques (BCTs).8 All these components share a common factor: empathy.

What is digital empathy?

Empathy is the ability to understand the feelings of another. It is often confused with sympathy, which is about sharing someone else’s feelings and emotions without understanding them.9 Empathy has a positive effect on patient outcomes in all kinds of healthcare fields, especially behaviour change.10 However, empathy is often overlooked, and more research is needed, particularly on how to evaluate and improve it.11

Video calls mimic physical interactions pretty well so we can use empathy in a similar way. Asynchronous text messaging is a relatively new way of communicating and everyone has a different way of expressing themselves through their messages, for example, how they use punctuation marks or emojis. However, different people might read and interpret the same text message differently. Have you ever used a smiley about something that was not really making you smile? For example, “My week has been crazy ☺”. If this was a health coaching interaction, should the coach assume that you are happy about how your week went? Or should they ask you a little more about what made it crazy and how you feel about it? Depending on how the coach interpreted it, there might be a misunderstanding or a missed opportunity to show digital empathy.

Investigating how to measure digital empathy

For my PhD and as part of the Bump2Baby and Me study, I am looking at how best to measure digital empathy in text messages-based communications. I spent the first year of my PhD looking for the best approach to text messages analysis, which taught me the value of empathy in changing lifestyle behaviours. If a coach is not empathetic, the chances of a patient/client developing a good relationship with them and thus achieving successful behaviour change is smaller. It subsequently became the focal point of my research.

The challenge for digital empathy is that showing (and measuring) it is more difficult than face-to-face empathy. There are features from live conversations, such as tone of voice, facial gestures, and body language, that text messages lack. When we write text messages we often try to compensate for this, for example, with capital letters, question marks, or emojis. Some researchers have used questionnaires and surveys to evaluate digital empathy after the conversation has taken place. However, these methods miss what happens during the actual interaction. Even though technologies are so widespread in our daily lives, studies on digital empathy in text messages are limited. As a dietitian and nutritionist, I am investigating alternative approaches like language analysis, which I am still learning and experimenting with every day. This will hopefully lead me to the best method to measure digital empathy.

Currently I am working on a text message analysis tool to identify empathetic opportunities for health coaches and to evaluate their responses. I also recently submitted my first article on this, where I combined empathy and language analysis. Although it is currently under review, you can read the preprint edition here:

For the remaining half of my PhD, I will be refining and testing the text message empathy tool with real text messages from the Bump2Baby and Me study. My findings will help me write an asynchronous coaching manual to support health coaches to show digital empathy and develop a better relationship with their patients/clients. This manual will be included in the overall Impact Diabetes Bump2Baby project Implementation Toolkit, providing information and resources to support the implementation and scale up of the Bump2Baby and Me intervention.


1Hammersley V, Donaghy E, Parker R, McNeilly H, Atherton H, Bikker A, et al. Comparing the content and quality of video, telephone, and face-to-face consultations: A non-randomised, quasi-experimental, exploratory study in UK primary care. British Journal of General Practice. 2019;69(686):E595-E604.

2Antoun J, Itani H, Alarab N, Elsehmawy A. The Effectiveness of Combining Nonmobile Interventions With the Use of Smartphone Apps With Various Features for Weight Loss: Systematic Review and Meta-analysis. JMIR Mhealth Uhealth. 2022;10(4):e35479.

3 DeAngelis T. Better relationships with patients lead to better outcomes. Available at: 2019.

4Meskó B, Drobni Z, Bényei É, Gergely B, Győrffy Z. Digital health is a cultural transformation of traditional healthcare. Mhealth. 2017;3:38.

5Malecki HL, Gollie JM, Scholten J. Physical Activity, Exercise, Whole Health, and Integrative Health Coaching. Phys Med Rehabil Clin N Am. 2020;31(4):649-63.

6Deci EL, Ryan RM. Intrinsic Motivation and Self-Determination in Human Behavior: Springer US; 2013.

7Epstein RM, Franks P, Fiscella K, Shields CG, Meldrum SC, Kravitz RL, et al. Measuring patient-centered communication in Patient-Physician consultations: Theoretical and practical issues. Social Science and Medicine. 2005;61(7):1516-28.

8Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med. 2013;46(1):81-95.

9Jeffrey D. Empathy, sympathy and compassion in healthcare: Is there a problem? Is there a difference? Does it matter? Journal of the Royal Society of Medicine. 2016;109(12):446-52.

10Abdulrahman A, Richards D, Ranjbartabar H, Mascarenhas S. Verbal empathy and explanation to encourage behaviour change intention. Journal on Multimodal User Interfaces. 2021;15(2):189-99.

11Del Piccolo L, Goss C. People-centred care: New research needs and methods in doctor-patient communication. Challenges in mental health. Epidemiology and Psychiatric Sciences. 2012;21(2):145-9.