Sanarai is a digital health company that arranges for the delivery of psychosocial and emotional supportive services to adults (aged ≥18 y) via telehealth technologies from licensed Spanish-speaking professionals from Latin America to Spanish-speaking adults located in the United States and other countries. These services are primarily provided direct-to-consumers and target Latino/x and Spanish-speaking populations residing in the United States with the goal of increasing access to high-quality, culturally congruent, and affordable subclinical mental health supportive services. The company services include: advice related to general mental health and wellness; life coaching and recommendations for setting personal goals; emotional support related to interpersonal relationships, sexuality, and gender; and emotional support related to feelings of anxiousness, stress, and depression. Sanarai addresses the subclinical population, emphasizing support for individuals dealing with challenges that may not meet the clinical threshold but still significantly impact their well-being. The focus of the services is to provide early intervention and preventive support. The company was founded in 2020.

Sanarai has developed a simple workflow to onboard users into its platform. First, users can browse the up-to-date provider database found on the Sanarai website to select the provider of their choice (step 1) and choose their desired appointment time (step 2). Then, users provide basic contact and payment information (step 3) to book the appointment, which is confirmed via email and conducted via Zoom (Zoom Communications, Inc; step 4). Users have the flexibility of changing their provider at any time in the process.

Sanarai users may sign up for an introductory 30-minute initial consultation or a full 50-minute session, either as an individual or as a couple. All sessions are conducted via live video calls on the video platform, Zoom. At the time of this evaluation, the initial consultation was priced at US $20.00 and served as an opportunity for the user to get to know their provider and their working style. The individual and couples’ sessions, US $49.00 and US $59.00, respectively, are focused on addressing the psychosocial and emotional wellness needs of the user. Sanarai’s providers are licensed mental health professionals from Latin America with at least a master’s degree and a minimum of 5 years of clinical experience. However, Sanarai notifies its users that despite the providers’ educational background and clinical expertise, Sanarai’s services are not considered psychiatric, psychological, or mental health therapy services as traditionally provided by a licensed mental health provider in the United States. Thus, Sanarai providers do not diagnose, prescribe medication, or accept health insurance. As needed, Sanarai will provide resources and referrals to users who need a higher level of care or are seeking services related to mental health diagnoses or medication management.

Sanarai has routinely collected quantitative and qualitative data as part of its ongoing services. Data included in this study were collected between August 2020 and September 2024. Quantitative data sources included three sources: (1) individual customers’ appointment data, (2) individual sessions payment data, and (3) customer satisfaction data. Specifically, all appointment and user data (1) were sourced directly from the booking platform, Acuity Scheduling, via automatic export. This system was consistently used throughout the entire evaluation period, ensuring uniformity. This appointment data included the date and time of each appointment, the type of appointment, the price and amount paid for each appointment, and whether the user was referred via an organizational partnership. Users’ first name was used to generate a gender variable consistent with Spanish-language name norms (ie, first names ending with the vowels “a” or “e” were coded as “Woman participants,” those ending with “o” were coded as “Man participants,” and a manual review was done to double check the coding). Payment data (2) was used to extract the user’s zip code, if available. These quantitative data served as the basis to analyze reach and adoption by examining trends in users’ engagement and session data. In addition, after each individual session, Sanarai automatically emailed users inviting them to participate in a brief web-based satisfaction survey (3) using a standardized Google Form, which included questions about satisfaction with services, willingness to recommend the services, and the Net Promoter Score measure. These data provided a snapshot of the acceptability of the service.

Quantitative data analysis was conducted using R software (R Foundation for Statistical Computing) [33] and included computing descriptive statistics for the number of users, the number and types of sessions attended, session engagement metrics, and the geographic distribution of users across the continental United States. Though this study was focused on a description of implementation outcomes and not hypothesis testing, exploratory analysis was conducted to examine usage patterns by gender and by time to schedule the first appointment.

Qualitative data were obtained from transcribed notes of telephone or video-based user interviews conducted by Sanarai staff (3 members of the executive team) between August 2020 and May 2024. The primary goal of these interviews was internal product improvement, not formal research, yet these interviews were structured and used a questionnaire based on the “Jobs To Be Done” framework. The “Jobs To Be Done” framework focused on understanding the motivations and decisions that drive a user to select a product or service to accomplish their goals or meet their needs (aka meet the requirements of the job they want done) [34]. The interviews focused on understanding the user experiences, motivations, and preferences for seeking mental health services with Sanarai. Participants were recruited via generalized outreach to the entire user base on a quarterly basis. Participation in these interviews was based on 100% self-selection, and everyone who expressed interest was interviewed. At times, the company prioritized interviewing “super users” (high session count) or users who had recently stopped seeking services in order to understand specific use patterns. Users who opted in to participate in these interviews were offered a discount of up to 15% on their next session. These qualitative data served as the basis to analyze acceptability.

We examined the user interview transcript and conducted reflexive thematic analysis (TA) [35,36] to examine users’ attitudes and experiences with seeking and accessing mental health services, including services provided by Sanarai. The reflexive TA was conducted by the first author, who began by reviewing the transcripts and independently coding the data. Codes were generated based on an inductive data-driven and semantically focused approach [36] with the goal of summarizing patterns in the data via themes that best represented the beliefs and experiences of the participants. A key concept in reflexive TA was that themes emerge at the intersection of the data and the researcher’s subjectivity and research skills [36]. Thus, to provide an extra layer of validation of the qualitative findings, the codes, themes, and narrative presentation of the qualitative results were reviewed and approved by the second and fourth authors, who had more familiarity with the interview process and qualitative interviews.

This study was reviewed by the University of California, Berkeley Institutional Review Board (IRB #2024-08-17735) and granted exempt status as it satisfies the federal and UC Berkeley requirements under category 70: research that involves no greater than minimal risk to subjects. The data used in this study were collected by Sanarai, as part of enrollment in its services, users provide broad consent to the potential use of their data for program evaluations and secondary analysis. Data were not fully anonymized, as the data sources included a unique Sanarai ID comprised of the email address the participant used to enroll in the services. To safeguard participant information, data were shared directly between Sanarai and the first author and stored under university-sponsored password-protected accounts. Data were accessed under a data transfer agreement between the University of California, Berkeley and Sanarai. Participants who completed the user interviews were offered a discount of up to 15% for their next session. No additional participant compensation was provided. The study’s conceptualization, analysis, and interpretations were conducted independently by the first author.

During the 4-year period between August 2020 and September 2024, Sanarai provided psychosocial and emotional wellness support services to a total of 6163 users. The majority of users were women (n=3662, 59.4%), and the remaining were men (n=2501, 40.6%). In terms of geographic region, payment data indicated that 65.7% (n=4049) of users made payments using a credit card obtained in the United States; 6.27% (n=387) made payments using a credit card obtained outside of the United States. For the remaining 28.02% (n=1727) of users, their geographic region was unknown as the payment data did not include country or zip code information. Within the US-based sample, 97.06% (n=3930) of the users had available zip code data, which were used to estimate participant locations within the United States (Figure 1). In sum, all 50 states of the United States, the District of Columbia, and Puerto Rico were represented in the sample, yet 55% of the users were concentrated in just 5 states: Texas (n=621, 15.34%), California (n=567, 14%), Florida (n=539, 13.31%), New York (n=246, 6.08%), and New Jersey (n=190, 4.69%). All other states represented 43.64% (n=1767) of the users, and 2.94% (n=119) were unknown. Sanarai users were reached via online advertisements, partnerships with community-based organizations, and word of mouth (recommendations by family and friends). During this evaluation period, Sanarai’s user base and number of active users grew an average of 47% quarter over quarter (Figure 2).

Among the 6163 users served by Sanarai, the first point of contact for 53.33% (n=3287) was an initial consultation, and the rest (n=2876, 46.67%) began with a full session. In terms of appointment availability, 43% (n=2650) of users scheduled their first appointment within 1 day or less, and an additional 30% (n=1849) scheduled within 2 to 3 days. Overall, the vast majority of users (n=5793, 94%) scheduled a first appointment within 7 days, and a minority scheduled their first appointment after more than 7 days (n=370, 6%).

Regarding engagement pattern and service use types, 36.26% (n=2235) of users attended 1 appointment only (either a consultation or 1 single full session), and 1.14% (n=70) had consultations without a single full session; whereas 62.6% (n=3858) of users engaged with Sanarai services at least two or more times via a combination of consultation and sessions or sessions alone (Table 1). Among this subsample of users with greater than or equal to 2 sessions of any type, we calculated the total number of sessions attended, days between sessions, and time between first and last session. Full descriptive statistics for these engagement metrics are reported in Table 2. In sum, users attended an average of 8.94 sessions, with an average of 12.4 days between sessions, and remained engaged for an average of 110 days. Finally, during the evaluation period, Sanarai provided a total of 36,858 appointments—including individual consultations (n=3563, 9.67%), individual sessions (n=31 905, 86.6%), couples sessions (n=1179, 3.2%), and couples initial consultations (n=211, 0.57%). This represented approximately 768 appointments per month.

To further contextualize engagement patterns, we conducted two exploratory analyses. First, we conducted an independent samples 2-tailed t test to examine whether the total number of sessions and the total number of days engaged differed by gender. The results indicated that there were no statistically significant differences in total number of sessions between women participants (mean 8.99, SD 12.75) and men participants (mean 8.86, SD 13.41; t_3338.6=0.29; 95% CI −0.72 to 0.97; P=.77). Similarly, we did not observe any statistically significant differences in the number of days engaged (women participants: mean 114.27, SD 169.89; men participants: mean 105.15, SD 167.57; t_3476.6=1.66; 95% CI –1.67 to 19.92; P=.10). Finally, we conducted a correlation between time to schedule first appointment and total number of sessions to examine if prompt services were associated with greater intervention engagement and found a very small and weak negative correlation (r=−0.038, 95% CI −0.063 to −0.013).

This study evaluated the reach, engagement, and acceptability of a telehealth Spanish-language psychosocial and emotional wellness service offered by a digital health company, Sanarai. The service delivery model focused on connecting users to Spanish-speaking licensed mental health providers from Mexico and Argentina to receive subclinical mental health supportive services via telehealth. The results of this mixed methods evaluation suggest that Sanarai services are accessible and acceptable as evidenced by the reach of the services to over 6000 users across the United States, an average duration of 9 sessions attended per user, and some preliminary indication of high satisfaction rates. Factors that may contribute to Sanarai’s model acceptability include providing prompt (next-day session availability), relatively affordable rates compared to market rates in the United States (US $49-$59 for individual and couples’ sessions), offering culturally and linguistically congruent mental health services for Latino/x adults, and having an accessible and easy-to-use technology platform.

A central goal of the Sanarai model of mental health support was to increase the availability of language-concordant mental health providers for Spanish-speaking adults. The geographic reach of Sanarai’s services is representative of the widespread need for professional mental health care services in the United States. According to the Health Resources and Services Administration, there is a significant shortage of mental health professionals at the national level, as only 26.4% of the mental health professional workforce needs were met as of March 31, 2025 [37]. According to the report, in the top 5 US states where Sanarai had the highest user enrollment, the percent of needs met were 15.6% (New York), 22.4% (California), 23.7% (Florida), 31.3% (Texas), and 52.7% (New Jersey) [37], indicating an ongoing significant need for additional mental health professionals. Further, between 2014 and 2019, there was a 17.8% decrease in facilities that offered mental health treatment in Spanish despite a 4.5% growth in the Latino/x population during the same time period [38]. The importance of having access to Spanish-speaking health care providers cannot be overstated, as current estimates suggest only 5% to 6% of providers identify as Latino/x and were able to provide Spanish-language services [7,8], and many Latino/x people preferred to receive health care services in Spanish, particularly when discussing emotional concerns [6,39,40].

In terms of availability, Sanarai users waited on average 2.87 days to meet with their provider. The availability of Sanarai’s providers is drastically different from the availability of psychologists in the United States. According to a 2023 national survey by the American Psychological Association, more than half of psychologists (56%) reported having no openings for new patients or having a waitlist of 3 months or more [41]. The risk of long wait times to receive services may result in a patient’s worsening mental health [42] and greater health care expenditures, or patients may lose interest in engaging in services despite having an ongoing need. In this study, we did not find a significant association between appointment waiting time and total engagement with services. Sanarai users in this study attended an average of 9 sessions. Comparatively, other studies have shown that Latino/x individuals attend an average of 5 sessions for remote telephone-based services [43] and 8 sessions for in-person mental health care [15]. Finally, women typically endorse more positive health-seeking attitudes for mental health issues than men [44], are more likely to report needing and accessing mental health services [45], and are more likely to engage with digital mental health interventions [24]; however, in this study, we did not find any statistically significant differences in session engagement or duration of treatment by gender, suggesting that both men and women accessed and engaged with Sanarai at similar rates. Examining additional demographic variables, such as age and educational background, can further help explain patterns in service use among diverse segments of the population.

The qualitative data provides a rich description of the various reasons why Sanarai users engaged with the services and helps contextualize the quantitative findings. Contrary to the quantitative data in which there was a more balanced breakdown of gender (60% women participants and 40% men participants), the respondents of the qualitative surveys were predominantly women (70%); thus, these results should be interpreted with caution due to the potential risk of bias and limited generalization. The respondents’ reasons for seeking services were varied in intensity and ranged from managing symptoms related to mental health concerns to addressing situational stressors and self-growth. Severity of symptoms has been associated with greater engagement with digital mental health interventions [9,24] and may partly explain the engagement rates observed in this study. Users noted a wide range of barriers to accessing in-person mental health services within their communities. Many of the issues raised were also well documented in the extant literature, including barriers due to language fluency, cultural differences between patient and provider, lack of access to low-cost mental health services, and perceived lower quality of mental health care [5,45,46]. For the participants in this study, these barriers may have been the precursor to engagement and acceptability of digital mental health services.

Acceptability of digital mental health services in general, and Sanarai’s services specifically, can be understood within the multifaceted framework of health care intervention acceptability [26,27]. Specifically, users endorsed ease of access, scheduling, technology navigation, and availability of providers (eg, low burden of engagement) as a significant facilitator to engaging with Sanarai. Similarly, the users perceived the services to be affordable and a good fit given their cultural values, goals, and language preference, and perceived the providers as trustworthy and helpful (ie, concurrent acceptability), which are all facilitators associated with increasing acceptability, engagement, and effectiveness of digital mental health interventions [24,26,27,39,40]. These findings provided evidence for the value of leveraging mental health providers from the Spanish-speaking countries to deliver mental health supportive services to Spanish-speaking adults in the United States. In addition, it is unclear how the acceptability of the service would impact clinical outcomes; thus, future research may include an outcomes-based evaluation or a randomized clinical trial design.

This study had several limitations. First, the data were primarily descriptive, based on users from one private telehealth company, and did not have a comparison group. These limitations limit generalizability, as it was possible that the sample included in this research was not representative of the broader Spanish-speaking populations. Also, due to the limited availability of demographic data collected via the appointment data, we were unable to examine the representativeness of the sample and how known factors such as income or health insurance status impacted users’ participation with Sanarai services. Similarly, at the time of this evaluation, Sanarai was beginning to collect clinical effectiveness data; thus, we were not able to assess the clinical impact of these online services on users’ mental health outcomes and how these outcomes are related to engagement and acceptability. This limitation remained an area of priority for future work. Regarding acceptability, though the user satisfaction survey was shared regularly with all users active in the service—less than 25% of the total sample participated in this survey—potentially limiting the generalizability of these findings to the entire sample and inflating positive findings as a result of self-selection bias. In addition, the results focused on acceptability were based on the qualitative data analysis, which included an overrepresentation of women relative to men and thus did not generalize. Similarly, the user interviews were conducted by company staff, and despite using a standardized protocol, it was possible that users responded with bias. Areas for future directions included collecting clinical outcomes data; increasing the collection of demographic data to facilitate greater exploration of reach, engagement, and acceptability patterns; increasing representativeness of samples; and increasing response rates to satisfaction surveys.

Overall, Sanarai’s model appears to be meeting a need for mental health services for Spanish-speaking Latino/x communities by delivering accessible, prompt, and linguistically and culturally congruent mental health supportive services.