ORIGINAL ARTICLE Pre-Implementation Strategies to Adapt and Implement a Veteran Peer Coaching Intervention to Improve Mental Health Treatment Engagement Among Rural Veterans Christopher J. Koenig, PhD; 1,2 Traci Abraham, PhD; 3,4 Kara A. Zamora, MA; 1 Coleen Hill, BA; 1 P. Adam Kelly, PhD, MBA; 5,6,7 Madeline Uddo, PhD; 5,6,8 Michelle Hamilton, PhD; 5,8 Jeffrey M. Pyne, MD; 3,4 & Karen H. Seal, MD, MPH 1,9,10 1 San Francisco Veterans Affairs Health Care System, San Francisco, California 2 Department of Communication Studies, San Francisco State University, San Francisco, California 3 Center for Mental Healthcare & Outcomes Research, Health Services Research and Development, Little Rock, Arkansas 4 Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas 5 Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana 6 South Central Mental Illness Research Education Clinical Center (MIRECC), Little Rock, Arkansas 7 General Internal Medicine & Geriatrics, Tulane University School of Medicine, New Orleans, Louisiana 8 Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, Louisiana 9 Department of General Internal Medicine, University of California-San Francisco, San Francisco, California 10 Department of Psychiatry, University of California-San Francisco, San Francisco, California Funding: This research was supported by CREATE award #12-083 from the United States Department of Veterans Affairs Health Services Research and Development. Acknowledgments: We would like to thank the veterans and VA clinic staff who took time out of their busy schedules to meet with us in order to discuss the study and how it might fit into their busy daily lives. This article does not reflect the official opinion of the Department of Veterans Affairs, and responsibility for the views expressed lies entirely with the listed authors. For further information, contact: Christopher J. Koenig, PhD, Department of Communication Studies, 1600 Holloway Avenue, San Francisco State University, San Francisco, CA 94132; e-mail: cjkoenig@sfsu.edu. doi: 10.1111/jrh.12201 Abstract Purpose: Telephone motivational coaching has been shown to increase ur- ban veteran mental health treatment initiation. However, no studies have tested telephone motivational coaching delivered by veteran peers to facili- tate mental health treatment initiation and engagement. This study describes pre-implementation strategies with 8 Veterans Affairs (VA) community-based outpatient clinics in the West and Mid-South United States to adapt and im- plement a multisite pragmatic randomized controlled trial of telephone peer motivational coaching for rural veterans. Methods: We used 2 pre-implementation strategies, Formative Evaluation (FE) research and Evidence-Based Quality Improvement (EBQI) meetings to adapt the intervention to stakeholders’ needs and cultural contexts. FE data were qualitative, semi-structured interviews with rural veterans and VA clinic staff. Results were rapidly analyzed and presented to stakeholders during EBQI meetings to optimize the intervention implementation. Findings: FE research results showed that VA clinic providers felt over- whelmed by veterans’ mental health needs and acknowledged limited mental health services at VA clinics. Rural veteran interviews indicated geographical, logistical, and cultural barriers to VA mental health treatment initiation and a preference for self-care to cope with mental health symptoms. EBQI meet- ings resulted in several intervention adaptations, including veteran study re- cruitment, peer veteran coach training, and an expanded definition of mental health care outcomes. Conclusions: As the VA moves to cultivate community partnerships in order to personalize and expand access to care for rural veterans, pre- implementation processes with engaged stakeholders, such as those described here, can help guide other researchers and clinicians to achieve proactive and veteran-centered health care services. Key words health services research, mental health initiation and en- gagement, pre-implementation research, qualitative research methods, rural veterans. The Journal of Rural Health 00 (2016) 1–11 c  2016 National Rural Health Association 1