107 Grip on Health intervention among lower socioeconomic position workers In the study about the development of the intervention (17), the Self Determination Theory was selected as a theory to enable lower SEP workers to actively identify and solve problems and may further clarify why both OHPs and workers perceived the intervention to be effective. This theory argues that by increasing autonomy, competence and relatedness, health related behaviors are more likely to be initiated and maintained and thereby motivation of workers to actively solve their problems is increased (31). The need for autonomy, competence and relatedness could all be identified in the findings of this study regarding mechanisms of impact. Autonomy may have been fulfilled, as both OHPs and participants described that this intervention made workers more aware of the problems they could intervene on, and that workers were in the lead to identify the most relevant problems and solutions, which could improve their feelings of self-control. Competence may have been fulfilled, as OHPs described that the intervention led to small and practical solutions, which in turn increases one’s belief in the ability to succeed (32). Finally, relatedness of workers may have been fulfilled by a supportive environment of OHPs or other stakeholders to solve their problems. Strengths and limitations A strength of this study is the use of a comprehensive framework to evaluate the implementation process, which resulted in detailed information about implementation of the Grip on Health intervention in practice. Although Grip on Health was developed using an intervention mapping protocol (17), this study provided additional information on the applicability and feasibility of this intervention in practice. Moreover, data was collected from both the perspective of OHPs and lower SEP workers, and a combination of quantitative and qualitative data collection was performed, increasing credibility of findings (33). The data from interviews helped to interpret the results of the checklists or to ensure that findings of the checklists are grounded in the experiences of OHPs and lower SEP workers about the intervention. A limitation of this study is that a large proportion of the data on lower SEP workers was collected through OHPs. OHPs may hold different views on the intervention than lower SEP workers themselves (34), affecting credibility and transferability of findings (33). However, the contextual factors affecting implementation of Grip on Health in this study were also found in other studies (9, 22), suggesting good transferability and confirmability of findings. Another limitation is that selection bias may have occurred. Lower SEP workers, that were interviewed in this study, all participated in the Grip on Health intervention and were mainly positive about the intervention. We failed to recruit lower SEP workers that did not participate in the intervention to obtain a more complete view of the experiences of lower SEP workers. This means that it is debatable whether data saturation took place for the qualitative data among lower SEP workers, affecting dependability of findings (33). This was not the case among OHPs, both those who delivered and those who did not deliver 4
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