**5. Conclusions**

Leadership is a critical to TWH system effectiveness in small business. In this qualitative study we aimed to integrate both health promoting leadership and safety leadership to begin to understand small business leadership practices that protect and promote employee health. The interviews demonstrate that small business leaders care about the health of their employees, but because of the perceived value to their business, not to employees or themselves. Thus, they may lack the knowledge and skills to be successful TWH leaders. The present study supports a need for continued TWH leadership research in a small business context, including mixed methods research to understand and quantify TWH leadership practices from the small business leader and employee perspectives, as well as the development and evaluation of TWH leadership development strategies.

**Author Contributions:** Each author contributed to this paper. Conceptualization: J.T., N.V.S., L.T., and L.S.N.; Methodology: J.T. and N.V.S.; Software: J.T. and N.V.S.; Validation: J.T. and N.V.S.; Formal analysis: J.T. and N.V.S.; Investigation: J.T., N.V.S., L.T., and L.S.N.; Resources: N.V.S., L.T., and L.S.N.; data Curation: J.T.; Writing—original draft preparation: J.T. and N.V.S.; Writing—review and editing: J.T., N.V.S., L.T., L.S.N.; Visualization: J.T. and N.V.S.; Supervision: N.V.S.; Project administration: J.T.; Funding acquisition: L.S.N., L.T., and N.V.S.

**Funding:** This study was funded by a Total Worker Health Center of Excellence Cooperative Agreement 1 U19 OH 011227-01, funded by the Centers for Disease Control and Prevention and the National Institute for Occupational Safety and Health. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, or the Department of Health and Human Services.

**Conflicts of Interest:** The authors declare no conflict of interest.
