**1. Introduction**

Chronic diseases remain the leading cause of death and disability in the United States, as well as the leading contributor to the nation's healthcare cost [1–3]. More than 150 million Americans are workers with most spending more than half of their waking time at work [4]. Maintaining a healthier workforce can lower direct costs to the business (e.g., insurance premiums and workers' compensation claims) as well as indirect costs (e.g., absenteeism, return on investment, and worker productivity) [5–9]. With changes in the workforce population, chronic health conditions have become a growing concern for employees and businesses [10]. Worksite health and wellness programs offer an important population health strategy to address the increase in chronic diseases [11–13].

While adoption of workplace health programs have increased in the U.S. in recent years, there is still variation in uptake by business size and industries [14–16]. Many workplaces also lack a comprehensive, integrated approach that addresses multiple risk factors and health conditions. Successful worksite health programs are tailored to their employee population, thus making it difficult to evaluate initiatives across multiple businesses. However, all successful programs should be built on a solid foundation. According to the Centers for Disease Control and Prevention (CDC) Workplace Health Model, this foundation requires a basic organizational governance infrastructure to administer and manage health promotion activities [17].

Organizational factors are important for other aspects of worker health, including worker safety and occupational injury and illness prevention [18]. Employers have many opportunities for promoting safety and occupational injury and illness prevention at the organizational level [19]. One example is the Total Worker Health® (TWH) framework, which involves organizational-level strategies aimed at integration of worksite injury prevention and health promotion activities [20]. TWH is defined as policies, programs, and practice that integrate protection from work-related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well-being [21].

While many organizational approaches exist to improve worker health and safety through workplace initiatives, there is a need to better understand the adoption of these initiatives among employers. Findings have the potential to yield useful information when developing public health policies and prevention activities for improving worker health, safety, and well-being. The primary aim of this study is to assess the implementation of workplace health governance and safety strategies among worksites in the largely rural State of Nebraska, over time and by industry sector. Secondary aims include describing employer perception of barriers related to implementing workplace health strategies and employee health issues that negatively impact business. Responses on the Nebraska Worksite Wellness Surveys from 2010, 2013, and 2016 were utilized for the study.
