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Characterizing Workplace Exposures in Vietnamese WomenWorking in California Nail SalonsThu Quach, PhD, Robert Gunier, MPH, Alisha Tran, Julie Von Behren, MPH, Phuong-An Doan-Billings, Kim-Dung Nguyen, Linda Okahara,Benjamin Yee-Bun Lui, MD, Mychi Nguyen, MD, Jessica Huynh, and Peggy Reynolds, PhD

Nail care services has been a booming industryover the past 2 decades. According to industryestimates, the United States currently hasmore than 58000 beauty salons and nearly350000 licensed nail technicians.1 California,in particular, experienced the largest expansionin this sector; the number of licensed nailtechnicians grew nearly 3-fold from 35500 in1987 to 114000 in 2007.2 The growth of thisservice sector was also accompanied by signifi-cant demographic shifts in this workforce, withthe proportion of Vietnamese nail techniciansincreasing from 10% in 1987 to 59% in 2002.3

The health and safety of workers in thisindustry drew public attention because ofconcerns about hazardous chemical ingredi-ents in personal care products. Nail technicianshandle solvents, glues, polishes, and otheragents on a daily basis, exposing them tonumerous chemicals, many of which areknown or suspected to cause cancer, allergies,and respiratory, neurologic, and reproductiveharm. Despite their heavy use, industrialchemicals in cosmetic products are largely un-regulated in the United States. Of the 10000chemicals used in personal care products,nearly 90% have not been assessed for safety.4

The striking emergence of the nail salonindustry, with a workforce composed largely ofVietnamese immigrant workers, combinedwith the lack of governmental regulation ofcompounds in cosmetics, underscores thecomplexity of worker health and safety issuesin this vulnerable population. A primary con-cern lies with the heavy use of volatile com-pounds in poorly ventilated salons. Solventssuch as toluene are used indiscriminately in thisprofession and pose a threat to workers be-cause they are linked to adverse neurologic andreproductive effects as well as endocrinedisruption.5,6 Occupational exposure studies innail salons are limited, and most are eitherdecades old or were not conducted in the UnitedStates.7---9 Thus, data to date have inadequately

captured the complexities of this burgeoningindustry, the changes in nail care services that arelikely to result in changes in chemical use, andthe changes in salon characteristics as the busi-ness expands.

In response to the growing concerns for thenail salon workforce, a community-researchpartnership between a cancer prevention re-search organization and a community healthcenter serving indigent Asian populations wasestablished to examine workplace exposureand prevalent health problems to informworker health and safety promotion efforts. Asan initial step to examining the relationshipbetween workplace exposures and adversehealth outcomes, we collected personal andarea measurements of selected solvents in nailsalons with Vietnamese workers. We intendedthis pilot project to provide descriptive infor-mation on solvent levels in nail salons andinhalation exposure among salon workers.Furthermore, we assessed the feasibility of

engaging Vietnamese salon owners andworkers, a group that has been historicallyunderstudied, for future research endeavors.This study is the first to focus on Vietnamesenail salon workers to collect personal and areaair monitoring data along with relevant salonand worker characteristics.

METHODS

We built this study on a developmentalcommunity-based participatory research pro-ject between a research organization and acommunity health center to characterize nailsalon worker chemical exposures and healthproblems.10 In addition, members of the Cali-fornia Healthy Nail Salon Collaborative, a largenetwork of community advocates, public healthexperts, health practitioners, and environmentalactivists, provided input into the development ofthe study instruments, protocols, recruitmentprocess, and interpretation of results.11 We also

Objectives. We engaged Vietnamese nail salon workers in a community-based

participatory research (CBPR) study to measure personal and area concentra-

tions of solvents in their workplace.

Methods. We measured average work-shift concentrations of toluene, ethyl

acetate, and isopropyl acetate among 80 workers from 20 salons using personal

air monitors. We also collected area samples from 3 salons using summa can-

isters.

Results. For personal measurements, the arithmetic mean was 0.53 parts per

million (range=0.02–5.50) for ethyl acetate, 0.04 parts per million (range=0.02–

0.15) for isopropyl acetate, and 0.15 parts per million (range=0.02–1.0) for tol-

uene. Area measurements were lower in comparison, but we detected notable

levels of methyl methacrylate, a compound long banned from nail products.

Predictors of solvent levels included different forms of ventilation and whether the

salon was located in an enclosed building.

Conclusions. Using a CBPR approach that engaged community members in

the research process contributed to the successful recruitment of salon workers.

Measured levels of toluene, methyl methacrylate, and total volatile organic

compounds were higher than recommended guidelines to prevent health

symptoms such as headaches, irritations, and breathing problems, which were

frequently reported in this workforce. (Am J Public Health. 2011;101:S271–S276.

doi:10.2105/AJPH.2010.300099)

RESEARCH AND PRACTICE

Supplement 1, 2011, Vol 101, No. S1 | American Journal of Public Health Quach et al. | Peer Reviewed | Research and Practice | S271

convened a community advisory committeecomposed of Vietnamese salon owners andworkers to provide guidance on recruitmentstrategies and survey development.

We asked workers who participated in thestudy to wear a small personal air-monitoringdevice during their work shift. Each workerparticipant contributed 2 to 3 measurementson nonconsecutive work days. Participantsalso responded to a questionnaire that wasadministered by a bicultural and bilingualinterviewer after each sampling event. In ad-dition, we collected area samples in a fewsalons using stationary monitors. The studyprotocol was reviewed and approved by theinstitutional review board of the Cancer Pre-vention Institute of California. Air monitoringand survey administration were conductedbetween November 2008 and June 2009.

Recruitment of Salons and Workers

We selected salons from different areas ofAlameda County, California, through conve-nience sampling. To our knowledge, no rostersof nail salons with Vietnamese workers exist;our selection of salons was informed by ourknowledge of and existing relationships withsalon workers and owners. During recruitment,our staff first approached salon owners toexplain the purpose of the study and what typeof information would be collected from thesalon and workers for the air-monitoring mea-surements. With permission from the owners,our staff then approached Vietnamese femaleworkers in that salon to recruit them into thestudy. We based selection of worker partici-pants in the salon on the workers present at thetime and, in some cases, recommendationsfrom salon owners.

The overall response rate for salons was50%. Of the 20 salons in which owners andworkers agreed to participate in the air-moni-toring study, 13 (65%) shops agreed on a firstvisit by our staff. Midway through the recruit-ment phase, the study was publicized in localpopular Vietnamese ethnic media, with aresulting increase in response rate from 30%to 75%.

Description of the Salons and Work

Performed

Our interview staff documented observa-tional data about select salon characteristics

during visits to collect the air-monitoring de-vices and administer the questionnaire. Staffmeasured the volume (cubic feet) of the salonusing an ultrasonic tape measure to obtain thesalon’s length, width, and height. Other obser-vational salon characteristics included whetherthe shop was in an enclosed building such as anindoor mall and the number of manicure andpedicure stations in the salon.

The staff administered the questionnaire atthe end of each work shift when the air-monitoring device was worn. The question-naire included information on the length oftime that the worker wore the device, includingany times when the worker may have takenit off to go outside the salon, the type andnumber of nail care services, the number ofcustomers in the salon, and the different typesand length of time that specific types of venti-lation were used (e.g., table fan, ventilationtable, roof fan, doors or windows open, andcentral ventilation system). In addition, wecollected information about the workers, in-cluding demographics, work history, self-reported health problems, and use of protectivework equipment (e.g., gloves and masks).

Personal and Area Air Monitoring

To obtain personal air measurements, wemeasured time-weighted average concentra-tions during the work shift for toluene, ethylacetate, and isopropyl acetate among workerparticipants using a passive organic vapormonitor (Organic Vapor Monitor 3500; 3M,St. Paul, Minnesota). The worker participantclipped the passive monitor on the collar of hershirt or coat to obtain samples near thebreathing zone. We measured the temperatureand relative humidity in the salon at thebeginning of each monitoring period. Eachparticipant wore the device for an entire workshift, with a minimum sampling time of 4 hours.We collected and sealed the air-monitoringdevices at the end of each sampling event. Theair-monitoring devices were stored at 4°C forup to 1 month until laboratory analysis.

Laboratory analysis was conducted by anAmerican Industrial Hygiene Association---accredited laboratory (Columbia AnalyticalServices, Monrovia, California), using solventdesorption followed by gas chromatographyand mass spectroscopy (GC---MS) to determinethe mass collected on the charcoal absorbent.12

Quality assurance procedures included field andsolvent blanks to check for contamination, regu-lar calibration with certified standards, and du-plicate samples to determine measurementvariability. We calculated personal air concen-trations using the mass absorbed, sampling time,and diffusion coefficient for each compound. Themethod reporting limits for a sample collectedover a typical sampling time of 360 minuteswere 0.03 parts per million for toluene, ethylacetate, and isopropyl acetate.

In addition to personal air monitoring, wealso conducted area air monitoring in a few nailsalons to quantify air concentrations for a morecomprehensive set of volatile organic com-pounds. We collected area samples using 6-liter summa canisters in 3 randomly selectednail salons at which we had previously con-ducted personal air measurements. The summacanisters were placed near manicure or pedi-cure stations, and we sampled using a flow rateof 1 liter per hour for 6 hours at each salon.The canisters were analyzed by GC---MS atthe same laboratory.13 The method reportinglimits for toluene and ethyl acetate were 0.002parts per million.

Data Analysis

We calculated standard descriptive statisticsfor the questionnaire and air-monitoring data,including mean, median, proportions, standarddeviation, and range. Because personal airmeasurements were not normally distributed,we used nonparametric methods for statisticalcomparisons. We calculated Spearman rankcorrelation coefficients to examine continuousvariables and used the Wilcoxon rank-sum testfor categorical comparisons. We did not con-duct categorical comparisons for isopropylacetate because the levels were always at ornear the method reporting limit. We set thestatistical significance level to .05 and per-formed all analyses using SAS Version 9.1 (SASInstitute Inc., Cary, North Carolina).14

RESULTS

We collected data from 80 Vietnamesefemale nail salon workers from 20 differentnail salons. Each nail salon worker had 2 to 3measurements (air monitoring and question-naire completion), for a total of 167 measure-ments. Characteristics of the salons and worker


S272 | Research and Practice | Peer Reviewed | Quach et al. American Journal of Public Health | Supplement 1, 2011, Vol 101, No. S1

participants are shown in Table 1. Each salonhad on average 4 worker participants and 8personal air measurements. Half of the salonsthat participated were in the city of Oakland.Salons ranged, an order of magnitude in size,from approximately 127 to more than 1300square feet, with a mean of 512 square feet. Six

salons (30%) were located in enclosed build-ings, and only 1 salon also offered hair careservices. The mean worker age was 41 yearsand ranged from 21 to 67 years. On average,participants had worked in the nail salon sectorfor 8 years. One participant started workingas early as 13 years old. Workers typically

worked 35 hours per week, which, however,often included long (>8 hours) days. Whenasked whether workers had experienced cer-tain health symptoms such as irritations, head-aches, nausea, and breathing problems, ap-proximately one third (31.3%) responded thatthey had experienced at least 1 of these symp-toms after entering this workforce (Table 2).Irritations of the nose, throat, lungs, skin, andeyes were the most common symptomsreported (26.5%).

Measured personal concentrations of the 3compounds were moderately correlated, withSpearman correlation coefficients between0.21 and 0.55. Temperature was weakly cor-related with toluene and isopropyl acetatelevels. Sample time in minutes or percentageof relative humidity had no relationship withmeasured personal concentrations for any ofthe compounds.

Distributions of personal and stationary air-monitoring concentrations are shown in Table3. For personal air measurements, the arith-metic mean for ethyl acetate was 0.53 parts permillion (range=0.02---5.50); for isopropyl ace-tate, 0.04 parts per million (range=0.02---0.15); and for toluene, 0.15 parts per million(range=0.02---1.0). In comparison, area mea-surements were lower, with an arithmetic meanof 0.09 parts per million (range=0.02---0.15)for ethyl acetate and 0.04 parts per million(range=0.01---0.06) for toluene. Area moni-toring also detected other volatile compounds,including methyl methacrylate in all 3 salons,with the highest level at 1.3 parts per million.

Results from our categorical analysesshowed that salons using table ventilators hadsignificantly lower measured personal levels oftoluene and ethyl acetate (Table 4). Salons thatwere in an enclosed building had higher mea-sured levels of both compounds. Salons usingother forms of ventilation also had lowermeasured personal levels, including openingdoors for toluene and the use of table or rooffans for ethyl acetate. However, worker par-ticipants who reported use of a central venti-lation system had higher personal levels ofethyl acetate than those who did not. Workerswho performed pedicures were more likely tohave higher measured levels of ethyl acetate.We also found that those who performed silknails and acrylic nails had lower personal levelsof toluene and ethyl acetate, suggesting that

TABLE 1—Descriptive Characteristics of Nail Salon Shops and Female Vietnamese

Nail Salon Workers: Alameda County, CA, 2008–2009

Characteristics Mean (Median; Range) or No. (%)

Salons

Nail salons (n = 20)

Volume (cubic ft) 5882 (4754; 1158–14 853)

Area (square ft) 512 (453; 127–1338)

No. of workers measured in salons (n = 80) 4 (4; 1–8)

No. of measurements taken in salons (n = 167) 8.35 (8; 2–16)

Nail salon participants (n = 80)

Age, y, at survey 41.3 (41; 21–67)

Age, y, at hire 33.3 (32; 13–59)

No. of years worked as nail technician 8 (7; 0.5–22)

No. of work hours per week 35.4 (40; 20–60)

Salon workers

Birthplace

United States 0 (0)

Vietnam 80 (100)

Language spoken at home

English 0 (0)

Vietnamese 80 (100)

Decade began working as nail techniciana

1970–1979 3 (3.8)

1980–1989 20 (25.3)

1990–1999 31 (39.2)

2000–2008 25 (31.6)

Manicure tables

< 5 9 (45)

‡ 5 11 (55)

Pedicure stations

< 5 14 (70)

‡ 5 6 (30)

Hair stations

None 19 (95)

‡ 1 1 (5)

Geographic location

Alameda 2 (10)

Oakland 10 (50)

Hayward 2 (10)

Other area 6 (30)

aMissing n = 1.



products used for these services may notcontain those compounds or contain lowerlevels.

DISCUSSION

The complexities of this largely immigrantworkforce, characterized by chronic exposureto several different compounds, and the lack ofgovernmental oversight in chemical regulationin cosmetics and worker health surveillance,underscore the challenges but importance ofevaluating exposures in this hard-to-reachpopulation. By applying a community-based

participatory research approach that engagedcommunity advocates and members in ourresearch process, we were successful inrecruiting participants from this vulnerablepopulation and in beginning to understandsome of the hazards they face in their work-place.

Measured personal concentrations in thisstudy were similar to personal measurementsfrom a recent study in California for toluene,15

higher than those measured in Europe for bothtoluene and ethyl acetate,9,16 but lower thantoluene levels measured in the United States 20years ago.8 Personal air-monitoring levels werehigher than stationary air-monitoring levels.Stationary monitors are sensitive to place-ment in the salon, and personal air monitorsplaced on the shirt collar of the worker arecloser to the source and better reflect workerexposure. Previous studies using stationarymonitors may have underestimated workerexposures, even when stationary monitorswere placed close to the worker’s breathingzone.9,16

All measured values were much less than theoccupational limits set by the California Di-vision of Occupational Safety and Health.17

However, the average measured level of toluenefrom personal air monitoring was higher than theCalifornia Environmental Protection Agency’srecommended ambient air levels of 0.08 partsper million.18 In 1974, the Food and DrugAdministration identified methyl methacrylate asa hazardous substance and banned its use in

adhesives for cosmetic nail products.19 Yet, in ourstudy the average measured level of methylmethacrylate was 0.54 parts per million, which ismore than 3 times higher than the US Environ-mental Protection Agency’s recommended am-bient air levels of 0.17 parts per million.20

Moreover, the levels of total volatile organiccompounds measured using area samples weremuch higher than recommended guidelines(<0.2 mg/m3) in indoor air for nonindustrialworkers and may explain some of the healthsymptoms reported by workers in this study.21---23

Although concentrations from area sampleswere less than those from personal samples, theconcentration of total volatile organic com-pounds from our area samples were in the range(3---25 mg/m3) at which discomfort is expectedand complaints of health symptoms, includingheadaches and irritations of the eyes, nose, andthroat, are common.22

When asked whether they experienced se-lect acute health symptoms after they beganworking in the nail care industry, one third ofour study participants responded positively.The highest prevalence was for irritations ofthe eyes, nose, throat, and skin, with morethan one quarter reporting experiencing suchsymptoms. In our previous survey of 201Vietnamese nail salon workers in AlamedaCounty, California, we found that 47% ofworkers reported health symptoms potentiallyrelated to solvent exposure.10 Yet, despite thehigh prevalence in both studies, we suspectthat this figure is still an underestimate of the

TABLE 2—Health Symptoms

Experienced by Female Vietnamese

Nail Salon Workers (n=80) Since

Performing Nail Care Services:

Alameda County, CA, 2008–2009

Health Symptoms No. (%)

Nose, throat, lung, skin, or eye irritation

Yes 21 (26.3)

No 59 (73.8)

Headaches

Yes 1 (1.3)

No 79 (98.8)

Nausea

Yes 4 (5.0)

No 76 (95.0)

Increased pulse rate

Yes 1 (1.3)

No 79 (98.8)

Confusion

Yes 2 (2.5)

No 78 (97.5)

Coughinga

Yes 4 (5.1)

No 75 (94.9)

Shortness of breath

Yes 7 (8.8)

No 73 (91.3)

Chest tightness

Yes 2 (2.5)

No 78 (78.0)

Any listed health symptoms

Yes 25 (31.3)

No 55 (68.8)

aMissing n = 1.

TABLE 3—Distribution of Personal and Area Monitoring Solvent Concentrations Among

Female Vietnamese Nail Salon Workers: Alameda County, CA, 2008–2009

Solvents No. of Salons No. of Measurements Mean 6SD (Range), ppm

Personal air monitoring

Ethyl acetate 20 167 0.53 60.71 (0.02–5.50)

Isopropyl acetate 20 167 0.04 60.02 (0.02–0.15)

Toluene 20 167 0.15 60.15 (0.02–1.0)

Stationary air monitoring

Acetone 3 3 3.10 63.20 (0.31–6.60)

Butyl acetate 3 3 0.03 60.02 (0.01–0.06)

Ethyl acetate 3 3 0.09 60.06 (0.02–0.15)

Isopropyl alcohol 3 3 0.82 61.03 (0.06–2.0)

Methyl methacrylate 3 3 0.54 60.66 (0.12–1.30)

Toluene 3 3 0.04 60.03 (0.01–0.06)



overall prevalence of health problems in thisworkforce because many workers have likelyalready left the workforce because of problem-atic health symptoms.

Nail salon workers and owners have a pre-vailing distrust of regulatory agencies becausemost of their interactions have focused onpenalizing workers and owners for violations of

standards in the workplace. Workers oftencomplain that they do not always understandwhy they are being cited.24 Thus, we initiallyencountered some challenges in engagingtheir participation in our research study.However, the partnership with a well-knowncommunity health center that had a longhistory of serving this population helped toaddress some of the challenges and to allevi-ate some of the perceived threat to workers’job security in participating in a researchproject of this nature. Furthermore, our use ofethnic media helped to inform workers of thepurpose of our study and served to enhancestudy participation.

We applied a right-to-know principle inwhich we communicated results to study par-ticipants to inform them of their exposures andto help promote future efforts to reduce theirworkplace exposure. After obtaining air-moni-toring results, we communicated grouped re-sults to worker participants and salon ownersand made recommendations on how theycould lower their exposures. We reportedgrouped results rather than individual resultsto safeguard individuals and salon owners fromany liability.

As a preliminary exploration, our study hadsome limitations worth noting. The smallnumber of participating salons and salonworkers and convenience sampling may haveresulted in a study population that was notrepresentative of all nail salons and workers inCalifornia or the United States. We focused onairborne exposures to solvents and measuredonly a few compounds, although several othercompounds may also be of high concern inthis workforce. We did not address skin ab-sorption, which may be an important route ofexposure to solvents and could also contributeto the health problems reported in our study.Our questions about health symptoms werebrief and did not include questions aboutchronic health problems. Thus, we could notassess the type and extent of health problemsthat may be associated with chronic exposuresto these compounds and the synergistic effectsfrom the numerous compounds handled byworkers. Overall, we intended this study toprovide a descriptive overview of inhalationexposures, which are of high concern, andprovide some insight into the feasibility ofrecruiting Vietnamese immigrant workers into

TABLE 4—Univariate Analysis of Personal Monitoring Concentrations and Categorical

Variables Among Female Vietnamese Nail Salon Workers: Alameda County, CA, 2008–2009

Toluene Ethyl Acetate

Variable and Categories Proportions, % Mean (SD), ppm P Mean (SD), ppm P

Doors open in salon < .001 .98

Yes 73 0.13 (0.13) 0.59 (0.81)

No 27 0.20 (0.18) 0.39 (0.32)

Windows open in salon .35 .61

Yes 10 0.14 (0.07) 0.14 (0.07)

No 90 0.15 (0.16) 0.52 (0.72)

Table vent used by worker < .001 < .001

Yes 8 0.03 (0.01) 0.14 (0.08)

No 92 0.16 (0.15) 0.57 (0.73)

Roof fan used in salon .77 .03

Yes 4 0.10 (0.05) 0.18 (0.05)

No 96 0.15 (0.15) 0.54 (0.72)

Table fan used by worker .79 < .001

Yes 92 0.15 (0.16) 0.40 (0.38)

No 8 0.12 (0.06) 2.05 (1.57)

Central ventilation system used in salon .07 < .001

Yes 28 0.17 (0.17) 0.98 (1.15)

No 72 0.14 (0.14) 0.35 (0.29)

Waxing performed by worker .44 .46

Yes 21 0.19 (0.20) 0.43 (0.51)

No 79 0.14 (0.13) 0.56 (0.76)

Silk nails performed by worker .005 .01

Yes 10 0.08 (0.07) 0.28 (0.33)

No 90 0.16 (0.15) 0.56 (0.74)

Acrylic nails performed by worker .68 .02

Yes 78 0.16 (0.16) 0.41 (0.40)

No 22 0.12 (0.08) 0.98 (1.25)

Pedicure performed by worker .46 .03

Yes 77 0.15 (0.16) 0.60 (0.79)

No 23 0.15 (0.12) 0.30 (0.22)

Manicure performed by worker .09 .40

Yes 72 0.14 (0.15) 0.59 (0.82)

No 28 0.17 (0.15) 0.37 (0.29)

Salon in enclosed building structure .02 .003

Yes 26 0.18 (0.17) 0.97 (1.18)

No 74 0.14 (0.14) 0.37 (0.33)

Gas station near salon .23 .27

Yes 56 0.17 (0.18) 0.62 (0.90)

No 44 0.12 (0.08) 0.42 (0.33)

Note. Univariate analyses performed using the Wilcoxon rank-sum test.



research studies that can help inform futuretargeted outreach efforts.

Future analyses will include the use ofmixed-effects models to account for correlationbetween measurements taken within the sameworker over time and between workers inthe same nail salon. Ultimately, this informationcan inform future research efforts, such asa cohort study on chronic health effects anda randomized intervention trial to evaluatethe effectiveness of training both nail salonworkers and owners in ways to reduce work-place chemical exposures.

Our study highlighted the importance ofidentifying appropriate recruitment and moni-toring strategies to characterize workforce ex-posures in this immigrant population, and itcould not have been accomplished withoutactive collaboration between the research andcommunity partners. Our study findings high-light, the need to go beyond the traditionalapproach of comparing measured values withexisting occupational exposure limits, whichwere set decades ago and do not take intoaccount changes in the industry. These stan-dards are also based on serious health out-comes (e.g., death or cancer) and do notaddress other health symptoms that may beearly warning signs of more serious healthproblems to come. Our findings underscore theneed for more attention to preventive publichealth strategies for this workforce. Recom-mendations to promote worker health andsafety include policy changes to update occu-pational exposure limits that take into accountvarious chronic health conditions, better regu-latory oversight of chemicals in cosmeticproducts, and more research focused on thehealth of understudied and vulnerable workerpopulations. j

About the AuthorsThu Quach, Robert Gunier, Julie Von Behren, and PeggyReynolds, are with the Cancer Prevention Institute ofCalifornia, Berkeley. Alisha Tran, Phuong-An Doan-Billings, Kim-Dung Nguyen, Linda Okahara, BenjaminYee-Bun Lui, and Mychi Nguyen are with Asian HealthServices, Oakland, CA. At the time of the study JessicaHuynh was with the University of California, Berkeley.

Correspondence should be sent to Thu Quach, PhD,MPH, Cancer Prevention Institute of California, 2001Center Street, Suite 700, Berkeley, CA 94704 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the ‘‘Reprints/Eprints’’ link.

This article was accepted December 2, 2010.

ContributorsT. Quach conceptualized and supervised the study,conducted some of the data analysis, and led the writingof the article. R. Gunier and J. Von Behren conducted thedata management and data analysis. A. Tran collectedall the data and helped in the results interpretation andcommunication. P. A. Doan-Billings, K. D. Nguyen, andL. Okahara provided significant input in the interpreta-tion of the results and the writing of the article. Giventheir knowledge of the workforce members. B. Y.-B. Luiand M. Nguyen provided critical input in the resultsinterpretation. J. Huynh entered the data and assisted inanalysis and results interpretation. P. Reynolds, who wasthe principal investigator of the study, provided overallscientific direction for the project, including survey de-velopment, data collection, data analysis, and resultsinterpretation. All authors contributed to the writing ofthe article.

AcknowledgmentsThis work was supported by the California Breast CancerResearch Program (grant 13BB-3400).

We thank members of the California Healthy NailSalon Collaborative for their input on the study.

Human Participant ProtectionThis study was reviewed and approved by institutionalreview board of the Cancer Prevention Institute ofCalifornia.

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23. Njelsen GD, Hansen LF, Wolkoff P. Chemical andbiological evaluation of building material emissions: II.Approaches for setting indoor air standards or guidelinesfor chemicals. Indoor Air. 1997;7(1):17---32.

24. Quach T, Mendiratta A, Fu L, et al. Framinga proactive research agenda to advance worker health andsafety in the nail salon and cosmetology communities.California Health Nail Salon Collaborative Web site.Available at: http://www.cahealthynailsalons.org/wp-content/uploads/2010/07/Framing_A_Research_Agenda.pdf. Published 2010. Accessed July 29, 2010.



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pchp.press.jhu.edu © 2012 The Johns Hopkins University Press

Policy and Practice

Developing a Proactive Research Agenda to Advance Nail Salon Worker Health, Safety, and Rights

Thu Quach, PhD, MPH1,2,3,4, Julia Liou, MPH1,2, Lisa Fu, MPH1, Anuja Mendiratta, MES1, My Tong, MPH1,3, Peggy Reynolds, PhD1,3,4

(1) California Healthy Nail Salon Collaborative; (2) Asian Health Services; (3) Cancer Prevention Institute of California; (4) Stanford University School of Medicine

Submitted 14 February 2011, revised 11 August 2011, accepted 26 August 2011.

Nail care services have become a popular trend among women, teenagers, and even children. Numerous nail salon shops have emerged across the United

States in response to the growing consumer demand. In recent decades, the cosmetology industry has become one of the fastest growing professions, with an estimated 58,000 beauty salons and 350,000 nail technicians in the United States.1 California has experienced the largest expansion, where the number of licensed nail technicians has grown to over 114,000 as of 2007.2 Furthermore, the workforce has undergone major demographic changes, with the proportion of Vietnamese workers increasing from 10% in 1987 to 59% in 2002.3

The nail salon business has become an economic corner-stone for Vietnamese immigrants. Many are drawn to this sec-tor because they can start their own small business or become

AbstractThe Problem: Nail salons represent a burgeoning industry with Vietnamese immigrant workers making up the majority. Workers routinely handle cosmetic products containing hazardous compounds, with implications for their health.

Purpose of Article: This paper describes how a collaborative of multiple organizations and community members collec-tively developed a proactive research agenda for salon worker health, safety, and rights during a pivotal multistakeholder convening, and advanced on such recommendations, includ-ing creating groundbreaking policy changes.

Key Points: Key recommendations included (1) creating a multidisciplinary research advisory committee, (2) conducting research on workplace exposures and long-term health

impacts, (3) advocating for better governmental oversight of product manufacturers, and (4) identifying safer product alternatives via green chemistry, albeit with cost consider-ations to salon businesses.

Conclusion: The participation of diverse stakeholders in the discussions allowed for cross-dialogue on a complex issue, helped to align different stakeholders as allies, and identified critical resources to addressing research gaps.

Keywords

Nail salon, green chemistry, occupational exposures, cosmetic products, worker health

independent contractors. The required training to become a licensed professional is short and inexpensive. Moreover, the work does not require English proficiency. However, workers make a number of health compromises working in this sec-tor. Nail salon workers routinely handle cosmetic products containing numerous hazardous compounds, including carcinogens, reproductive and developmental toxicants, respiratory irritants, and allergens. Chemicals in personal care products are virtually unregulated in the United States. Manufacturers are not required to conduct premarket testing for safety, and government regulators have no authority to require manufacturers to disclose product ingredients.4,5 Of the 10,000 chemicals used in personal care products, includ-ing nail products, only 10% have been assessed for safety.6 Recent studies have shown that salon workers are exposed to

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Progress in Community Health Partnerships: Research, Education, and Action Spring 2012 • vol 6.1

a number of these compounds, ranging from volatile solvents like toluene7 to semivolatile compounds like phthalates.8 Workers face exposures to hazardous chemicals, poor ventila-tion in salons, lagging regulatory standards and enforcement, language barriers, and limited health care access. Together, these issues have produced a strong need for a unified voice to address and ameliorate these concerns.

Community EngAgEmEntAsian Health Services (AHS) is a community health center

in Oakland Chinatown that provides medical services and health education/outreach to the underserved Asian American population in Alameda County, California. Over the last decade, AHS clinicians and community health workers have observed that many of AHS’s Vietnamese patients and local community members who work in nail salons presented with acute health symptoms (e.g., skin irritations, headaches, and muscle pain) and voiced concerns about workplace hazards. In response, AHS began to engage other organizations to collectively address health disparities in this worker popula-tion, including developing a community research partnership with the Cancer Prevention Institute of California to conduct research to better understand health issues,7,9,10 collaborations with other community agencies such as Asian Law Caucus to conduct health outreach, and partnerships with national allies like the National Asian Pacific American Women’s Forum on policy advocacy.

These activities coincided with significant public policy debates around the safety of chemical ingredients in cosmetic products—debates primarily driven by consumer concerns with little attention to workers despite their disproportionate exposure to the chemicals in nail care products. In response to the growing health concerns for nail salon workers and owners, the California Healthy Nail Salon Collaborative (Collaborative) was co-founded in 2005. Coordinated by AHS and composed of public health and environmental advocates (e.g., Breast Cancer Action, The Breast Cancer Fund, and Women’s Voices for the Earth), community-based organizations (e.g., Asian Advocacy Project of Community Action Marin), salon workers and own-ers (e.g., The United Hair and Nail Associations), and represen-tatives from government agencies (e.g., California Department of Public Health and U.S. Environmental Protection Agency, U.S. E.P.A.), the Collaborative was established to proactively

address health and safety concerns facing the salon worker community through an integrated approach using research, policy advocacy, and outreach/education strategies.11 The Collaborative makes decisions by consensus and is governed by a Steering Committee composed of representative members. The Collaborative conducts its work through three primary subcommittees—Research, Policy Advocacy, and Community Outreach/Engagement. As one of the first collaborative, multi-disciplinary, multi-issue efforts to address the health and safety needs of an underserved workforce that is predominantly Asian American, the Collaborative has been nationally recognized by the U.S. E.P.A., funders and advocacy organizations for its work toward social equity.

The purpose of this paper is to describe how a collaborative of multiple organizations and community members collec-tively developed a proactive research agenda for salon worker health, safety and rights during a pivotal multi-stakeholder convening, and advanced on such recommendations, includ-ing creating groundbreaking policy changes. The objective of the paper is to discuss the process for engaging multiple stakeholders and its impact, particularly on policy changes, to inform advocacy work with similar populations.

multistAKEholdEr CollAborAtionsThe Collaborative recognized that, although policy and

public health practice should be supported by systematic, empirical evidence, there was a dearth of research on nail salon workers and their workplace hazards. Thus, the Collaborative along with its national counterpart, the National Healthy Nail Salon Alliance (Alliance),12 hosted a multi-stakeholder research convening with the intention to develop a proactive research agenda to effect social change. Based on the community-based participatory research concept, which “begins with a research topic of importance to the community, has the aim of combin-ing knowledge with action and achieving social change to improve health outcomes and eliminate health disparities,”13,14 the convening provided an opportunity to bring together different representations of community, from workforce members to community advocates, along with other stake-holders (e.g., government agencies, cosmetic manufacturers and researchers) to collectively develop recommendations to advance a research agenda that would ultimately promote needed social change. A critical component of the discus-

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Quach et al. Advancing Nail Salon Worker Health, Safety, and Rights

Table 1. Descriptive Information on the Research Convening 2009 Attendees: General Occupation Categories and Geographic Regions (n = 121)

Geographic Regions

General Occupation CategoriesNorthern

California (%)Southern

California (%)Other West Coast

States (%)East Coast States (%) Total

Academic (e.g., professor) 3 (2) 0 (0) 0 (0) 2 (2) 5 (4)

Cosmetic industry 2 (2) 0 (0) 1 (1) 0 (0) 3 (2)

Environmental/health/labor advocates 32 (26) 4 (3) 1 (1) 7 (6) 44 (36)

Funder 2 (2) 0 (0) 0 (0) 0 (0) 2 (2)

Government 15 (12) 4 (3) 3 (2) 2 (2) 24 (20)

Hair salon worker/owner 2 (2) 0 (0) 0 (0) 0 (0) 2 (2)

Nail salon worker/owner 20 (17) 0 (0) 0 (0) 0 (0) 20 (17)

Media 1 (1) 0 (0) 0 (0) 0 (0) 1 (1)

Researcher 9 (7) 0 (0) 0 (0) 2 (2) 11 (9)

Student 4 (3) 0 (0) 0 (0) 0 (0) 4 (3)

Total 95 (79) 8 (7) 5 (4) 13 (11) 121

sion was focused on research that informs policy advocacy directed at current regulatory and legal inadequacies, and ways in which community members could play a role in the policy change process.15,16 This includes but is not limited to advocat-ing for legislation requiring greater government oversight of cosmetic manufacturers, such as requiring premarket testing and full disclosure of product ingredients.

Held in Oakland, California, on April 27 and 28, 2009, the convening attracted more than 120 researchers; envi-ronmental, public health, and labor advocates; nail salon workers and owners; cosmetologists; cosmetic industry members; government agency representatives; and public health experts (Table 1). Details of the convening were sum-marized in a publicly available report (available from: http://www.cahealthynailsalons.org/wpcontent/uploads/2010/07/Framing_A_Research_Agenda.pdf).17 To encourage participa-tion of limited English-speaking salon workforce attendees, simultaneous Vietnamese language interpretation was pro-vided. As a result, salon workers and owners were able to express their ideas, concerns, and needs in their own language. Their voices and input, integrated into the presentations and discussions, grounded the meeting in the lived experiences and wisdom of this workforce.

In addition to the research convening, the Collaborative convened quarterly worker and owner meetings in Southern and Northern California to provide an additional mechanism by which community concerns and needs could be voiced. Discus-sions on a number of issues that arose from the research con-vening were continued at these targeted meetings. Further more, the Colla borative hosted a follow-up meeting with cos metic manu facturers shortly thereafter to address issues that arose from the convening and explore potential collaborations.

KEy rECommEndAtionsA number of key themes emerged from the collective

discussions at the convening as well as in follow-up discus-sions. Table 2 lists a number of related recommendations. From the tenor of the different discussions, it was clear that this occupational issue was very complex and that concerns were not restricted to the health arena, but included issues of worker’s rights and livelihood. The themes also emphasized that health research does not exist in a vacuum, but must also be contextualized within the everyday concerns of the workers in the industry.

Given the complexities of this workforce and the research gaps, it was recommended that the Collaborative establish

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Table 2. List of Recommendations from the Research Convening 2009 by Topic Categories

Topic Categories

Convening Recommendations

Exposure assessment and reduction

Examine different resources for informing exposure assessment, including the Skin Deep database and the California Safe Cosmetics Program.

Advocate for additional ambient air quality studies, both within salons as well as in the immediate vicinity outside of salons.

Consider how to address important barriers to advancing green chemistry: (1) information data gaps; (2) safety and accountability gaps; and (3) technology gaps.

Advocate for product reformulation and the development of safer “green” salon products by manufacturers that are safer, affordable and retain high functionality.

Advocate for improved ventilation in salons.

Incentivize salon product manufacturers to create safer products through financial benefits and publicity.

Incentivize beauty salons that follow “greener” practices (e.g., use of products with less toxic ingredients).

Health effects and surveillance

Compile a comprehensive list of research on the health impact of salon products targeted to particular ethnic groups.

Develop a health surveillance program for tracking health problems in the cosmetology workforce, including hair and nail care professionals.

Advocate for more affordable and accessible health care for salon workers.

Explore opportunities for developing free medical testing for workers.

Promote research that investigates the cumulative and synergetic impacts of occupational exposure to multiple chemical compounds through multiple routes of exposure in salons over significant periods of time.

Advocate for further research on adverse reproductive health outcomes (e.g., miscarriages, low birth weight, and infertility) related to occupational exposures.

Effective education and outreach

Ensure that the material safety and data sheets (MSDS) of salon products are easier to read and understand from a layperson’s perspective and translated into multiple languages.

Advocate for better, more detailed labeling of salon products so workers will know what compounds they contain and the corresponding safety precautions to take.

Develop and implement culturally and linguistically appropriate health and outreach interventions that focus on workplace chemical exposure reduction (including choosing safer alternatives, ventilation, best practices – proper storage and handling).

Evaluate whether Vietnamese beauty schools include the appropriate safety training in their curriculum.

Engage in social research on attitudes of workers to engage in research (e.g., willingness to discuss their occupational and health concerns, etc.).

Conduct a survey of consumer knowledge and attitudes regarding health and safety issues in salons.

Worker rights and empowerment

Advocate for better enforcement of existing regulatory standards and worker rights (e.g., minimum wage, mandated breaks, etc.).

Research models and programs for worker empowerment and engagement so that salon workers increasingly advocate on their own behalf.

Promote more comprehensive education outreach programs that include labor and worker rights issues, such as reviewing the (mis)classification of nail salon workers as independent contractors, which results in workers not being eligible for health benefits.

Push for changes and greater transparency in how salon inspections are conducted by regulatory agencies, with regards to regulations, fines, process, worker/owner responsibilities, dispute resolution, etc.

Policy advocacy

Push for federal chemical policy reform like the European Union’s REACH program.

Advocate for increased authority for the U.S. Food and Drug Administration to regulate cosmetic ingredients.

Introduce legislations aimed at improving salon worker health and safety at the state and national level.

Work to secure the passage of the Federal Safe Cosmetics Act to prevent the use of toxic chemicals in cosmetic products and in salons.

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a multidisciplinary research advisory committee to provide technical guidance on future research efforts. This body would provide critical knowledge resource to address research gaps. With respect to health research, there were recommendations to dedicate research efforts to elucidating the relationship between chronic exposures to harmful compounds and long-term health problems, including adverse reproductive health. A number of community advocates and some research-ers stressed the need for reducing chemical exposures, and recommended exploring ways to advance green chemistry efforts, including understanding barriers to reformulation, advocating for product reformulation, and incentivizing product manufacturers and beauty salons to adopt “greener” or “safer” products. However, salon owners also stressed the importance of cost considerations when pushing for these safer alternative products.

The perceived mistreatment of salon workers and own-ers by regulatory agency inspectors was a key, and somewhat unexpected, theme that emerged from the discussions. Salon participants criticized the way in which regulatory agencies inspect salons, and (mis)treat salon owners and workers dur-ing inspections. They referred to the numerous and constant changes in regulatory rules, of which workforce members were often unaware, highlighting the need for better communica-tion from responsible agencies. Additionally, workers and owners often felt that inspectors did not communicate well with workers and owners during their on-site inspections. Salon participants advocated for greater transparency in the way by which regulatory agencies conduct salon inspections and urged increased efforts to be directed at creating better relationships between government and workforce members.

Another critical theme emerged around how government agencies are often stymied by outdated laws for occupational standards and the lack of government oversight of the product manufacturers, owing in part to limited authority. Convening participants developed policy recommendations that would provide more authority to the Food and Drug Administration and other regulatory agencies to effectively regulate product manufacturers, including requiring pre-market testing and disclosure of product ingredients. In addition, there was inter-est in moving the United States more toward a precaution-ary principle approach, that is, that precautionary measures should be taken even “if some cause and effect relationships

are not fully established scientifically.”18 This would include banning harmful compounds in cosmetic products.

lEssons lEArnEdThere were a number of lessons learned from the process

of engaging multi-stakeholders, highlighting the need to bal-ance theoretical objectives with practical realities. Together, the convening and subsequent meetings represented one of the first times in which Vietnamese salon workers were given “a seat at the table” to strategize on ways to improve their health, safety, and rights. However, although workers and owners strongly believed in the need for more health research, they also voiced other concerns, including transparency in regulatory enforcement of salons and workers, and economic considerations in policy recommendations. Some salon participants expressed a strong view that some of the recom-mendations from other stakeholders did not factor in cost concerns that were critical to their livelihood. For example, some researchers and government agencies suggested ban-ning artificial nail care services because this service requires the use of certain harmful compounds like methacrylates. A number of salon participants strongly argued against this recommendation, stating that such services were the “bread and butter” of their business. They urged that policy changes for safer workplaces incorporate economic considerations for workforce members.

Salon participants at the convening expressed concerns that a number of recommendations put the onus on the work-force members rather than on government in taking responsi-bility around health risks. One salon worker stated to the panel of government agency representatives, “We pay taxes to the government, so we expect that you would protect us. So why do you allow manufacturers to put bad chemicals in products to sell to us? Why do you then ask us to make changes?” This comment and many others expressed during the convening underscored the need to push for greater accountability from the government and cosmetic manufacturers as well as emphasized the importance in addressing these issues through upstream systems and, therefore, administrative and legisla-tive policy approaches.

Overall, the research convening represented a pivotal event, which was the outgrowth of grassroots efforts, and which also articulated long overdue discussions around nail salon worker

80


health, safety, and rights. However, this single event only scratched the surface of the issues. To impact social change, the Collaborative needed to continue to provide mechanisms for thoughtful and inclusive discussions. Furthermore, although the idea of a large, multi-stakeholder convening was important and fruitful, some convening participants also expressed the need for follow-up discussions among targeted groups (e.g., workers/owner meetings and cosmetic manufacturer meet-ings) to allow for more dedicated time to specific issues.

ProgrEss on rECommEndAtionsThe Collaborative has actively pursued several recommen-

dations generated from the multi-stakeholder convening and subsequent discussions.

infrastructure

In September 2010, the Collaborative established a multidisciplinary Research Advisory Committee, consisting of experts in industrial hygiene, chemistry/biochemistry, toxicology, epidemiology, and environmental health science from around the nation to provide technical guidance on research efforts. The Research Advisory Committee has been instrumental in guiding the Collaborative on policy recom-mendations as well as the design of intervention studies.

outreach

The work of the Collaborative has been organic and it continues to constantly retool its work to achieve the ultimate goal of grassroots social change. In January of 2009, the Outreach/Education Committee formalized a process for gathering regular input from the salon community to inform research, policy, and outreach. The Committee continues to convene quarterly regional worker and owner meetings in both Northern and South ern California to not only provide a forum in which commu nity concerns and needs can be voiced, but also to obtain guidance and input from this community. Through these meet-ings as well as through community forums, nail salon commu-nity members have helped to identify and vet policy recom men-da tions, guide research, and provide input on effective out reach and com mu nications. Furthermore, the Collabor a tive works with salon owners and workers on leadership skills development so that community members can fully engage in effecting social change, particularly for policy change and practice.

Policy

Based on the concept of green chemistry, specifically pollution prevention strategies to reduce the use of toxic substances before they contaminate the environment and our bodies, the Collaborative has been working with San Francisco government agencies and policymakers as well as local nail salon workers to establish a citywide program to encourage nail salons to utilize products that do not contain select toxic compounds dubbed the “toxic trio” (dibutyl phthalate, formaldehyde, and toluene). These compounds have been linked to serious health impacts, including cancer and adverse reproductive outcomes.5,19-22 San Francisco was chosen as the initial site for the ordinance because of the well-established base of salon workers and owners and key relationships with members of the Board of Supervisors. In October 2010, her-alded by extensive press coverage, San Francisco passed the groundbreaking Nail Salon Recognition Program Ordinance, the first ordinance in the nation designed to recognize those salons that use nail polishes and top/base coats free of the toxic trio. The idea originated from workforce members and advocates during one of the regional worker/owner meetings. This ordinance applies a “carrot” approach to creating change instead of a “stick” approach that penalizes for wrongdoing. The unanimous passage of the ordinance was due in large part to the considerable number of salon workers and owners who provided testimony in front of the city council and attended the hearing in support of the ordinance. Lessons learned from the implementation of the San Francisco program will help the Collaborative plan for similar efforts in other parts of the state and nation.

At the federal level, the Collaborative, through its mem-bership in the national Alliance, has ensured that salon worker health issues are embedded in the Safe Cosmetics Act, federal legislation that would reform the cosmetics industry to increase consumer and worker protection by requiring pre-market safety testing of products and full disclosure of product ingredients. Salon workers and owners have participated in policy advocacy efforts for the bill, including participating in congressional staff briefings and visiting congressional lead-ers to obtain co-sponsorship and support for the bill. One participating worker commented that she felt empowered to be part of the political process.

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research

In response to specific recommendations to identify effective outreach and intervention strategies, members of the Collaborative designed a pilot intervention study to work with Vietnamese nail salon owners to train their workers on ways to reduce workplace chemical exposures. Following the principles of a lay health worker approach in which commu-nity members are trained as trainers to promote health,23,24 this study aims to build a stronger relationship between workers and owners so that both groups can be knowledgeable of the chemical hazards and can collectively work to reduce their collective workplace exposures. In addition, the Collaborative continues to explore additional studies of chronic health and exposure assessments to inform policy changes.7

ConClusionsThe research convening was a groundbreaking event that

galvanized a multitude of stakeholders to work toward safer work environments for salon workers. The recommendations generated during the convening shaped a proactive research agenda for participatory research to provide the critical evidence to impact social change. In follow-up discussions, such recommendations were further fleshed out and put into policy practice. Efforts to date have shown significant progress on moving several recommendations forward, including the passage of the local ordinance in San Francisco and the (re)-introduction of the Federal Safe Cosmetics Act.

Key to these recommendations is the participation of workforce members who grounded the meeting and helped to shape the research agenda. These perspectives reinforced the importance of nesting research objectives within the larger con-text of the everyday concerns of the workers in the industry.

The structure of the Collaborative and its integrated approach toward social change promotes work across differ-

ent disciplines (e.g., toxicology, epidemiology, law, and green chemistry), issues (e.g., health, business, immigration, and worker rights) and languages. The participation of diverse stakeholders allowed for cross-dialogue on a complex issue and some consensus building. It also helped to align different stakeholders as allies (e.g., regulatory agencies with com-munity advocates and workforce members) and to identify critical resources (e.g., the Research Advisory Committee) to addressing research gaps.

Recommendations from the convening have served as a blueprint to guide the ongoing work. The convening served as an integral first step toward building the foundation by which the Collaborative could develop concrete policy, research and community-building strategies for implementing the key recommendations from the ground up.

ACKnowlEdgmEntsThe authors acknowledge Women’s Voices for the Earth

(WVE) and the National Asian Pacific American Women’s Forum (NAPAWF) for co-hosting the Research Convening. We thank Jamie Silberberger and Alex Gorman Scranton from WVE and Nancy Chung and Amanda Allen from NAPAWF for their contributions to report on the research convening. In addition, we thank all of convening’s participants, particularly the salon workforce members, whose contributions were vital to the dis-cussions and the development of a grounded research agenda. Funding support for the convening came from the California Breast Cancer Research Program; the California Wellness Foundation; the Women’s Foundation of California; Tides Foundation – Reproductive Justice Fund; the Environmental Protection Agency, Region 9; the Center for Environmental Health’s Justice Fund; the Northern California Environmental Grassroots Fund (Rose Foundation); Women’s Voices for the Earth; and the Environmental Protection Agency White House Initiative on Asian Americans and Pacific Islanders.

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