(5 pages) Compare and contrast the experiences of Chinese Americans and Vietnamese Americans in the United States

Identifying and Understanding the Role of Key Stakeholders in Promoting Worker Health and Safety in Nail Salons

Thu Quach, Janice Y. Tsoh, Gem Le, Minhthu Le, Alene Pham, Lisa Fu, Vinh Luu, Kim Ngo, Peggy Reynolds

Journal of Health Care for the Poor and Underserved, Volume 26, Number 2, May 2015 Supplement, pp. 104-115 (Article)

Published by Johns Hopkins University Press DOI:

For additional information about this article

Access provided by UCLA Library (15 Aug 2018 17:24 GMT)

https://doi.org/10.1353/hpu.2015.0060

https://muse.jhu.edu/article/581384

© Meharry Medical College Journal of Health Care for the Poor and Underserved 26 (2015): 104–115.

Identifying and Understanding the Role of Key Stakeholders in Promoting

Worker Health and Safety in Nail Salons

Thu Quach, Ph.D. Janice Y. Tsoh, Ph.D.

Gem Le, Ph.D. Minhthu Le Alene Pham

Lisa Fu, M.P.H. Vinh Luu Kim Ngo

Peggy Reynolds, Ph.D.

Summary: The nail salon sector is booming, predominantly with Vietnamese immigrant workers who regularly handle nail care products containing harmful chemicals. Based on lessons learned from an ongoing randomized controlled trial, occupational interventions need to incorporate inputs from different stakeholders, including salon owners, workers, and customers as well as governmental regulatory agencies.

Key words: Occupational exposures, chemicals, Vietnamese, nail salons, intervention.

A lack of government oversight (with weak U.S. Food and Drug Administration [FDA] regulations1) has enabled wide use of cosmetic products containing com- pounds linked to cancer, reproductive harm, or respiratory problems.2,3 Chemicals in cosmetics are largely unregulated. The FDA cannot require manufacturers to conduct pre- market testing, provide data for safety testing, or even disclose product ingredients.1 Given the ubiquity of these products among women, as well as their growing use by

REPORT FROM THE FIELD

DR. THU QUACH is affiliated with the Cancer Prevention Institute of California; Stanford University, School of Medicine, Department of Health Research and Policy; California Healthy Nail Salon Collabora- tive; and Asian Health Services. DR. JANICE Y. TSOH is affiliated with University of California, San Francisco (UCSF). DR. GEM LE, MS. MINHTHU LE and MS. ALENE PHAM are affiliated with the Cancer Prevention Institute of California. MS. LISA FU is affiliated with the California Healthy Nail Salon Collaborative. MR. VINH LUU and MS. KIM NGO are affiliated with Community Action Marin. DR. PEGGY REYNOLDS is affiliated with the Cancer Prevention Institute of California and Stanford University, School of Medicine, Department of Health Research and Policy. Dr. Quach is the corresponding author and can be reached at the Cancer Prevention Institute of California, 2001 Center Street, Suite 700, Berkeley, CA 94704, and by email at thu.quach@cpic .org.

105Quach, Tsoh, G. Le, M. Le, Pham, Fu, Luu, Ngo, and Reynolds

men and even children, there are potential health concerns for consumers. Workers, handling these products in large quantities and high frequency (such as nail salon work- ers) are likely to be more vulnerable than everyday consumers to the health effects of exposure.

In the last two decades, the nail salon sector has been booming, with nearly 350,000 licensed nail technicians in the U.S.4 California has experienced the largest expansion in this sector, with an estimated 114,000 licensed nail technicians in 2007.5 In parallel with the growth of the nail salon sector, Vietnamese nail salon workers, many of whom are immigrants and women,4 have rapidly increased from 10% in 1987, to 59% of the nail salon workforce in 2002.6

Many Vietnamese immigrants are drawn to this profession because it does not require long training or high English proficiency and because salons are often owned by family and friends.* They are often hired as independent contractors and thus do not benefit from labor regulations. Many workers are not fluent in English, yet health and safety information (e.g., Material Safety Data Sheets) incorporates highly technical language and is available mostly in English. In contrast to retail cosmetic products, professional products are not required to list ingredients on its labels.7 Previous studies of nail salon workers have documented a high prevalence of acute health symptoms (e.g., headaches, skin irritations, breathing problems, numbness, and eye and throat irritations)8– 11 and adverse reproductive outcomes, including spontaneous abortions,12 low birth weight, preterm delivery, and small- for- gestational age.13,14

One of the major players in regulating the nail care sector, along with other sectors in cosmetology in California is the California Board of Barbering and Cosmetology (BBC). The BBC has a mandate to protect consumers by regulating licensed beauty care workers and beauty salons,15 including sending out inspectors to conduct salon audits. Inspectors can fine salons and workers for noncompliance with BBC regulations.

In order to address health and safety issues facing the salon worker community through an integrated approach using research, policy advocacy, and community outreach/ engagement strategies, the California Healthy Nail Salon Collaborative (Col- laborative) was founded in 2005. The Collaborative comprises community- based orga- nizations, advocates, salon workers and owners, and governmental agency representa- tives.16 Its research arm, led by the Cancer Prevention Institute of California (CPIC), implemented a health and safety train- the- trainer intervention study adapted from a lay health worker intervention approach17,18 that involves training community members to disseminate health information to their social network.19

We are currently conducting a randomized controlled trial to reduce workplace chemical exposures by engaging salon owners to disseminate information on best practices to their workers. The purpose of the current report is to describe focus group interviews with these workers and owners to provide early insights into factors that may influence workforce members’ behavior changes.

*Ly M. Assessing and communicating occupational health risks to Vietnamese nail salon workers (honors thesis). Medford, MA: Tufts University, 2003.

106 Worker health in nail salons

Design of the Parent Study

Entitled “Keeping a Healthy Occupational Environment and Developing Empowerment Program” (KHOE DEP, where khoe means healthy and dep means pretty in Vietnamese), the project includes four phases, with each focusing on a different geographic area with a high density of nail salons in California (Figure 1). Within each phase, participating salons are randomized into an intervention or control group, with the latter receiv- ing a delayed intervention. The intervention includes training an owner who in turn trains workers in his/ her salon. Workers are assessed at three time points: pre-, mid-, and post- intervention. Each assessment includes an in-person survey (e.g., questions include demographic characteristics, work history, as well as knowledge and behaviors on safer nail product alternatives, ventilation use, personal protective equipment use, and handling of products) and measurements of airborne compounds (toluene, methyl methacrylate, methyl ethyl ketone, and total volatile organic compounds) obtained from a personal air monitoring device (passive diffusion monitors 3M OVM 3500) worn by workers during the work- shift. The mid- intervention assessment is taken after the owner gets trained and before s/ he conducts the worker training. At the end of each phase, we also convene process evaluation sessions in a focus group format, stratified by workers and owners, to obtain feedback on the intervention process. The study protocol was approved by the CPIC institutional review board.

Focus Groups

We conducted three focus groups with 16 Vietnamese nail salon owners and one focus group with seven workers from the 18 nail salons that completed the first phase of the parent study (in Marin County and Contra Costa County). The focus groups were conducted in Vietnamese using a semi- structured interview topic guide, which included such questions as what they thought of the training intervention, having salon own- ers conducting the training, the contents in the training, wearing the air monitoring badge (e.g., whether it interfered with their work and whether customers asked about the badges). The interviews were audio- recorded, transcribed and translated. Two

Figure 1. Four phases of the KHOE DEP study, with each phase corresponding to a geographic region.

107Quach, Tsoh, G. Le, M. Le, Pham, Fu, Luu, Ngo, and Reynolds

researchers coded the transcripts with Dedoose,20 an online software for qualitative and quantitative mixed methods analyses, using an iterative code list, which was initially developed based on the topic guide and further enhanced as the coders reviewed the transcripts. Based on the organized quotations, the research team identified themes relating to key stakeholders.

Description of focus groups. Table 1 provides characteristics of the focus group participants (N=23). All were born in Vietnam, and three- quarters were women. They ranged from 31 to 57 years of age. On average, they had been working in the nail salon industry for nearly 10 years, with 6.5 years spent at the current nail salon. While the mean number of work hours per week is 38.5, individual workers reported a wide range, from two hours to 70 hours.

In general, the participants were very positive about the intervention, and appreci- ated the information about chemical awareness and strategies for reducing exposures, all of which were presented in Vietnamese. They shared that much of this information was not covered during their training to become licensed nail technicians.

Table 1. DEMOGRAPHIC INFORMATION OF FOCUS GROUP PARTICIPANTS (N=23)a

Characteristics mean (range) or n (%)

Participant type Owner 16 (69.6) Worker 7 (30.3) Age 45 (31– 57) Gender Male 6 (26.1) Female 17 (73.9) Birthplace Vietnam 23 (100) Years of U.S. residency 18.7 (1– 33) Highest education level Elementary school 0 Some high school 9 (39.1) High school graduate 10 (43.5) Some college/ vocational/ tech school 3 (13.0) Refused 1 (4.4) Years in nail industry 9.5 (0.1– 22) Years as (owner or worker) at this salon 6.6 (0.1– 22) Average work hours per week 38.5 (2– 70)

Note: aPercentages may not add up to 100 due to rounding.

108 Worker health in nail salons

We organized our notes on the discussions into three key domains to further our understanding of key stakeholders’ roles: 1) owner- worker relationships, 2) customers’ influence, and 3) regulatory agency, specifically the BBC. Table 2 provides themes and sample quotations for each domain.

Owner- worker relationship. The relationship between workers and owners is very complex, as owners may hire family and friends to work at the salon. Moreover, own- ers are often workers themselves and may share similar concerns as other workers. Given the long hours and tenure of work, the two groups can develop very close social relationships. As one owner remarked, “Workers are no strangers. I treat them just like friends.” However, each side has notable influences on the other, albeit not at equal levels. Owners control the salon settings (e.g., products used and ventilation systems) and workers’ schedules (e.g., when breaks are allowed). Furthermore, they can control some of the information that is given to workers. For example, most owners wanted to have the air monitoring results be only given to them so they could decide how these results would be given to workers, if at all. Contrarily, one worker voiced mistrust of the owner and a preference for receiving the results directly: “I think that the [air monitoring] results should be given directly to the workers because the owner might hide the results.” This reflects the control of information by owners to workers and trust issues. On the other hand, owners spoke about their concerns about retaining workers who are being unnecessarily “scared” by the results. Since they are in power to make salon- level changes, they prefer to see the results and take actions to improve the conditions on their own. Owners repeatedly voiced their concerns about workers leaving their salons, with one stating, “The owner avoids offending anyone [the work- ers]. We want to keep the workers. . . . don’t want to push them out. That’s the hard part.” Moreover, owners mentioned that they bore the full responsibility of economic sustainability and adherence to BBC requirements for the salon, a burden that workers do not have to bear. The weight of such burden is why they felt they needed to be in control of the salons and workers in their salons.

Customers’ roles. In a consumer- driven business, the customer has a huge role in influencing behaviors. As expressed repeatedly by both workers and owners, what the customers think and are willing to pay for are key to the business. For example, both workers and owners were concerned about implementing recommendations for wearing gloves while providing nail care services to reduce dermal exposures to chemicals,21 because: 1) customers might be offended as they think workers are wearing gloves because of the customer’s hygiene, or 2) customers worry about latex allergy (despite workers explaining they are wearing nitrile/ non- latex gloves). As one worker stated, “The problem is the customer . . . if we wear gloves then the customer will ask ‘Why?’,” suggesting that the customer may be offended that the worker is wearing gloves while providing nail care services to them. So even if workers wanted to wear gloves, the customer’s preference might override this desire. Similarly, owners stated that the safer nail polishes (without toxic compounds) do not carry popular colors that customers want, so they often have to continue to supply the less- safe products due to the cus- tomer’s preference. However, both owners and workers agreed that they could try raising awareness with customers about chemical safety in nail care products. Some workers

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111Quach, Tsoh, G. Le, M. Le, Pham, Fu, Luu, Ngo, and Reynolds

and owners have received positive responses from customers when they mentioned their participation in this study to reduce chemical exposures, which can be good for both workers and customers. Raising customer awareness and garnering their support may help boost business while promoting worker health and safety.

Governmental regulatory body. There have been anecdotal stories of what are felt to be unfair citations and bad communication between BBC inspectors and workforce members that were voiced by owners and workers during the course of our collective work. During the focus group discussions, the BBC issue came up multiple times. Owners spoke about the lack of transparency in how BBC inspectors audit their salons. As one owner stated, “First of all, they [inspectors] don’t have a professional attitude when visiting salons. Second of all, they think they work for the Government then they can do whatever they want to do [without getting in any trouble]. Third of all, they give out the fine on whatever they want to. We can’t say anything.” This quotation captures the sense of frustration and perceived unfairness in how BBC inspectors audit the salons. Interestingly, several owners commented how this intervention study has given them some sense of confidence and empowerment from following recommended best practices because they believe they are acting in accordance with recommended guidelines. As one owner stated, “Yes, if the BBC inspector visits salon, we can hold our heads high. We’re not afraid of them. Our heartbeat won’t rise up since we know we keep our workplace clean and healthy. However, they still try to dig for some mistake. I’m not afraid of them.”

Discussion

The focus groups we conducted underscored the importance of incorporating different stakeholders in our work to promote adoption of best practices. Otherwise, even though we may see desirable changes in knowledge and attitudes among workers and owners, the road to behavioral changes may remain blocked, and the ultimate goal of reducing chemical exposures for workers and owners may not be accomplished. In our ongoing study, we built our education intervention based on the PROCEDE- PRECEED model22 with an integration of the train- the- trainer model by first training the owners and hav- ing them deliver the education intervention to their workers. The intervention aims to increase knowledge among owners and their workers, enabling them to gain access to environmental resources (e.g., relevant policies). By engaging both the owners and their workers to provide a supportive social and work context, behavior changes of both owners (e.g., providing safer nail polish alternatives without some toxic compounds) and workers (e.g., using gloves and properly storing and handling products) can be reinforced and sustained to achieve the ultimate goal of chemical exposure reduction.

The worker- owner relationship is quite complex. While it appears that owners have major control over the salon environment and to some extent of the workers’ behav- iors, the owners also voiced how little control they have in retaining workers. They expressed the view that their workers, especially in Marin County where there is a shortage of experienced Vietnamese workers, also exerted influence over the owners’ behavior (e.g., how they talk to workers and what they require workers to do in terms

112 Worker health in nail salons

of best practices like storage and handling of nail care products). Both sides expressed frustrations and concerns, yet the owners also noted that they feel that the workers are their friends or like their own family. Thus, future interventions should emphasize strategies to promote the two groups to work more collaboratively towards a healthier workplace that can attract more business without compromising their health. Under- standing the pressures from the other side may help to build stronger relationships. To that end, efforts should be devoted to cultivating safe spaces for workers and owners to share their perspectives with each other in order to facilitate better communication and collaborations.

The role of customers in a service- based business sector is critical, and customers can drive both negative (e.g., gloves) and positive (e.g., safer alternative products) behaviors. Future interventions should focus on salon customers, as their patronage influences the workers and owners, and importantly, their buying power can influence product manufacturers. Given the growing use of social media, crowdsourcing sup- port of healthy salon and product changes, such as online salon ratings, might be an innovative and effective strategy to reach consumers through online communities.23

The BBC as a regulatory agency has substantial impact on workforce members’ attitudes towards interventions. Owners said that they felt more empowered when dealing with the BBC inspectors after their participation in the study because they felt they gained greater knowledge and self- confidence. However, it is worth noting that the BBC’s mandate focuses entirely on consumer safety and protection—not at all on the workers—so that the best practices for workers may not minimize BBC citations. For example, BBC regulations may focus more on preventing the spread of infections among customers, rather than minimizing chemical exposures in the nail salon to protect workers who spend long hours in these small work settings. Thus, using safer alternative nail care products or adding ventilation systems may not suffice to address the BBC requirements around sanitation. Future interventions should incorporate information about adherence to BBC regulations to respond to this need. Furthermore, there should be more policy advocacy concerning BBC transparency during salon site visits and to encourage greater sensitivity in how the BBC interacts with this immigrant workforce (e.g., interpretation during site visits).

The description we have offered here of the focus groups we conducted should be interpreted cautiously, given the small number of participants (especially workers) and the informality of this report. Both owners and workers were participants in an intervention study, and thus may not be representative of the general Vietnamese nail salon worker population. While there is a growing number of research studies on nail salons,8– 11,21,24 few focus on intervention strategies.25 This report provides insights on key stakeholders and issues that would inform the development of effective interven- tions to encourage workers and owners to work collectively to reduce their workplace exposures to harmful chemicals in nail care products.

The focus groups informed us about how key stakeholders, including salon customers and the BBC, can affect owner and worker behavioral changes. This information helped our research teams incorporate the role of these key stakeholders in our training, such as providing helpful messaging to the owners and workers to help explain to customers why gloves should be worn. The information regarding customers and the BBC is also

113Quach, Tsoh, G. Le, M. Le, Pham, Fu, Luu, Ngo, and Reynolds

useful for designing future interventions to target salon customers to raise awareness about chemical safety or to improve communications with the BBC regulatory body.

Lessons Learned

Future nail salon interventions should incorporate the perspectives of diverse stakehold- ers, including workers and owners, customers, and the BBC. While some stakeholders can create barriers, they can also become important partners in the drive for healthy behavioral changes.

Acknowledgments

Funding was provided by the National Institute of Environmental Health Sciences award #2R01ES019598. The ideas and opinion expressed herein are those of the authors and endorsement by the funder is not intended nor should be inferred.

References 1. U.S. Food and Drug Administration (FDA). Cosmetics: guidance & regulation.

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