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Developing a Proactive Research Agenda to Advance Nail Salon Worker Health, Safety, and Rights
Thu Quach, PhD, MPH
California Healthy Nail Salon Collaborative, Asian Health Services, Cancer Prevention Institute of California, Stanford University School of Medicine
Julia Liou, MPH
California Healthy Nail Salon Collaborative, Asian Health Services
Lisa Fu, MPH
California Healthy Nail Salon Collaborative
Anuja Mendiratta, MES
California Healthy Nail Salon Collaborative
My Tong, MPH
California Healthy Nail Salon Collaborative, Cancer Prevention Institute of California
Peggy Reynolds, PhD
California Healthy Nail Salon Collaborative, Cancer Prevention Institute of California, Stanford University School of Medicine
Abstract

The 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 collectively developed a proactive research agenda for salon worker health, safety, and rights during a pivotal multistakeholder convening, and advanced on such recommendations, including 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 considerations 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

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 cornerstone for Vietnamese immigrants. Many are drawn to this sector because they can start their own small business or become 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 sector. 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, including nail products, only 10% have been assessed for safety.6 Recent studies have shown that salon workers are exposed to [End Page 75] a number of these compounds, ranging from volatile solvents like toluene7 to semivolatile compounds like phthalates.8 Workers face exposures to hazardous chemicals, poor ventilation 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 Engagement

Asian 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 population, 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 owners (e.g., The United Hair and Nail Associations), and representatives 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 collectively developed a proactive research agenda for salon worker health, safety and rights during a pivotal multi-stakeholder convening, and advanced on such recommendations, including 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 Collaborations

The 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 combining 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 discussion [End Page 76] 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 advocating 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; environmental, 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 summarized in a publicly available report (available from: http://www.cahealthynailsalons.org/wpcontent/uploads/2010/07/Framing_A_Research_Agenda.pdf).17 To encourage participation of limited English-speaking salon workforce attendees, simultaneous Vietnamese language interpretation was provided. 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. Discussions on a number of issues that arose from the research convening 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 Recommendations

A number of key themes emerged from the collective discussions at the convening as well as in follow-up discussions. 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.

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

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

Given the complexities of this workforce and the research gaps, it was recommended that the Collaborative establish [End Page 77]

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

List of Recommendations from the Research Convening 2009 by Topic Categories

[End Page 78]

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 researchers 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 owners 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 during inspections. They referred to the numerous and constant changes in regulatory rules, of which workforce members were often unaware, highlighting the need for better communication 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 interest in moving the United States more toward a precautionary 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 Learned

There were a number of lessons learned from the process of engaging multi-stakeholders, highlighting the need to balance 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 recommendations from other stakeholders did not factor in cost concerns that were critical to their livelihood. For example, some researchers and government agencies suggested banning 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 responsibility 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 legislative 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 [End Page 79] 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 meetings) to allow for more dedicated time to specific issues.

Progress on Recommendations

The Collaborative has actively pursued several recommendations 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 recommendations 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 meetings as well as through community forums, nail salon community members have helped to identify and vet policy recom menda 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, heralded 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 membership 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 leaders to obtain co-sponsorship and support for the bill. One participating worker commented that she felt empowered to be part of the political process. [End Page 80]

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 community 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

Conclusions

The 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 context 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 different 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 community 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.

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

Acknowledgement

The 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 discussions 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. [End Page 81]

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