Journal of Community Health

, Volume 33, Issue 5, pp 336–343

A Preliminary Survey of Vietnamese Nail Salon Workers in Alameda County, California

Authors

    • Northern California Cancer Center
  • Kim-Dung Nguyen
    • Asian Health Services
  • Phuong-An Doan-Billings
    • Asian Health Services
  • Linda Okahara
    • Asian Health Services
  • Cathyn Fan
    • Environmental Health Investigations BranchCalifornia Department of Public Health
  • Peggy Reynolds
    • Northern California Cancer Center
Original Paper

DOI: 10.1007/s10900-008-9107-7

Cite this article as:
Quach, T., Nguyen, K., Doan-Billings, P. et al. J Community Health (2008) 33: 336. doi:10.1007/s10900-008-9107-7

Abstract

In recent decades, the nail salon industry has been one of the fastest growing in the U.S. California has over 300,000 workers licensed to perform nail care services. Though little is known about their health, these workers routinely handle cosmetic products containing carcinogens and endocrine disruptors that may increase a woman’s breast cancer risk. Additionally, an estimated 59–80% of California nail salons are run by Vietnamese women who face socio-cultural barriers that may compromise their workplace safety and health care access. In a pilot project designed to characterize Vietnamese nail salon workers in Alameda County, California in order to inform future health interventions and reduce occupational exposures, we conducted face-to-face surveys with a convenience sample of 201 Vietnamese nail salon workers at 74 salons. Of the workers surveyed, a majority reported that they are concerned about their health from exposure to workplace chemicals. Additionally, a sizeable proportion reported having experienced some health problem after they began working in the industry, particularly acute health problems that may be associated with solvent exposure (e.g. skin and eye irritation, breathing difficulties and headaches). Our findings highlight a critical need for further investigation into the breast cancer risk of nail salon workers, underscored by the workers’ routine use of carcinogenic and endocrine-disrupting chemicals, their prevalent health concerns about such chemicals, and their high level of acute health problems. Moreover, the predominance of Vietnamese immigrant women in this workforce makes it an important target group for further research and health interventions.

Keywords

VietnameseNail salonsOccupational exposureHealth surveysBreast cancer

Introduction

The nail salon industry has been one of the fastest growing in the United States (U.S.). In California alone, there are currently over 35,000 establishments and more than 300,000 technicians licensed to provide nail care services. Nail care workers routinely handle nail care products containing many potentially harmful compounds, some of which are carcinogens or have endocrine disrupting effects, yet are virtually unregulated [13]. Nail salon workers are likely to have higher exposures to these compounds than consumers.

Nail care products contain many toxic and potentially hazardous ingredients, including solvents, plasticizers, resins and acids [4]. Carcinogens such as methylene chloride, formaldehyde, and benzene, as well as endocrine disruptors, such as toluene and dibutyl phthalates, can be found in small amounts in several nail care products [57]. Benzene and methylene chloride have been shown to induce mammary gland tumors in animal studies [3]. Although individual nail care products are thought to contain low levels of these compounds, their prevalence in salons is likely to be continuous and the chronic effects of which are largely unknown.

In the last few decades, the nail salon industry has tripled in size and the demographics of the nail salon workforce have shifted dramatically to include large numbers of newly immigrated workers. It is estimated that currently 59–80% of California manicurists are of Vietnamese descent and 95% are female [8, 9]. Between 1987 and 2002, the estimated number of licensed Vietnamese nail salon workers increased 10-fold, from 3,900 in 1987 to 39,600 in 2002 [8]. The nail salon industry holds numerous attractions for new immigrant workers: required training is short, readily available, and inexpensive, and the industry’s flexible work schedules appeal to immigrant mothers with family obligations [10]. Furthermore, the work does not require a high English proficiency. The nail salon industry draws so many Vietnamese workers that Vietnamese is one of the primary foreign-language options for the license examinations offered in California [11]. The nail salon industry’s rapid growth has mirrored the expansion of California’s Vietnamese population; from 1990 to 2000, the U.S. Census showed a 60% increase in the state’s Vietnamese population [12].

Despite the occupational health and safety concerns surrounding nail salon workers, very little is known about them—particularly the Vietnamese immigrants who comprise a majority of this workforce. In 2005, as part of a community-research collaboration, the California Breast Cancer Research Program funded a pilot project to conduct an initial examination of California’s current nail salon workforce. The project was initiated by Asian Health Services (AHS), a comprehensive community health center in Oakland’s Chinatown, and the Northern California Cancer Center (NCCC), a non-profit organization dedicated to finding the causes of cancer. This project sought to systematically collect preliminary descriptive data from Vietnamese women currently employed in Alameda County nail salons, in order to characterize the workforce and, ultimately, to help inform future targeted health interventions and reduce occupational exposures in this immigrant worker population.

Methods

Building on AHS’s active, ongoing outreach activities, we designed a survey targeting a sample of Vietnamese women in Alameda County’s nail salon workforce. Community participation was a key component in this process-driven project. To ensure input from the affected populations, we convened a Community Advisory Committee comprised of 10 Vietnamese community members, which included nail salon workers, AHS patients, cosmetology instructors, mental health counselors and breast cancer survivors. These committee members guided the project and advised us on matters of survey development and implementation, as well as future research directions. The Community Advisory Committee provided critical advice on the most effective strategies for optimizing survey participation among nail salon workers. In addition, we conducted two focus groups, consisting of Vietnamese nail salon workers and owners, with the intention of gathering input for our survey development and survey implementation strategies.

Participation in the survey was both voluntary and confidential. We obtained verbal consent from participants before administering the survey. We did not collect any personal identifying information from survey participants because our focus group results indicated that workers might perceive such data collection as a possible threat to their job status (workers may fear that possible violations would be reported to regulatory agencies). Our project protocol was reviewed and approved by the Northern California Cancer Center Institutional Review Board.

Survey Instrument and Administration

Based on advice from our Community Advisory Committee and our project’s community health advocate staff, we recruited and trained five Vietnamese community members to administer the survey to nail salon workers. These community members were former or current nail salon workers or had family members who work in the industry [13]. The purpose of using community members as survey workers was twofold. First, we wished to engage Vietnamese community members in the project, in order to raise awareness about worker health issues. Second, we hoped that survey workers’ knowledge of the industry and of issues important to the Vietnamese community would encourage nail salon worker participation.

Our survey workers administered a structured 10-min, Vietnamese-language questionnaire to nail salon workers in the salons where they worked. The survey instrument assessed baseline characteristics about the workers, including their sociodemographics, immigration history, reproductive history, work history, health experience, work-related health concerns, health care utilization and work environment. Through observation, the survey workers also assessed characteristics of the nail salons (e.g. number of doors and windows, ventilators and workstations). Survey questions were designed by project staff, with input from both the Community Advisory Committee and the focus groups. The survey was pilot tested with five nail salon workers and revised for clarity. The surveys were conducted between July and December of 2006.

Sample

All survey participants were Vietnamese women currently working at nail salons in Alameda County, California. We targeted nail salons that offered nail care services alone or in combination with hair care services. Based on AHS’s long history with working in the Vietnamese immigrant community, we knew that it would be difficult to enroll workers using traditional sampling strategies and thus used a community-based approach, relying on AHS’s 15 years of experience with health outreach to Vietnamese women in nail salons. Since no rosters exist for all Vietnamese nail salon workers currently working in Alameda County, survey workers identified a convenience sample of nail salons in various areas of Alameda County, including the cities of Berkeley, Oakland, Alameda, San Leandro, Fremont and Hayward. They visited neighborhoods where AHS staff have often conducted their health outreach and areas where there was a known high density of nail salons. Because work productivity was important to survey participants, the survey workers approached nail salon workers during off-peak business hours (e.g. early mornings, in the beginning of the week), in order to avoid interfering with the worker’s business. The survey workers often visited a number of the salons multiple times in order to identify an appropriate time to administer the survey. Since personal identifying information was not collected and a worker could refuse at one time but agree to participate at another time, we were unable to accurately estimate a participation rate.

Analysis

We entered all collected survey data into a Microsoft Access database and double-checked for data-entry errors. All descriptive analyses were performed using SAS Version 9.1. Because we were interested in differences by years of U.S. residency (a proxy measure for acculturation), we stratified some analyses by <10 years (more-recent immigrants) versus ≥10 years (less-recent immigrants). Data from 14 of the survey participants were omitted from these stratified analyses: 12 because they did not answer the question about year of immigration to the U.S. and 2 because they were born in the U.S. We performed tests of significance (Fisher’s exact test for cells with less than five counts) for some variables to assess whether differences were statistically significant.

Results

Shop Location and Work Environment:

A total of 201 surveys from 74 different beauty shops offering nail care services were completed. The shops were located in the cities of Oakland (62%), Alameda (15%), Berkeley (7%), San Leandro (5%), Fremont (4%), Hayward (3%), and in other various locations in Alameda County. Twenty percent of the shops also included hair care services. As an indirect measure of neighborhood safety (or stress), the survey included a question on whether customers entering the shop needed to be “buzzed-in” by the worker. Seventeen of the shops (23%) used this method of entry.

Among the shops, there was considerable variability in the number of workstations for nail care services (includes manicure and spa pedicure services), ranging from 1 to 14 workstations. Table 1 summarizes the salon characteristics as observed by our survey workers. Since information on the actual size of the salon was difficult to obtain, the number of workstations serves as a proxy for both salon size and potential exposure levels. A majority of the shops had more than five workstations (59%). Shop ventilation has been a major concern for the nail salon industry. General room ventilation requires an adequate supply of outside air, usually 20 cubic feet per minute per occupant, as recommended by the American Society for Heating, Refrigeration, Air Conditioning Engineers (ASHRAE) in their Standard 62-1989: Ventilation for Acceptable Indoor Air Quality (and maintained in all subsequent updates to Standard 62) [14]. Having multiple pathways for air to enter and exit a room (e.g. windows and doors) increases indoor-outdoor air exchange. One third of the surveyed shops had only a single door for ventilation, with no secondary air pathway. Furthermore, at the time of the survey less than half of the shops (45%) were using local exhaust ventilation, which helps reduce chemical exposure and improve air environment.
Table 1

Observed shop characteristics for a convenience sample of beauty/nail salons (N = 74) in Alameda County, California

Shop characteristics

N

(%)

Number of nail care stations

    ≤5

30

(41)

    >5

44

(59)

Provides hair services

    Yes

15

(20)

    No

59

(80)

Number of windows/doors

    1

25

(34)

    2

39

(53)

    ≥3

10

(14)

Shop ventilators in use

    Yes

33

(45)

    No

41

(55)

Shop entry method

    Walk-in

57

(77)

    Buzz-in

17

(23)

Worker Sociodemographic Characteristics

Survey participants ranged in age from 21 to 61 years, with a median age of 39. All but two (99%) of the women surveyed were born in Vietnam. The majority (over 77%) were born in Southern Vietnam and lived there before immigrating to the U.S. This was true both for the more recent immigrants as well as for those who had been in the U.S. at least 10 years. Over half of these workers (51%) had resided in the U.S. for 10 years or longer. Table 2 summarizes the survey participants’ immigration history. Most of the women reported similar reproductive history, with a large majority (79%) having had children before they were 30 years of age. Furthermore, we found that while only a small fraction of the women smoked cigarettes (3%), nearly half (47%) lived with a cigarette smoker.
Table 2

Immigration history of surveyed Vietnamese-born nail salon workers (N = 199) in Alameda County, California

   

U.S. residencya

  

<10 years (N = 85)

≥10 years (N = 102)

N

(%)

N

(%)

N

(%)

Birth place

    Northern Vietnam

4

(2)

0

(0)

4

(4)

    Central Vietnam

42

(21)

14

(16)

25

(25)

    Southern Vietnam

153

(77)

71

(84)

73

(72)

aData from 14 of the survey participants were omitted from this stratified analysis: 12 because they did not answer the question about year of immigration to the U.S. and 2 because they were born in the U.S.

Work History and Practices

Over half of the survey participants had worked in the nail salon industry for more than 5 years, and 23% had worked for more than 10 years (see Fig. 1). Fully half of these women routinely work more than 40 h/week (see Fig. 2). With respect to safety equipment, a large majority reported wearing gloves (72%) and masks (84%) while providing nail care services.
https://static-content.springer.com/image/art%3A10.1007%2Fs10900-008-9107-7/MediaObjects/10900_2008_9107_Fig1_HTML.gif
Fig. 1

Work history reported by surveyed Vietnamese nail salon workers (N = 201) in Alameda County, California

https://static-content.springer.com/image/art%3A10.1007%2Fs10900-008-9107-7/MediaObjects/10900_2008_9107_Fig2_HTML.gif
Fig. 2

Hours worked per week reported by surveyed Vietnamese nail salon workers (N = 201) in Alameda County, California

Reported Health Concerns and Problems

Most survey participants indicated that they were concerned about the chemicals in the products they used (80%), particularly nail polish remover, acrylic nail glues and nail polish. Participants reported Sation (88%) and OPI (55%) to be the most commonly used nail polish brands.

We asked the nail salon workers to report health symptoms and problems they have experienced after beginning work in the nail salon industry. Overall, 62% of the women reported experiencing some type of health problem. Ninety-four workers (47%) reported health symptoms that may be associated with solvent exposure, including skin irritations, breathing problems, numbness, and eye and throat irritations. These health problems are likely to be work-related since participants reported that the symptoms began after they began working in the industry. Eighty-four workers (42%) reported chronic pain after beginning work in this profession. We observed no significant differences between the more-recent and less-recent immigrant groups, for any of our surveyed work history or practices variables. Table 3 summarizes the health concerns and health problems reported by survey participants.
Table 3

Health concerns and problems reported by surveyed Vietnamese nail salon workers (N = 201) in Alameda County, California

   

U.S. residencya

  

<10 years (N = 85)

≥10 years (N = 102)

N

(%)

N

(%)

N

(%)

Any health concerns

    Yes

160

(80)

67

(79)

82

(80)

    No

41

(20)

18

(21)

20

(20)

Any health problems

    Yes

125

(62)

50

(59)

63

(62)

    No

76

(38)

35

(41)

39

(38)

Health symptoms potentially related to solvents

    Yes

94

(47)

39

(46)

48

(47)

    No

107

(53)

46

(54)

54

(53)

Chronic pain and other symptoms

    Yes

85

(42)

29

(34)

44

(43)

    No

116

(58)

56

(66)

58

(57)

aData from 14 of the survey participants were omitted from this stratified analysis: 12 because they did not answer the question about year of immigration to the U.S. and 2 because they were born in the U.S.

Health Coverage and Practices

Eighty-four percent of the participants reported having some type of health insurance. Notably, only four had work-based coverage. Participants’ sources of health coverage were most commonly MediCal (45%). Additional sources were through a family member (typically the husband) (26%) or self-purchased (27%). We observed a significant difference between the more-recent and less-recent immigrant group in the type of insurance coverage; the more-recent immigrant group were more likely to be MediCal enrollees, whereas the less-recent were more likely to have purchased their own health insurance. Table 4 summarizes the survey participant’s reported insurance coverage.
Table 4

Insurance coverage reported by surveyed Vietnamese nail salon workers (N = 201) in Alameda County, California

   

U.S. residencya

  

<10 years (N = 85)

≥10 years (N = 102)

N

(%)

N

(%)

N

(%)

Insurance

    Yes

164

(84)

70

(82)

88

(86)

    No

37

(18)

15

(18)

14

(14)

Insurance type (N = 164)

    Work-based

4

(2)

3*

(4)

1*

(1)

    Husband’s insurance

43

(26)

23*

(27)

18*

(18)

    Self-purchased

44

(27)

8*

(9)

32*

(31)

    MediCal

73

(45)

35*

(41)

33*

(32)

aData from 14 of the survey participants were omitted from this stratified analysis: 12 because they did not answer the question about year of immigration to the U.S. and 2 because they were born in the U.S.

P < 0.05 Fisher’s exact test

Among women over 40 years of age, 89% reported having been screened (either through a mammography or through a clinical breast examination) for breast cancer. A majority of these women (83%) were screened within the last 2 years. No significant differences in breast cancer screening were observed between the less-recent and more-recent immigrant groups. Screening rates were also similar among women with different types of health insurance coverage. Table 5 summarizes participants’ reported breast cancer screening.
Table 5

Breast cancer screening history reported by surveyed Vietnamese nail salon workers, 40 years of age or older, (N = 99) in Alameda County, California

   

U.S. residencya

  

<10 years (N = 85)

≥10 years (N = 102)

N

(%)

N

(%)

N

(%)

Had ever been screened

    Yes

88

(89)

17

(89)

64

(89)

    No

11

(11)

2

(11)

8

(11)

Year of last screening (N = 88)

    2003 or earlier

14

(16)

5

(26)

9

(13)

    2004

17

(19)

2

(11)

15

(21)

    2005

32

(36)

6

(32)

22

(31)

    2006

25

(28)

5

(26)

17

(24)

aData from 14 of the survey participants were omitted from this stratified analysis: 12 because they did not answer the question about year of immigration to the U.S. and 2 because they were born in the U.S.

Discussion

The purpose of our survey was to collect preliminary descriptive information about Vietnamese nail salon workers in Alameda County, with particular attention to sociodemographics, work environment, health concerns, health symptoms and health practices. It is notable that despite the tremendous growth in this industry, very little systematic descriptive data exist for workforce members and there have been no studies examining the chronic health effects among them. This is one of the first studies to gather baseline information on nail salon workers and their health issues.

Compared to the California Health Interview Survey (CHIS) for a 2003 and 2005 pooled sample, the proportion of uninsured Vietnamese women in our study (18.4%) is similar to the proportion of uninsured Vietnamese women statewide (20.7%; 95% CI: 15.5–25.9%) and slightly lower than the proportion of uninsured Vietnamese women in Alameda County (25.8%) [15]. However, the proportion of Vietnamese nail salon workforce members in our study who are covered by MediCal (45%) is much higher than for either all Vietnamese women in Alameda County (17.3%) or all Vietnamese women in California (27.7%). The higher proportion of MediCal enrollees among our study participants suggests that workforce members are more likely to be receiving indigent care, with ensuing implications for their access, utilization and quality of care. A study by the California Cancer Registry reported that women enrolled in MediCal were more likely than non-enrollees to be diagnosed with late-stage breast cancer [16].

The breast-cancer screening rate we observed (89%) among Vietnamese women in our study, aged 40 years and older, was higher than that reported for Vietnamese women in the CHIS 2003 and 2005 pooled sample for California (74.4%), but considerably lower than that reported in the CHIS sample for Alameda County (97.8%). Possible reasons for the impressive screening rates among the Alameda County population include ongoing targeted breast cancer screening efforts conducted by AHS and the Vietnamese Health Promotion Project of the University of California, San Francisco [17]. It is notable that despite the targeted screening intervention programs in Alameda County, women in this workforce were not able to avail themselves of these services at the level of other local Vietnamese women [18].

The few existing reports on nail salon workers’ health have focused primarily on acute health effects. Though no studies to date have addressed which specific exposures may be linked to reported acute health outcomes in nail salon workers, these studies of acute health effects do reinforce concerns about workplace exposures that may prove hazardous to this workforce. Previous studies have reported that workers experienced cognitive symptoms and had greater problems with attention [1921]. Moreover, an analysis of calls placed to a California occupational hazard hotline found that manicurists and cosmetologists were the third largest occupational sector to make hotline inquires regarding concerns about the effect of their work on their pregnancies [22].

Despite the large size of this workforce and its significant growth in the last few decades, only two other, very recently published surveys have been conducted to characterize these workers. NAILS Magazine and VietSALON published findings in the popular press from a national survey to VietSALON’s readership. They reported similar findings about the Vietnamese nail salon workforce sociodemographics, including immigration status (nearly all are born in Vietnam), age distribution and length of U.S. residency, as well as work characteristics (e.g., work tenure and number of technicians in a nail salon) [23]. Their study, however, did not collect information on salon characteristics, health coverage, health concerns or health experience.

A recently published peer-reviewed survey study of Vietnamese nail technicians in Boston found that these workers reported experiencing work-related headaches, skin problems and respiratory problems; these symptoms often improved when the workers were away from work for a day or two [4]. Despite the fact that their study was conducted in Boston and used an open-ended format that was administered at the participants’ homes, several findings were similar to our own. Our study and theirs reported similar prevalence of self-reported health effects, including respiratory, skin and musculoskeletal problems as well as a high frequency of health concerns about the potential health effects of workplace chemicals and use of protective masks and gloves. Our study found, through the surveyors’ observations of each salon, a lower percentage of salons with ventilation devices in use (45%) than were reported in their study (73%). This difference may reflect potential geographic differences in nail salons or reporting bias. The latter may reflect differences in obtaining data through surveyor observations rather than self-report. Notably, despite this apparent difference in use of ventilation devices, the prevalence of acute health effects is similar in the two studies.

Our study reinforces recent findings of reported acute health problems and a high prevalence of health concerns in the nail salon workforce. Our results suggest that Vietnamese nail salon workers tend to work long hours in potentially poorly ventilated beauty shops. The reported high use of protective equipment, such as gloves and masks, may further reflect the worker’s knowledge of potential health hazards in the workplace; this population may thus be particularly receptive to interventions by community-based organizations, such as AHS.

Unlike the previous studies, our study was designed to gather preliminary data in a more systematic approach, using a structured questionnaire that was conducted in-person at the nail salon. Our study also focuses on workers in California, where this workforce is the largest and has experienced the greatest and most rapid growth in the nation. Because of public concerns about toxic compounds in personal care products, California recently passed legislation requiring cosmetic companies to report compounds that are potentially carcinogenic or can cause adverse reproductive health in their products. Nail salon workers are likely to have higher exposures to compounds in such products than consumers, making them an important occupational group for understanding related health issues and informing ongoing and future legislation directed at this issue.

Our study has some limitations. Because this workforce includes a large number of immigrants, who, in the absence of a community-based liaison do not readily respond to researcher inquiries, the study required some compromises to a traditional survey design. We needed to use a convenience, rather than systematic, sampling strategy, which may have compromised the general representativeness of study participants. The direction and experience provided by our AHS outreach workers and community advisory members, however, give us confidence that our survey participants were reasonably representative of workforce members in this county. Many of our study results are also consistent with the few existing studies, which used different survey approaches. We were, unfortunately, unable to estimate a participation rate, due to our iterative recruitment strategy and because we lacked a full enumeration of active workforce members, by shop, for Alameda County. Additionally, there is the possibility of positive response bias in asking nail salon workers about their health concerns and their health experience. This bias, however, is inherent in most survey research.

While presenting some research challenges, the community-based nature of this study is also its major strength. Our study would not have been feasible, without the contributed expertise of community members actively involved in the industry and with workforce members. Likewise, that expertise enabled us to achieve a high level of participation and include participants from nail salons across Alameda County. In contrast to previous studies, our community-research partnership enabled us to use a structured questionnaire thus optimizing our collection of quantifiable responses. This study is an important first step toward an improved understanding of the potential health risks for this special worker population. It was conducted in the context of high interest in this population, as reflected by some of the growing efforts at the local, state and national levels to address nail salon worker health and safety issues. The potential for hazardous occupational exposures, combined with socio-cultural disparities in health care access for this largely immigrant population, make the nail salon workforce an important target for further research as well as health intervention.

Copyright information

© Springer Science+Business Media, LLC 2008