III Key Findings
V Recommendations for Policy, Practice, or Further Research
VI Key Learnings for Community Health
--Submitted by Cate Ahrens and Linor David, Queen West – Central Toronto Community Health Centre
Nail technicians in Toronto are typically female immigrants from China and Vietnam. They work in a profession where throughout the workday they are regularly exposed to chemicals known to cause cancer, respiratory illnesses and reproductive problems.  Issues such as gender, language, lack of income, past trauma, and immigration status create increased vulnerabilities for this group of workers.
The occupational health of nail technicians is critical and has not been substantially investigated in Canada.  Research in the United States found that nail technicians are exposed to volatile solvents like toluene and phthalates and that there are gaps in regulatory standards to address these exposures.  Nail technicians suffer from a variety of respiratory, skin and musculo-skeletal problems that they attribute to their chemical exposures and working conditions. 
These issues, in addition to unfair labour practices such as wage theft, were recently exposed in detail through an investigation by The New York Times.  The media attention has highlighted the problems that immigrant women in this profession have faced for many years, and points to why it is a health promotion issue worthy of attention in Ontario – particularly in urban centres.
Queen West - Central Toronto Community Health Centres (CTCHC) has been serving the Chinese new immigrant community in downtown Toronto for over 20 years. Its programs have created a strong connection with the Chinese community (primarily reproductive-aged women) and it has Mandarin and Cantonese speaking staff. CTCHC was interested in exploring the barriers to health for Chinese nail technicians in Toronto, many of whom were attending programs. Although there are other immigrant groups who work in the nail salon industry in Toronto, primarily Vietnamese women, this project focused on Chinese immigrants as they are a priority population being served at the health centre.
“I know it is very bad for the body but we work here, nobody tell us how to protect oursel(ves)” (Participant 2, 2014, CTCHC focus group with Toronto nail technicians)
As is the case with many marginalized groups, research is often done to them rather than with them. This project employed a community based participatory research approach which was designed to take into account nail technicians’ experiences and build up opportunities for them to take leadership roles. With funding from the Women’s College Hospital Women’s Xchange Fund, CTCHC hired peer facilitators who spoke Chinese and had experience in the nail salon industry, and who then were able to outreach and recruit other nail technicians. Through a focus group and a facilitated silk painting activity, we learned about the experiences of nail technicians and the barriers faced in mitigating their exposure to hazardous chemicals. We held four educational workshops to respond to some of the issues raised in the focus group targeting occupational health and employment standards. Through the workshops and outreach we learned about both the effectiveness of educational interventions and where gaps in resources and education still were. Finally, we held a multi-stakeholder roundtable with the research team, peer facilitators, nail technicians and a variety of non-profit organizations, academics, and public health professionals to: a) learn from each other about the environmental health risks of working in nail salons; and b) identify key interest areas and opportunities for future work.
III Key Findings
It became clear through the focus group, workshops, art piece, and roundtable that women working in nail salons have a variety of occupational health concerns. Participants in the focus group named several health effects from which they suffered: skin problems and irritations, allergies, nausea, trouble sleeping, tiredness, musculoskeletal issues, burning eyes and coughing. They also raised concerns they had around pregnancy and chemical exposures. The women expressed a strong desire to make their work safer but also conveyed feeling that their ability to do so was limited. Several barriers to reducing their risks were identified, including: lack of training, limited access to workplace safety information, few health and safety workplace policies and practices, and immigration and settlement issues.
Lack of Training
From the focus group we learned that nail technicians in Toronto who emigrated from China often learned their trade on the job, and they often paid their employer for the time spent while they were working and having their informal training. The only nail technicians who felt confident about how to protect their health at work were those who had completed formal training in Toronto and one whose owner was notably careful with his practices with respect to health. In the dominant scenario, in which technicians are learning solely through on-the-job training, owners become the gatekeepers for workplace practices and workers’ knowledge of how to protect themselves. Within our participant group this meant that with only one exception, workers were not informed by their employers about exposure risks or the steps available to protect themselves. Nail technicians reported that choosing to reduce their work hours was one of the only ways they knew to protect their health.
“I actually know how to do the nail when I was in China… But it is very unprofessional and when I came to Canada, I found a nail salon, I go inside and I said, “I can do the nail”, and the owner give me a polish and said, “ok, do my nails”, and I was shaking do(ing) her nail(s). And after that she said, “oh it’s the same as if you do your nails at home!” And so I pay the money to learn how to do the nail properly and be professional. But I think that is not enough, so last year I take a course,... to learn how to do nails professional(ly) and how to protect ourselves and even, also protect the customers.” (Participant 2, May 26, 2014, CTCHC focus group)
Health and safety practices and policies
Nail technicians also reported having very few workplace health and safety policies or practices in their salons. For example, most were familiar with health benefits of frequent hand washing but reported not being able to ask clients to do so. Most technicians also did not regularly wear gloves, and the gloves that were available were latex-based as opposed to nitrile, which is the appropriate material to best protect hands from exposures in nail salons. The nail technicians were unfamiliar with the regulatory standards that exist and many participants in the roundtable voiced that what minimal standards exist tend not to be in the interest of the workers (but rather clients) and are not well enforced. The women expressed a number of reasons why they thought the salon owners were not providing better health and safety protection for their workers. The two main reasons offered were the costs of protection measures and a lack of understanding of the issues.
The lack of education about and enforcement of workplace health and safety provisions are exacerbated by the immigration status of these nail technicians. Immigration and settlement impact nail technicians’ ability to protect themselves in terms of understanding their rights in the workplace, knowing where to get information, who to talk to about the risks and concerns, and fear of losing their job from speaking out or asking questions. For example, many technicians expressed learning important, new information about rights in the workplace from participating in the workshop. In the roundtable, it was reported that because employment and income are tied to immigration status, the women fear asking questions related to safety, seeking support for health concerns, or challenging owners’ practices because of the potential risk of losing their job.
Nail Technician Association
The nail technicians involved in this project reported becoming increasingly engaged in the issues of workplace health and safety in salons. They reported having an increased sense of agency and confidence in speaking about and acting on these issues; and members of the research team and partner agencies have also observed these changes within the peer facilitators. They have also identified the need for a Nail Technician Association, and leaders have emerged within the group to initiate this organizing. Through the support from Women’s College Hospital, Women's Xchange we convened an initial gathering of nail technicians to explore the role and work of this association and potential next steps.
“We need a nail technician association because one person, the voice is very weak, and if more nail technicians join the association and we are a more powerful voice” (Monica Fu, 2014, Bright Lives Video)
Partnerships and Collaboration
The California Healthy Nail Salon Collaborative was used as an example of other potential developments that Toronto and Canada could benefit from. Through this project we convened an initial gathering of organizations interested in continuing or already involved in work on these issues. The National Network on Environments and Women's Health (NNEWH), Chinese Interagency Network Labour Committee, Centre for Research Expertise in Occupational Disease (CREOD), and the Occupational Cancer Research Centre (OCRC) at Cancer Care Ontario are examples of the organizations interested in this future work. We are currently seeking funding for specific priorities identified by the group.
Building on the Healthy Nail Technicians Project CTCHC has launched a Peer-led Occupational Health Project focused on protecting nail technicians’ hands through a train-the-trainer model, funded and supported in kind by Centre for Research Expertise in Occupational Disease at St. Michael’s Hospital, through its funding from the Ontario Ministry of Labour. Outcomes from this project point to the effectiveness of educational interventions and support the need for additional work of this kind.
V Recommendations for Policy, Practice, or Further Research
There are many opportunities to improve workplace health in nail salons. We received positive feedback from the workshops and roundtable in terms of increasing the understanding of the health risks in nail salons and some of the ways to reduce these risks. Nail technicians told us that they learned new things about how to protect their health and that they wanted more information. Providing educational opportunities is one way we can continue to support nail technicians. Based on the work of the California Healthy Nail Salon Collaborative and our initial work on the Peer-led Occupational Health Project, we have also learned that working to build relationships with salon owners and bringing them on board with educational or other initiatives is critical to the success of improving workplace health. A third stakeholder that remains to be brought on board is the customers at nail salons. An opportunity to educate the wider public on these issues exists; which could build allies through customers at nail salons, who share in the impacts of chemical exposures in the salons.
VI Key Learnings for Community Health
This project has some additional learnings for the community health worker who is developing research with both academia and the communities they are working with. In order to maintain a participatory approach it is important to consider that building trust with a community takes time, and to build this time into the project. While it is tempting to push forward a variety of pressing research questions as quickly and efficiently as one can, making room for community members to drive the agenda can increase the leadership and support for the project within the community and create more valuable work in the long run. The second thing to consider is that there are huge benefits for community health organizations in working with solid academic partners: they can bring a different lens, they often bring resources that are usually harder to tap into, and many of them have great concern and investment in the problems. A well thought out partnership can bring about bigger changes than a small community organization can accomplish on its own.
Through the findings of this project as well as those uncovered by the New York Times investigation, it is increasingly clear that nail technicians too often face unhealthy and dangerous workplaces. Based on the experiences of nail technicians in Toronto, our research has helped to identify some of the key barriers that are preventing nail salons from being healthy places in which to work.
In partnership with other local agencies, initial steps have been taken to identify priorities and seek to protect the health and well-being of nail technicians in Toronto. Critically, these initiatives have emerged out of the expressed desires of nail technicians themselves, and where possible they have taken an active role in implementing them. With continued funding and engagement with nail technicians about the health issues they face, our project aims to help create healthy nail salons in Toronto.
 Quach, Thu, Julia Varshavsky, Julie Von Behren, Erika Garcia, My Tong, Tuan Nguyen, Alisha Tran, Robert Gunier, and Peggy Reynolds. "Reducing Chemical Exposures in Nail Salons through Owner and Worker Trainings: An Exploratory Intervention Study." American Journal of Industrial Medicine 56.7 (2013): 806-17. Print.
 Rochon Ford, Anne. “Overexposed, Underinformed: Nail Salon Workers and Hazards to Their Health / A Literature Review”. National Network on Environments and Women’s Health. Print.
 Quach, Thu, Julia Liou, Lisa Fu, Anuja Mendiratta, My Tong, and Peggy Reynolds. "Developing a Proactive Research Agenda to Advance Nail Salon Worker Health, Safety, and Rights." Progress in Community Health Partnerships: Research, Education, and Action 6.1 (2012): 75-82. Print.
 Roelofs, Cora, Lenore S. Azaroff, Christina Holcroft, Huong Nguyen, and Tam Doan. "Results from a Community-based Occupational Health Survey of Vietnamese-American Nail Salon Workers." Journal of Immigrant and Minority Health 10.4 (2008): 353-61. Web.
Quach, Thu, Robert Gunier, Alisha Tran, Julie Von Behren, Phuong-An Doan-Billings, Kim-Dung Nguyen, Linda Okahara, Benjamin Yee-Bun Lui, Mychi Nguyen, Jessica Huynh, and Peggy Reynolds. "Characterizing Workplace Exposures in Vietnamese Women Working in California Nail Salons." American Journal of Public Health 101.S1 (2011): S271-276. Print.
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Queen West – Central Toronto Community Health Centres, Bright Lives video: https://www.youtube.com/watch?v=S4y1p5EAu0g
Queen West – Central Toronto Community Health Centres, Women’s Xchange $15K Challenge video: www.youtube.com/watch?v=fpk6eCK9mnQ
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Perfect Nails, Poisoned Workers, New York Times http://www.nytimes.com/2015/05/11/nyregion/nail-salon-workers-in-nyc-fac...
Cuomo Orders Emergency Measures to Protect Workers at Nail Salons, The New York Times
Five Ways to Help Nail Salon Workers, Jacobin https://www.jacobinmag.com/2015/05/five-ways-to-help-nail-salon-workers