Safety and Health Risk Perceptions: A Cross-Sectional Study of Nail and Hair Salon Clients

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1 Safety and Health Risk Perceptions: A CrossSectional Study of Nail and Hair Salon Clients Lindsey Milich 1,2, Derek Shendell, D.Env, MPH 1,3,4*, Judith Graber, PhD 2,5 1 Rutgers School of Public Health, Center for School and CommunityBased Research and Education (NJ Safe Schools Program), Rutgers, The State University of New Jersey, New Brunswick, NJ 2 Department of Epidemiology, Rutgers SPH, Rutgers, The State University of New Jersey, Piscataway, NJ 3 Department of Environmental and Occupational, Rutgers SPH, Rutgers, The State University of New Jersey, Piscataway, NJ 4 Exposure Measurement and Assessment Division, Environmental and Occupational Health Sciences Institute, Rutgers, The State University of New Jersey, Piscataway, NJ 5 Department of Environmental Epidemiology and Statistics, Environmental and Occupational Health Sciences Institute, Rutgers, The State University of New Jersey, Piscataway, NJ * Corresponding/presenting author as ISIAQ member and advisor: SUMMARY Adverse health effects for nail and hair salon employment have been widely studied, with training efforts conducted to reduce hazards among these workers. There is substantial concern about whether the health risks of these hazards also pose a risk to clients of these salons. However, little is known about the risk perceptions of nail and hair salon clients. This study aims are to determine the health risks perceived by nail and hair salon clients in New Jersey (NJ), using a questionnaire developed by the NJ Safe Schools Program. Perceived health risks were similar among respondents sampled in person and by . Some questions relating to indoor air and environmental quality had failing scores ( 60%). Dermal symptoms had the highest prevalence (58.9% for nail salons, 25.6% for hair salons), however respiratory conditions were also present (12.2% for nail salons, 11.1% for hair salons). PRACTICAL IMPLICATIONS This study is the first to investigate risk perceptions of nail and hair salon clients about indoor air and environmental quality (IEQ). The results will begin to establish an understanding of the overall safety and health knowledge among these clients and can be used to inform future studies, training, and IEQ interventions. Such studies include a pilot field study being conducted in two counties of NJ focusing on physical characteristics of nail salons plus storage of chemical cleaning products and consumer/salon products used, as well as worker safety and health. KEYWORDS Safety and health, IEQ, risk perception, hair salon, nail salon

2 INTRODUCTION Health issues among nail and hair salon professionals are increasingly recognized and studied. Training efforts have been conducted to reduce exposure to known hazards; physical, chemical, biological and/or ergonomic hazards in these salons, and increase worker knowledge, attitudes, and awareness (KAAs) of areas such as worker rights, risk perception, use of personal protective equipment, and control have been implemented in the US and elsewhere (Apostolico et al. 2014; Patti et al. 2015; USDOL, 2016). With the increased attention to these potential exposures there is also concern about whether these hazards pose a risk to clients who utilize these salons. However, little is known about perceptions of the nail and hair salon clientele. A variety of adverse health outcomes have been documented among clientele of nail and hair salons. Contact dermatitis has resulted from exposure to from allergens or irritants found in nail products, including polish and artificial nails (Chang et al. 2007). Some salons use implements such as nail clippers and files more than once on clients, increasing the risk of contamination with pathogens such as Staphylococcus streptococcus, fungi, and viral warts (Rich, 2001; Sekula et al. 2002; Johnson, 2011). Use of these tools without proper sanitation can also result in the potential transmission of bloodborne pathogens (BBP) including the hepatitis B and C viruses (Webster, 2014). Other risks include ultraviolet ray exposure and respiratory irritation through poor indoor air quality as a result of toxic chemicals (Shendell et al. 2013; OSHA, 2011). Hair salons are popular for hair coloring and straightening treatments; some contain the chemical formaldehyde, posing a risk for both hair salon employees and clients; this chemical can cause allergic reactions of the skin, eyes, and lungs (Mayer et al. 2015). Use of sharp objects on the hair and scalp of clients can also put them at risk of BBP exposure if tools are not properly disinfected (Mayer et al. 2015). The primary purpose of this study is to determine the health risks perceived by nail and hair salon clients in New Jersey using a standardized in survey that was developed by the New Jersey (NJ) Safe Schools Program (SS) as part of a cosmetology training program for secondary school students and their teachers. Specifically, the aims are (1) To assess KAAs of safety and health (S&H) risks perceived by clients of NJ nail and hair salons, and (2) To assess the prevalence of symptoms, including respiratory and dermal, potentially associated with hair/nail salon services. Analysis of the risk perceptions of nail and hair salon clients will help establish a better understanding of the overall S&H knowledge of clients and to inform future interventions. 2 MATERIALS/METHODS The Salon Safety Quiz (SSQ) was developed by Rutgers School of Public Health s (SPH) NJ SS and the Georgia Tech Research Institute. The SSQ appears in three papers published on our use of it, in (Apostolico et al. 2014; Patti et al. 2015; Shendell et al. 2013a). This project s survey adapted questions from the SSQ to be appropriate for clients, and added questions to capture information on KAAs and risk perceptions of nail/hair salon clients. The survey has four

3 sections; (1) demographic characteristics, (2) nail salons, (3) hair salons, and (4) perceptions about visiting hair/nail salons. Question topics include: age, gender, race, and education demographics; frequency of hair/nail salon usage; prevalence of fungal, dermal, and respiratory symptoms; and awareness of biological and chemical hazards. Responses on perceptions will be used to determine a risk perception score. Data were obtained from salons in three adjacent counties in NJ and through an convenience sample in a link to an online form of the survey sent to students of the Rutgers SPH and others who resided in targeted counties. The convenience sample included personal contacts of the investigators and their referrals. Within each targeted county, nail salons were visited over the course of three days during the week at the same hours to generate a convenience sample of clients. This was done to account for technician and salon scheduling, logistical aspects, and ensuring safety by visiting during daylight hours. Certain holiday time periods were excluded from the study including the week of Thanksgiving and the threeday weekends of Christmas and New Year s to avoid the influx of potential out of state clientele. Hair and nail clients completed the questionnaire which did not collect any directly identifiable data. Participants who completed the survey online entered answers directly online via the survey database, housed in the data software tool PsychData. Data were extracted from PsychData and all analyses were conducted using SAS v.9.4. The sample is described by the number and percent of individuals that fall within sublevels of each sociodemographic characteristic. The 12 questions pertaining to hair/nail salon knowledge were combined additively into a risk perception score with a maximum of value of 12 points. RESULTS Two salons from each county were visited a couple times each; three attempted salons did not agree to have their clients participate, which produced a 66.7% salon response rate. A total of 141 s were sent; 69 participated, for a 48.9% response rate. Table 1 provides a demographic breakdown of survey participants stratified by (online) and inperson completion.

4 Table 1: Demographic characteristics of and reported symptoms by NJ hair/nail salon clients, 2015 (n=90; 69 by , 21 inperson) Characteristic n (%) Gender Age in years Male Female Race/Ethnicity NonHispanic White NonHispanic Black Hispanic Asian Education Associate s degree or less Bachelor degree Some grad school Master/Doctoral level Symptom Nail Salon Symptom Hair Salon Fungal Dermal Respiratory Dermal Respiratory 5 (5.6) 85 (94.4) 27 (30.0) 39 (43.3) 24 (26.7) 61 (67.8) 11 (12.2) 8 (8.9) 10 (11.1) 17 (18.9) 26 (28.9) 17 (18.9) 30 (33.3) 13 (14.4) 53 (58.9) 11 (12.2) 23 (25.6) 10 (11.1) The majority of the sample (76.7%) was obtained through online completion of the survey; most respondents were nonhispanic white (67.8%) and female (95.5%). Dermal symptoms were the most commonly reported symptoms (58.9% for nail salons, 25.6 for hair salons), followed by similar frequency of fungal (14.4%) and respiratory symptoms. Overall, the mean and median scores were similar (~67%); the range was %. Table 2 summarizes dermal and fungal symptoms as stratified by frequency of visits to H&N salons and adjusted for age (in years), race, and education. It should be noted how, in this study, high frequency was indicated by 10 hair/nail salon visits and midlow frequency was indicated by 9 hair/nail salon visits. The association between visiting a hair/nail salon 10 times and experiencing a dermal or fungal symptom was statistically significant (95% CI: 1.33, 8.51). The association remained significant after adjusting for age (in years), race, and education. The odds of experiencing a dermal or fungal symptom was 4.23 times higher among those who visited hair/nail salons 10 times than those who visited less often (95% CI: 1.42, 12.56).

5 Table 2: Adjusted odds ratios showing association between frequency of visits and prevalence of dermal and/or fungal symptoms, (n=41) n(%) Frequency of visits High frequency 1 19 (46.3) MidLow frequency 2 22 (53.7) Age in years Race NonHispanic White Education Associate s degree or less Bachelor degree 11 (26.8) 20 (48.8) 10 (24.4) 30 (73.2) Other 3 11 (26.8) 10 (24.4) 10 (24.4) Unadjusted OR % CI Adjusted OR , Graduate School 21 (51.2) 1 High frequency 10 hair/nail salon visits; 2 MidLow frequency 9 hair/nail salon visits 3 Other = nonhispanic Black, Hispanic and Asian participants combined Values in bold font were statistically significant at p< % CI 1.42, , , , , , 2.41 Table 3 provides results from the risk perception quiz. All participants were aware that they have the right to be safe and healthful in the hair/nail salon, indicating knowledge of their basic rights as a client. Questions 3, 4, 5, 7, and 8 directly relate to IEQ. Passing scores ( 60%) were indicated for understanding that cosmetologists are more likely to leave their job due to occupational related allergies than office workers and it not being safe to eat or drink in the beauty salon. Scores for the remaining three IEQ related questions were considered failing, indicating a lack of knowledge for the health risks nail/hair salon client s face, the percentage of toxic chemicals used by cosmetologists, and believing that lowodor/odorfree products are healthier than traditional products for salon air quality. Question 9 indirectly relates to IEQ; only 20% of participants correctly identified hazard communication as the top cited offence for beauty salons. The majority of the remaining 80% chose formaldehyde as the top cited offence, indicating knowledge and presence of this hazardous chemical in salons. It should also be noted that question 5 required participants to check all health risks that nail/hair salon client s face; correctly identifying all six risks indicated a correct answer.

6 Table 3: Scores stratified by question number on the risk perception survey (n=90) Question Correct n (%) 1. I have the right to be safe and healthful in the hair/nail salon 90 (100.0) 6. In the hair/nail salon, whose safety should be the top priority? 88 (97.8) 2. If your nail/hair technician wears gloves when using chemical 76 (84.4) products, do they also need to wash their hands afterwards? 12. Hand sanitizer can be a replacement for soap and water 72 (80.0) 10. Shaving legs 24 hours prior to a pedicure can increase risk of 71 (78.9) infection 3. Cosmetologists are more likely to leave jobs due to occupational 66 (73.3) related allergies and health problems than office workers 11. Who at your beauty salon is responsible for health and safety? 1 60 (66.7) 7. It is safe to eat and/or drink in the beauty salon 54 (60.0) 5. What health risks do nail/hair salon clients face? 2 50 (55.6) 4. What percentage of the nearly 3,000 chemicals used in 45 (50.0) cosmetology are classified as toxic substances by the United States government? 8. Lowodor/odorfree products are healthier than traditional 36 (40.0) products for salon air quality 9. What is the top cited offense overall for beauty salons? 18 (20.0) 1 Needed 3/3 checked to be scored correct 2 Needed 6/6 checked to be scored correct DISCUSSION In this study, the first to assess symptoms and risk perceptions among NJ hair and nail salon clients, we observed an unexpectedly high prevalence of dermatologic symptoms (58.9% for nail salons, 25.6% for hair salons). In both descriptive and multivariate analyses, dermal/fungal symptoms were more prevalent among clients who visited three times or more within the past year compared with less visits (OR: 4.23, 95% CI: 1.42, 12.56). This supports one hypothesis, i.e., clients who utilize hair/nail salons more frequently reported a higher prevalence of these symptoms. However, this was not the case for respiratory symptoms. Respiratory symptom prevalence was higher among clients with fewer salon visits, indicating a possible healthy client effect. This being those who experience IEQ specific respiratory symptoms including itchy/watery eyes, trouble breathing, headache/lightheadedness, and nausea may be less likely to revisit H&N salons. Although dermal symptoms were most common, the prevalence of respiratory symptoms specific to IEQ including runny nose, itchy/watery eyes, trouble breathing, headache/lightheadedness, and nausea, was also high at nearly one out of seven. The risk perception scores indicated lacking KAAs on three out of the five IEQ related questions. Six out of the seven remaining questions had overall average passing scores ( 60%).

7 Participants in the study were recruited from three adjacent NJ counties which have higher socioeconomic statuses (SES) than other counties in the state, so the findings may not be generalizable to nail salon clients in other counties. Although the majority of the sample was composed of nonhispanic white females with education indicative of greater than a Bachelor degree, there were still areas of the risk perception quiz that did not achieve average passing scores, which may indicate that education or SES is not strongly associated with salon S&H knowledge. Multivariate statistical modeling will be applied to further explore the association between such variables like SES and overall S&H salon knowledge. Despite such limitations, this is an exploratory study, which provides insight into the prevalence of health symptoms that may be associated with salon use, as well as providing important information about S&H salon knowledge. CONCLUSION While the prevalence of symptoms related to salon use seemed high among clients in our study, perceptions of risk and knowledge about risk was uneven. This study suggested those who utilize hair/nail salons frequently have increased odds of dermal and fungal symptoms as compared to those who utilize these salons less often. This association remained significant after adjusting for various confounders. A potential healthy client effect may exist for IEQ related respiratory symptoms. Currently, another field pilot study is being conducted in two cities in each of two counties in NJ (one northern, one central) focusing on physical characteristics of nail salons plus storage of chemical cleaning products and consumer/salon products used, and worker S&H. Results from both studies can inform future training and IEQ interventions to increase S&H knowledge and decrease salon related symptoms. ACKNOWLEDGEMENTS We thank the New Jersey (NJ) Department of Education, Office of Career Readiness (formerly the Office of Career and Technical Education) for funding the NJ Safe Schools Program grant to Rutgers School of Public Health). We acknowledge efforts of Teresa Janevic MPH, PhD and Sarah Kelly MPH for guidance in the overall design and technical aspects of this study. We also acknowledge efforts of current and prior NJ Safe Schools Program staff for assistance with pilot testing the survey (Ms. Alexsandra Apostolico, Ms. Alexa Patti, and Ms. Saisattha Noomnual).

8 REFERENCES Apostolico, A.; Shendell, D.; Lewis, A.; Kelly, S.; Murtha, A.; Houlroyd, J. The Salon Safety Quiz for pre/postevaluation assessment when training young cosmetology workers in public secondary schools. Journal of Chemical Health and Safety (1):1422. Chang, R.; Hare, A.; Rich, P. Treating cosmetically induced nail problems. Dermatol Ther :5459. Johnson, D. Assessment of the Risk of Bloodborne Pathogen Transmission in Nail Salons and Barber Shops and Regulatory Requirements in Virginia Retrieved from: (Accessed 10, August, 2015). Mayer, A.; Brazile, W.; Erb, S.; Autenrieth, D.; Serrano, K.; Van Dyke, M. Developing Effective Worker Health and Safety Training Materials: Hazard Awareness, Identification, Recognition, and Control for the Salon Industry. Journal of Occupational and Environmental Medicine (5): Occupational Safety and Health Administration (OSHA). Hazard Alert Update: Hair Smoothing Products that could Release Formaldehyde Retrieved from (Accessed 11, August, 2015) Patti, A.A.; Apostolico, A.; Milich, L.; Lewis, A.G.; Murtha, A.T.; Shendell, D.G. Evaluation of a Secondary School Cosmetology Safety and Health Training's Effectiveness after Implementation of a Hierarchy of Controls Pyramid Game" Using the Salon Safety Quiz. Journal of Chemical Health and Safety, in press (as of 11/30/2015). Rich, P. Nail cosmetics and camouflaging techniques. Dermatol Ther. 2001, 14: Sekula, S.; Havel, J.; Otillar, L. (Nail salons can be risky business. JAMA Dermatology (3): Shendell, D.G.; Mapou, A.M.; Kelly, S.W.; Lewis, A.G.; Houlroyd, J.L.; Murtha, A.T. 2013a. Assessing safety and health knowledge and awareness of young cosmetology students using a Salon Safety Quiz. Journal of Chemical Health and Safety, 20(6): Shendell D.; Mapou, A.; Kelly, S Younger Cosmetology Workers and Environmental and Occupational Asthma Triggers at Training Sites and in Salons. Journal of Asthma and Allergy Educators, 4 (2): United States Department of Labor (USDOL). Occupational Safety and Health Administration: Health Hazards in Nail Salons. Retrieved from (Accessed 26, January, 2016). Webster, H. Health Risks Lurking at the Nail Salon. US news and World Report Retrieved from: (Accessed 10, August 2015).

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