Stakeholders’ Perspectives on the Feasibility of Adopting a Healthy Nail Salon Recognition Program in Philadelphia: A Qualitative Study

Abstract Objectives The California Healthy Nail Salon Recognition Program is a statewide initiative to incentivize nail salons to adopt occupational health and safety best practices such as the use of safer nail products without certain harmful chemicals, ventilation systems upgrade, proper personal protective equipment use, and staff training. This public policy intervention is in response to the call to protect nail care workers, mostly women of color, who bear a disproportionate burden of chemical exposure at work. Because there is an interest to adopt a similar program in the Greater Philadelphia region, we conducted this formative research to document stakeholders’ perspectives on the feasibility of adopting a Healthy Nail Salon Recognition Program in Philadelphia. Methods We conducted semi-structured interviews with a purposive sample of 31 stakeholders in Philadelphia in 2021. Using the Consolidated Framework for Implementation Science as our theoretical framework, we developed the interview guide and analysed the data using qualitative research methods to identify key facilitators and barriers. Results Key facilitating themes were perceived need and benefits of program to improve workers’ health and working conditions, and willingness of stakeholders to leverage their organizational resources. Barriers included perceived high cost and time commitment from salon owners and employees, lack of funding and implementation leaders at the city government, community members’ willingness to be visible and advocate for the program affected by the stigmas of being immigrant workers, and fear of interacting with authorities, as well as the impact of COVID-19 pandemic. Conclusions Our results suggest successful adoption of a Healthy Nail Salon Recognition Program in Philadelphia will require outreach within the community to raise awareness of the benefits of the program and close partnership with community-based organizations to facilitate mutual understanding between the authorities and the ethnically diverse nail salon communities.


Introduction
Low-wage, precariously employed, minority nail care workers are an underserved community in the US (Sharma et al., 2018) despite the documented harmful respiratory, neurological, and reproductive health effects from chronic exposure to low levels of chemicals from nail products and other work-related hazards in this worker population across the country (LoSasso et al., 2002;Quach et al., 2008;Roelofs et al., 2008;Huynh et al., 2019;Ma et al., 2019;Quiros-Alcala et al., 2019;Dang et al., 2021;Siegel et al., 2021;Nguyen et al., 2022). Limited oversight at the federal level combined with a patchwork of laws at the state level to regulate toxic chemicals in personal care products and cosmetics has resulted in a plethora of harmful products available to consumers (US Food and Drug Administration, 2022;Campaign for Safe Cosmetics, 2022). Safer alternative products tend to be more expensive and limited in availability. With the lack of comprehensive federal oversight of chemical manufacturers and distributors of nail products, local and state governments turn to regulating the workplaces, putting the responsibility of reducing chemical exposures on small business owners, workers, and consumers. Women of color with disadvantaged backgrounds bear the brunt of the chemical exposure burden. Currently, very few local and state governments have been able to develop public policies to address this occupational health injustice (CA Department of Toxic Substances Control, 2022;New York State, 2022;Seller et al., 2019). Policy interventions have ranged from strict regulations in the state of New York to voluntary programs in California (CA).
Since 2010, with the help of the California Healthy Nail Salon Collaborative, several local health departments in CA have implemented healthy nail salon recognition programs (HNSRP) to incentivize salons to adopt occupational safety and health best practices (California Healthy Nail Salon Collaborative, 2022). Nail salons that meet the program criteria are formally certified as 'healthy nail salons.' These criteria include the use of safer nail products without certain harmful chemicals, installation of ventilation systems, proper personal protective equipment use, and training of staff (CA Department of Toxic Substances Control, 2022). The success of these local programs led to the passage of the CA Assembly Bill AB2125, a bill which requires the CA Department of Toxic Substances Control to publish guidelines for local cities and counties across the state of CA to voluntarily implement the program (Bill Text-AB-2125 Healthy Nail Salon Recognition Program., 2016). A pilot program evaluation of the HNSRP conducted in 2012 in San Francisco (the first county to adopt the program) suggested early evidence of positive impact of the program on the salon environment and the workers (Garcia et al., 2015). In this 'natural experiment' study, the research team conducted personal air monitoring and surveys assessing knowledge and behaviors of workers from six participatory salons (intervention group) and five salons that did not participate in the program (control group). They found decreases in levels of toluene and total volatile organic compounds, as well as an increase in knowledge and self-reported positive practices in the participatory salons compared to the control group (Garcia et al., 2015).
The Greater Philadelphia region is one of the most populous metropolitan areas in the US and has high concentration of Asian American communities and minority-owned nail salons. While there have been documented health needs in the nail salon community (Huynh et al., 2019;Ma et al., 2019;Freeland et al., 2021), public policy to address the issue is lacking. This study was built upon an existing academic-community partnership with both a local community-based organization (CBO) and the nail salon community. This study was conducted in parallel with an ongoing pilot community-based occupational health intervention study with a local CBO, salon owners, and workers where the academic team worked closely with the community and stakeholders on the intervention development and implementation. We heard a desire for public policy interventions including recognition of salons that went above and beyond to maintain a healthy work environment. During this formative research phase, we considered various policies and chose to focus on the California's program due to its collaborative nature with the CBOs and the nail salon community including small, disadvantaged business owners who make up the majority of the businesses in the nail salon industry. The adoption of a similar program by the city of Philadelphia could potentially serve two purposes: (i) incentivize salons to improve the work environment, and (ii) provide an opportunity for the city and CBOs to work together to amplify outreach efforts within the diverse communities in Philadelphia. The purpose of this study is to document stakeholders' perspectives on the feasibility of adopting the HNSRP in Philadelphia. Findings from our study could be useful for local policymakers and public health authorities to assess their programs and functions and for community organizers to strategize their next steps to advocate for programs that meet the needs of the community.

Theoretical framework
We used the Consolidated Framework for Implementation Research (CFIR) as the basis for the design of this study. The CFIR incorporates a suite of constructs from the literature that have been associated with effective program implementation. The framework includes five domains (innovation, outer setting, inner setting, individuals, and implementation process) and constructs within each domain (Damschroder et al., 2022). The website dedicated to the dissemination of CFIR offers numerous resources for implementation science practitioners to use for their study (CFIR Research Team, 2022). In the context of this study, we selected constructs from both the inner and outer setting domains that relate to organizational readiness to qualitatively gauge stakeholders' perspectives on the city's level of readiness for such a program because organizational readiness is a critical component for successful implementation of a new program (Scaccia et al., 2015;Kononowech et al., 2021). To keep the interview <30 min, we selected only a few constructs from an exhaustive list of organizational readiness constructs from the CIFR Technical Assistance website. This type of formative research, conducted prior to the development of a program, could provide useful information to program planners and community organizers. We used the CFIR constructs to guide both the creation of the questionnaire and data analysis. The main and probing questions for the interview are presented in Table 1. The interviewers asked all the main questions and may selectively ask follow-up probing questions if they did not hear the answers from the main questions.

Participants
We conducted semi-structured interviews with a purposive sample of 31 stakeholders in the Philadelphia area that included staff members in city and government systems (n = 4), public health experts (n = 2), community leaders (n = 2), non-governmental organizations (NGO) community outreach workers (n = 2), cosmetology instructors (n = 2), nail supply store owners (n = 3), nail salon owners (n = 6, including 2 who are also cosmetology instructors and 1 who also owns a nail supply store), and nail salon workers (n = 14, including 1 who is also an outreach worker). The Vietnamese nail salon community was the focus of this study due to the high percentage of nail salons in Philadelphia that are owned by Vietnamese.

Data collection and analysis
We identified potential interviewees from publicly available online information on governmental websites, referrals from our community advisory board and our community partner Vietlead (from our parallel pilot study), and in-person outreach. We recruited participants via emails (n = 7), phone calls (n = 18), and in-person visits (n = 6). We conducted 10 interviews in English and 21 in Vietnamese. After agreeing to participate, participants received either an electronic or a physical package that included basic information about the California HNSRP, how to participate, and the criteria to be certified as a healthy nail salon. They also received the interview questionnaire in advance. Our bilingual Vietnamese research team members conducted all the interviews. All phone (n = 25) and in-person interviews (n = 6) were recorded, translated into English if needed, transcribed, de-identified, and stored in a secure digital folder until the analysis.
The de-identified transcripts were then coded using NVivo 12 by 2 independent coders. We identified themes using the CFIR to identify patterns of facilitators and barriers. After the data analysis, we generated a bilingual preliminary report and sent it to all participants for feedback and validity check for the data interpretation. We actively heard back from eight participants and all the feedbacks were positive. The participants expressed their appreciation for being included in the data analysis and report. Qualitative data were analysed using standard qualitative research methods (NIH Office of Behavioral and Social Sciences, 2018; Creswell and Poth, 2018).
This project was reviewed and approved by the Institutional Review Board of Drexel University Figure 1 summarizes key facilitators (blue ovals), barriers (orange rectangles), and themes that can be both a barrier and a facilitator (gray rectangles) to adopting a HNSRP in Philadelphia in the context of the CIFR framework.

Key facilitators
Perceived benefits of the program to improve health and working conditions All participants believed the program would raise awareness of work-related health issues in their community and ensure workers are professionally trained and protected. Many interviewees expressed concerns about nail salon workers and owners currently not having access to accurate safety information and training such as workers' rights due to the language barrier. From the community's perspective, this program would fill the gap in the current cosmetology training and professional development and ensure that workers' rights are protected. A director of a local community organization serving many Vietnamese nail salon workers and owners said, 'I know those nail salon workers who work with many chemicals may not know their rights in the workplace. Many times, it's because they've never come across the information, or they may have heard some misinformation.' Many salons worker and owner participants also emphasized the importance of ongoing safety training as the nail salon industry is a major source of income for many Vietnamese families and most workers are chronically exposed to chemicals for long hours every day. An owner said, '[The program] helps protect the health of nail workers. They work long-term, connected for a long time at work. They work every day, every week, from year to year, so health is especially important.' From the state's and city's perspectives, the program would support them to do their job by ensuring the correct information can reach the community and workers know their rights and the process to make a complaint if needed. It has been especially challenging for them to connect with the community due to the language barrier. One Occupational Safety and Health Administration (OSHA) employee said: The workforce has limited English proficiency and limited information about what we can do for protection. They might not know what the process is and what their rights are to make that complaint, but as you know in Philadelphia there are a lot of salons… There's a good amount of work and workers that would need that intervention to make sure that they have proper safety measures at the workplace.
Moreover, most participants believed the program would incentivize employers to improve the work environment and being a recognized 'healthy nail salon' can also have a positive impact on the salon's public image and attract more customers. One owner expressed, 'It helps the owners protect their workers better and protect the customers and the environment.' The willingness of some stakeholders to leverage their organizational resources to support the adoption of the program Most participants (e.g., OSHA employee, city staff members from the Department of Labor, community leaders, and NGO directors as well as nail salon owners and workers) endorsed the program and expressed interest in being involved in the adaptation and implementation of the program in Philadelphia. All of the interviewees believed the program would require hand-in-hand collaboration between the city and the community. When asked about how each stakeholder could play a role in making this initiative happen, many respondents believed either the city's health department or labor department could take the lead. One city official expressed, 'Philly is a big union town, so worker rights are very well understood. The labor office is where we should start.' The director of a grassroots organization for working-class Asian communities said: It would be great if our organization can be part of [the program]. Let's say the Office of Labor receives city funds to hire a staff member that supports the certification of this program. They could work with community-based organizations like us, which lead to putting together a training program that nail salon owners and workers must go through and commit to implementing these steps. And then you can get city recognition as a certified healthy nail salon. Once that certification happens and the Office of Labor needs to periodically check in to ensure that the practices are in place… and that could also happen with the support of a community-based organization that has established those relationships with those new clients.

Perceived as a necessary step to improve the underserved salon community
Most interviewees acknowledged the need for investment in the immigrant nail salon worker community and perceived the program to be a necessary step to create trust and partnership between the city and the community. From the public health perspective, the program was believed to have a powerful impact in facilitating a better understanding of the issues the community is facing and thus would help address the current health disparities and social inequities. A city goverment's public health expert said: [The program] will help us better understand the health disparities and gaps and negative health outcomes and negative working conditions. What are the biggest issues that are impacting this community and how are they impacting them? It will help us improve health outcomes and hopefully address the health disparities in the nail salon worker community in Philadelphia. I do not think anyone else is going to do it. This initiative can also pave the way for future public health programs and workers' rights initiatives, as well as community development and empowerment projects. A city official said, 'The program can assist with community engagement and help the nail salon community feel like they are an important part of the larger Philadelphia community and help people feel like they are prioritized.' A state official also said, 'It's important for the city of Philadelphia, and for the state to know how diverse our communities are and for us to develop programs that can impact that through workplaces, where people get their livelihoods, and we want these communities to be safe at our workplaces.' One public health expert said, 'The program might help members of that community to become more empowered to take charge of their own health or to be advocates, or to be more engaged in community level work, community policy, things like that.' This also translates into the development of projects to empower immigrant-owned, woman-owned small businesses and uplift the entire working-class, immigrant community.

Perceived high cost and time commitment from the owners and workers
Cost and time commitment are the biggest barriers for many owners and workers to participate in the program. Most nail salon workers interviewed work 5-6 days a week, 9-12 h a day, and reported not having time for continuing training and professional development. They said they would be much more likely to participate in the training if it were paid. One salon worker expressed: I think the first is income. If people have enough money to provide for their family, they will have the peace of mind to work. But now they can't even make the basic income, how can they think about anything else? If they make enough money, they may want to talk with you. But now their income is too low, all they care about is compete for customers, they would not have time for you. Several salon owners acknowledged the benefits of the program and their willingness to change their salon's environment and working habits but considered the costs to upgrade their nail salons to meet the certification standards to be a prohibitive factor. They expressed concerns that switching to safer products with less harmful chemicals and upgrading the ventilation systems would cost them a lot of money. Most owners said that their family business had already been operating at a very narrow profit margin. Therefore, increased costs could be detrimental to their businesses. An owner expressed, 'It will be hard for us because we will have to pay more and take care of more things and it will be more restrictive for us to do business.'

Funding to afford language assistance and community outreach
The program was perceived by some stakeholders as 'complex' given language and cultural differences that need to be overcome. Some said it could come across as 'too niche to be funded' given the issues in this industry not being well-known at the city level. A director of a community organization said, 'I think the service industry in general is overlooked by the city… There's very, very little attention paid to language access. If there was ever a recognition program that was rolled out with language access, primary language access must be at the forefront.' A state official also expressed concerns about funding sources for this initiative: A potential barrier is that it would seem so specific that it will not be impacting a larger workforce that people will feel like it is too niche to fund. It is about placing the program and how it permeates various aspects of the Philadelphia economy. It would be helpful for people to understand the importance of the program situated within the bigger context.
Others disagreed that the program is 'niche to be funded.' One participant said: It's not that the program is niche to fund, but I think there got to be larger education around the nail salon industry, who owns it, how it operates and the work safety standards that need to be implemented or discussed. It's an issue with education around this workforce at the Philadelphia level in terms of city council and the city offices to learn about the importance of this. It would be good to analyze how these programs came to be in terms of funding, both at the city level but also at the state level. It will be good to present what happened in California with Santa Monica and San Francisco to try to figure out how other states support the implementation of this and having that history will help inform some of the State senators and the House representatives.
Language assistance and partnerships between the city and community organizations need to be established at the forefront for the program to be successfully implemented. Ongoing financial and technical support is also needed at every step of the process of planning, implementation, and evaluation.

Buy-in and visibility from the nail salon community
Policy expert participants emphasized the importance of the community's visibility in pushing forward the adoption of the program at the city level. One city official expressed: I think once you've gotten those numbers together, build some momentum behind those numbers, increase the visibility of the program, hold town halls or community hearings or go to City Hall. Visibility is going to be important, but it can be difficult for people to step out in the spotlight. Data along with people showing up to be visible will be helpful in getting people to pay attention.
However, the community's buy-in for the program was affected by an overall lack of awareness of the program. A community organizer said, 'The barrier for this program is it's too new so the owners may not be willing to be open-minded. They may understand this issue is important, but the owners and workers are already used to their own ways of doing things. They do not want to change. They don't think it's important enough for them to participate.' The community's willingness to be visible and advocate for the program was also affected by the stigmas of being immigrant workers, fear of interacting with authorities, and lack of trust in the government, as well as the impact of COVID-19 and the associated anti-Asian sentiment. A community leader said, 'You're talking about an industry that is mostly comprised of immigrant workers and immigrant small business owners. There are a lot of stigmas to show up to those kinds of things and a lot of mistrust.' Another community member mentioned the fear of interacting with the authorities eloquently through what he witnessed with his mother, a nail salon worker. He said: You know, my mom is a nail salon worker. All her friends are. When we moved here from Vietnam, we know that is the only thing. If you are a woman and you are Vietnamese immigrant, that is one of the three things you can do. The other two are working in a restaurant or working in a factory, where any of those spaces are also equally exploited. My folks do not speak English and immigrants are afraid of stirring waves and contacting with authority. They just put up with it. My mom was exploited her whole life. But every time I am like 'you should put a complaint' and she is like 'no.' She does not want to make waves. She does not want to be the one who snitched out… It is just a big shame to have it happen to her in the first place.
All the interviewees from the community emphasized the importance of making the intention of the program clear from the beginning and educating the community on the benefits of the program to improve buy-in and encourage participation. One nail salon worker said, 'You should make it clear that this program is designed to help them and the community, not to report anybody.'

Lack of implementation leaders/champions within the city departments
Despite the endorsement of the program from many stakeholders, there was no clear consensus on who should be the implementation leader of the program. This is a critical missing piece because the program's transdisciplinary nature requires an implementation leader to act as a liaison to bring various city departments together to work with the community. According to the interviewees, one of the reasons for this lack of clarity is those city departments, such as the labor department, the health department, and the Licensing & Inspection department, often work in silos with a narrow margin of funding on their own, which makes it challenging to create and manage new collaborative projects. To address this issue holistically, these departments need to work together and community organizations can organize to force the city to pay more attention to these issues.
Moreover, the interviewees emphasized the importance of enrolling the 'actual people' at the city level on boards to be the champions for the program. One city official said, 'It depends on who is leading. Philly is a town where it is less about the organization or the name of the organization and more about the actual person. It sucks because then, if the person leaves, there is really no permanence. It can be excellent one year and then not the next year.' Interviewees also expressed concerns about the sustainability of the program and agreed that one of the city departments needed to house it as an official program, where they could allocate ongoing staff time and resources.

Discussion
The purpose of this study was to bring various stakeholders' voices to the discussion about potential public health policies to improve the work environment for nail salon workers, a community traditionally underserved in Philadelphia and in the US. One of the key barriers was the lack of buy-in and visible advocacy from the community, which stems from lack of awareness of the program and fear of stigmas of being immigrants. Most nail salon workers are immigrants and refugees (Sharma et al., 2018) who are not familiar with the legal system in the US and are afraid of interacting with the authorities. They are especially cautious when it comes to programs that require monitoring and reporting for fear of causing trouble with the authorities and leading to more targeted oversight, despite being at high risk of work-related illnesses. This visibility issue has been well-documented in other public health and occupational projects working with immigrants from the Latino and other Asian communities (Eggerth and Flynn, 2010;Morey, 2018;Wallace and Young, 2018). More education and outreach within the nail community is needed to raise awareness of the issues and encourage the community to be visible and advocate for policies suitable for their needs. Community-engaged participatory research, especially pilot programs where nail salon workers and owners can participate and learn about the issues and the HNSRP, are beneficial to build trust and raise awareness of the program in the community.
Another barrier was the lack of government funding. This partly stems from lack of awareness of the issues at the city level and the overall underinvestment in this community. Public health literature refers to this phenomenon as 'structural invisibility,' society's privileging and paying more attention to some social group over others, or simply 'you cannot fix what you don't see.' (Flynn et al., 2022) Structural invisibility manifests in lack of attention paid to language assistance and community outreach, leading to the absence, or lack of surveillance data on this group of minority workers, which filters the 'reality' that institutions see, what they consider as important and how they allocate funding (Rodriguez-Lainz et al., 2018;Flynn et al., 2022). It is important to reframe the narrative and recognize the issues experienced by nail salon workers are a part of larger inequities experienced by immigrants and BIPOC (Black, Indigenous, and People of Color) communities, women, and small business owners, as well as the working class in Philadelphia. More advocacy at the city level is needed to reveal this blind spot and bridge the gap between the authorities and community. It's important for organizations and governmental agencies to reassess their processes and develop the institutional capacity to work with this increasingly diverse workforce more effectively.
The program was also perceived as providing better strategies for participatory nail salons to advertise for their business and attract customers. Future research on social marketing could be explored to gain insights into how the HNSRP can impact the public image of nail salons and into ways to support salons to leverage this as a marketing tool. According to many salon owners and workers in the study, local nail supply stores also play a critical role in the success of the intervention given that they are the source where salon owners and workers purchase nail care products and supplies for their salons. Outreach and collaboration with local nail supply stores may also facilitate the program's uptake.
Perceived challenges related to the cost to buy more expensive alternative products, and implement engineering controls, or the time commitment for staff training are not unique to the nail salon industry but well-documented challenges for small businesses in general (Moutray, 2009;Honan et al., 2022). Like many other businesses, nail salon small business owners and their employees were highly impacted by the COVID-19 pandemic with limited support (Honan et al., 2022;. Both salon owners and workers reported difficulty applying for pandemic relief funds such as the Paycheck Protection Program and other small business loans for owners or unemployment benefits for workers (Herrera et al., 2020;Herrera et al., 2021;. These reports underscore the need for public policies to support small businesses and their employees, with an emphasis on language justice for non-English speaking communities as these small businesses are the economic backbone of many new immigrant communities in the US. Our study has several limitations. The first limitation is the inclusion of stakeholders who speak English or Vietnamese only. While Vietnamese Americans make up a large majority of the very racially and ethnically diverse nail salon workforce (Sharma et al., 2018), salon owners and workers who are not Vietnamese Americans may have very different lived experiences, needs, and perspectives on this program. The second limitation is the absence of key stakeholders such as the Pennsylvania State Board of Cosmetology and License & Inspection due to their non-responding to our invitation. Another key stakeholder group is the consumers. Our future work with the local community organizations will include surveying consumers in the Philadelphia area as this would provide critical information for advocacy purposes. Finally, our snowball sampling through referrals may result in participation and volunteer biases and the small sample size, while suitable for in-depth qualitative inquiry, may limit generalizability of research findings.
Despite these limitations, the strength of our study is the diverse voices that we were able to bring together to shed light on ways stakeholders could work together to promote health and well-being of an underserved worker community through public policy. Local policymakers, public health practitioners, and community organizers may find our findings useful to inform their next public health programming and/or advocacy strategies. As a continuation of this work, we plan to collaborate with the CA Healthy Nail Salon Collaborative and local health departments that have such programs to identify lessons learned. While our study's focus is in Philadelphia, various aspects of our findings may have relevance for other municipalities across the US that may contemplate the adoption of similar voluntary programs to meet the needs of the nail salon workforce within their states and preserve the economic stability of small businesses. This type of study may be replicated in other geographic locations to better understand the local political landscape and the level of engagement from CBOs to address the issue in a more sustainable way.

Conclusions
We used the CFIR framework to identify key facilitators and barriers to implementing the HNSRP in Philadelphia. The success of this program and many other community-engaging public health interventions, depends on the awareness of the complex underlying social factors that influence the community's willingness and capacity to participate, effective collaborations between various key players in the public and private sectors, relationshipbuilding between the state and the communities, as well as secured funding for language assistance and community outreach.