Increasing Physical,Emotional,and Social Wellbeing in Adolescents Following a Multi-Week Indian Classical Dance Program: Results From a Single-Arm Pilot Study

Abstract

Background

The physical, emotional, and social wellbeing of U.S. high school-aged adolescents is a growing public health concern.

Objective

To describe the development and initial effects of an 8-week Bharatanatyam (Indian Classical Dance) intervention on wellbeing indicators in Midwestern high school students.

Methods

Using a single arm design, freshmen at a Midwestern high school completed an ethics-approved 8-week Bharatanatyam program teaching movements rooted in social cognitive theory and cultural foundations. At baseline, four, and 8 weeks, participants completed PROMIS Pediatric Profile-25 (Physical Function Mobility, Anxiety, Depressive Symptoms, Fatigue, Peer Relations, Pain Interference, and Pain Intensity), Body Appreciation Scale, Anti-Bias Behavior Scale (PSABBS), State Mindfulness Scale, and an 8-item acceptability questionnaire. Analyses included descriptive statistics, paired t-tests, Cohen’s d effect sizes, Pearson’s correlations, and linear regressions.

Results

Forty-six students provided assent and parental consent and completed the intervention. Most were female (62%) and Caucasian (80%). Feasibility and retention indicators were high (83-89%). Fifty-nine percent reported independent exercise 2-5 times weekly. Controlling for exercise frequency, significant decreases (P < 0.05) were observed between baseline and 8 weeks in PROMIS Anxiety (d = .80), Depressive Symptoms (d = .51), Fatigue (d = .61), and Pain Intensity (d = .77), with significant increases in Peer Relations (d = .80) and Body Appreciation (d = .97). Positive associations were found between anti-bias attitudes and lower anxiety (r = .485, P < .05), depressive symptoms (r = .510, P < .01), fatigue (r = .395, P < .05), and pain intensity (r = .567, P < .05). Anti-bias attitudes had significant associations with pain intensity, depression, and anxiety, and mindfulness was significantly associated with (P < .05) body appreciation.

Conclusion

This study provides initial evidence that an 8-week Bharatanatyam program improved emotional health and physical symptoms (ie, fatigue and pain) among adolescents, with mindfulness and anti-bias attitudes associated with overall wellbeing. Further testing with more rigorous study designs is warranted.

Keywords

bharatanatyam wellbeing adolescent

Introduction

Over the past two decades, stress, anxiety, and depression have increased significantly among adolescents in the United States.¹ In fact, a 2023 National Survey of Children’s Health found that 20.3% of U.S. adolescents aged 12-17 had a diagnosed mental or behavioral health condition, which represents a 61% increase in anxiety and 35% increase in depression from 2016.² Prior to the COVID-19 pandemic, some of the factors contributing to this increase include academic and socio-cultural pressures, biological and cognitive developmental factors,³ peer competition, toxic family environment, poor interpersonal skills, and negative physical-body perceptions.⁴ The direct and indirect physical, social, and mental health effects brought on by the COVID-19 pandemic worsened these elevations through increased social isolation, uncertainty, and goal interference.^5,6 Adolescents without adequate internal and external supports (eg, parental and peer support) are at elevated risk for moral disengagement.^7,8 Further, longitudinal studies have found that adolescent anxiety and depression may be associated with school refusal (OR = 13, 95% CI 3.4-42),⁹ later onset of substance use disorders (n = 627, 4-year follow up),¹⁰ and increased rate of suicide ideation (OR = 2.8, 95% CI 1.71-4.58, n > 1000).¹¹

Cultural bias is defined as an unfair judgement rooted in cultural differences. These biases exacerbate adolescent vulnerability to mental health disorders and disproportionately affect adolescents from marginalized backgrounds.¹² A mechanism to mitigate cultural biases may be cultivating cultural empathy, which is the ability to understand, appreciate, and relate to individuals from diverse cultural backgrounds. One measurable component of cultural empathy is anti-bias attitudes.¹³ Emerging research has shown that anti-bias awareness programs may help adolescents reflect on their own cultural experiences (n = 195 seventh graders),¹⁴ challenge exclusionary attitudes, and strengthen cross-cultural peer relationships (P < .001, n = 983 students).¹⁵

Conventional mental health treatments (eg, psychotropic medications¹⁶ and cognitive behavioral therapy¹⁷) and integrative, mind-body approaches (eg, yoga and tai chi) have demonstrated promise in promoting adolescent wellbeing and cultural empathy skills within educational settings.¹⁸ Dance-based interventions represent a distinct framework by combining physical and emotional exploration with narrative engagement and social connection. Dance is associated with improvements in psychological (eg, depressive symptoms, executive function) and physical health outcomes (eg, daytime fatigue, pain reduction) for school-aged children.^19-23 Dance also facilitates communication of emotions, cultural experiences, and identity with others.^24,25 Emerging evidence suggests that these shared, embodied experiences can strengthen social bonding (P < .0001, n = 58 adolescents)²³ and overall cultural empathy in adolescents.²⁶ Further, body-based, nonverbal communication encourages somatic exploration and provides a unique approach to anti-bias development.²⁷

School-based programs that strengthen physical and psychological well-being have demonstrated efficacy in mitigating anxiety and depression in adolescents (P < .01, n = 22 420).²⁸ Similarly, cultural immersion experiences targeted to develop an anti-bias awareness can be effectively administered in educational settings.²⁹ Social Cognitive Theory (SCT) provides a useful framework for school-based behavior change, where facilitating core SCT principles (eg, observational learning, guided practice, and social interaction) strengthen learning and engagement.³⁰

While the aforementioned research demonstrates efficacy of school-based mental health programs,^28,31 variety in available resources remain limited³² as present programs are centered on Western psychological frameworks (eg, cognitive behavioral therapy).^28,33 One less frequently studied dance-based movement practice that may address this need is called Bharatanatyam. Originally known as Sadir Aatam, Bharatanatyam is an ancient Indian Classical dance form created by hereditary dancers from Tamil Nadu, India.³⁴ Bharatanatyam is practiced for a variety of purposes, from exploring mythological stories to cultural identities. Bharatanatyam embodies three main concepts: nritta, natya, and nritya.³⁵ Nritta represents geometric movements made by hand gestures (mudras) and basic footwork (adavus), which are set to a talam or a rhythmic measure. Natya represents exploring emotions through music, literature, and drama. Nritya merges nritta or geometric movements with natya or emotional exploration to convey expressive stories.³⁵ The integration of storytelling with movement may support overall wellbeing by connecting physical engagement with a sense of self and the environment.³⁶

To date, Bharatanatyam as an adjunct dance-based intervention in integrative medicine has been largely unexplored. Previously, Bharatanatyam practices were applied to help medical students improve inter-cultural communication,³⁷ while another study found significant effects of Bharatanatyam practice on motor skill and balance improvement in 36 children aged 6-10 years living with Down syndrome.³⁸ Further research found that Bharatanatyam helps strengthen cognitive functions, wellbeing, mindfulness, and reduction in stress.^36,39,40

In our current study, we present information on the development, delivery, and evaluation of an 8-week Indian Classical Dance program to high school freshmen on outcomes of mental wellbeing and cultural empathy. Additionally, we describe associative variables that highlight critical components of the intervention.

Method

Procedures

Ethics Approval

This study was reviewed and approved by the Middleton-Cross Plains Area School District Ethics Board, which serves as the district institutional review board. Permission was granted for this research project to be conducted at Middleton High School during a school health course called Foundations of Health.

Participants

Participants were high school freshmen recruited from the Foundations of Health class. Assent and parental consent were provided by all research participants and their guardians. All students enrolled in Foundations of Health were allowed to be in the program regardless of their elective participation to be in this research project. However, data was only collected and analyzed from students who provided signed consent and assent forms. Participants were informed during the consenting process and throughout the study that they could abstain from any part of the course that felt uncomfortable or too difficult, and they could withdraw their participation at any time.

We analyzed data from the 46 students who received parental consent and participated in the intervention programming. The majority of the participants were female (62%), Caucasian (80%) and were on average 14 years old. Fifty-nine percent reported exercising between 2-5 times a week. See Table 1.

Table 1.

Demographic Characteristics of Participants at Baseline

Baseline characteristics	N	%
Age
M = 14.2 (SD = .38)
Birth year
M = 2004 (SD = .47)
Gender
Female	28	60.9
Male	15	32.6
Transgender female	0	0
Transgender male	1	2.2
Gender Variant/Non-conforming	0	0
Not listed	0	0
Prefer not to answer	2	4.3
Race
White	36	78.3
Black	0	0
Asian or Pacific Islander	6	13.0
Native American or Alaskan native	0	0
Mixed race background	3	6.5
Other	0	0
Exercise frequency
Daily	15	32.6
4-5 times each week	12	26.1
2-3 times each week	15	32.6
Once each week	1	2.2
A few times each month	1	2.2
Not at all	2	4.3

Measures

Participants completed four self-report measures at baseline, four weeks, and 8 weeks; an additional acceptability questionnaire was administered at 8 weeks only. At baseline, four weeks, and 8 weeks, participants completed the PROMIS Pediatric Profile-25, which is a 25-item measure that has a 5-point rating scale, ranging from 1 (never) to 5 (always).⁴¹ Participants were asked to reflect on the past 7 days for each question. The scale includes short forms of Physical Function Mobility, Anxiety, Depressive Symptoms, Fatigue, Peer Relations, Pain Interference, and Pain Intensity. All short forms except Pain Intensity were scored with a T-score metric (eg, Mean = 50; Standard Deviation = 10). Participants used a 5-point scale from 1 (never) to 5 (very much) to complete the State Mindfulness Scale (SMS), which measured present moment awareness of mental processes and bodily sensations through two subscales state-body (ie, awareness of physical sensations) and state-mind (ie, cognitive and emotional awareness). Participants also completed a 17-item Personal Self-Assessment of Anti-Bias Behavior Scale (PSABBS), which measured self-awareness of personal attitudes and behaviors about other cultures, and the Body Appreciation Scale (BAS), which is a scale reflecting positive body image.⁴²

In addition, we measured feasibility by calculating retention and attrition data. We measured a component of social validity, which is the perceived acceptability of the intervention.^43,44 Participants completed an eight-item acceptability questionnaire at 8 weeks using 5-point Likert scale items from 1 (not at all) to 5 (very much). Items (eg, “this program has been helpful to me” or “I was satisfied with the information provided”) were designed to capture multiple dimensions of acceptability, particularly satisfaction, perceived helpfulness, clarity of materials, and appropriateness of intervention structure (eg, pace, duration). Participants were also asked to identify the most and least helpful components of the intervention (footwork, hand gestures, combination of both, or neither). These items aimed to capture one element of ecological validity (social validity) and aimed to reflect the extent to which our intervention was meaningful and relevant within school-based contexts.

Statistical Analysis

Using SPSS (version 29), we calculated descriptive statistics and frequencies of sociodemographic and feasibility/acceptability data, as well as pre-post change on questionnaires between baseline and 8 weeks using paired t-tests and general linear models (ANCOVA). For acceptability questions, we collapsed the categories 3-5 (somewhat to very much) to indicate endorsement. A rating of “somewhat” was selected as the threshold to reflect a meaningful positive orientation toward the intervention, whereas lower ratings (eg, “slightly” or “not at all”) were not considered indicative of endorsement. Given the exploratory nature of the feasibility and acceptability measures, these data points were analyzed descriptively. Given the potential confounding role of previous experiences with exercise, self-reported exercise frequency was held constant in models. Statistically significant changes were identified as P < .05. Unless otherwise noted, all references to “significant” indicate statistical significance (P < .05). Although data was collected at four weeks, primary analyses focused on changes between baseline and 8 weeks to evaluate overall intervention effects rather than to characterize early trends. This is consistent with recommendations for a pre-post analytic approach in exploratory, single arm designs.⁴⁵ We also calculated Cohen’s d effect size coefficients (M1 - M2/σpooled) to estimate the relative magnitude of change, controlling for the correlation coefficient of pre/post-test means. Cohen’s d may be interpreted for clinical significance with a small effect size ≤.3, medium .5-.6, and large ≥.7.⁴⁶

Following this, we conducted exploratory Pearson correlation analyses to explore bivariate associations between improvements in outcome variables. Change scores were calculated between baseline and 8 weeks for all outcome variables and were coded such that positive values signified improvement (eg, decreases in anxiety, depressive symptoms). Significant correlations (P < .05) in the initial analysis were then further examined in a linear regression model to examine whether increases in state mindfulness (state mind and state body) and anti-bias scores were associated with improvements in outcome variables.

Intervention Development

Members of our group (SP, CS, BH, DV) developed an 8-week Bharatanatyam-based mind-body program that could be implemented within a high school health class curriculum. The first author (SP) is a classically trained Bharatanatyam dancer, with 18 years of experience. She led the creation of program content and pedagogical adherence to Bharatanatyam principles. Other co-authors (CS, BH, DV) have expertise developing, implementing, and evaluating mind-body research programs and advised on structural, procedural, regulatory, and research-related aspects of program implementation. Early in development, decisions were made regarding program length (8-weeks, 45 minute-long sessions) and delivery mode (in-person, group based) to be practical within a school-based health curriculum while ensuring sufficient exposure to intervention. These decisions were made to be consistent with other gold standard mind-body interventions, such as Mindfulness-Based Stress Reduction (MBSR).⁴⁷ For example, MBSR interventions delivered using similar modalities have demonstrated meaningful improvements in psychological outcomes in adolescent populations.^48-50

Each 45-min session consisted of a structure that balanced movement-based practice with guided reflection. Approximately 25-30 min were dedicated to learning and practicing Bharatanatyam movements and the remaining 15-20 min focused on guided reflection and discussion, where students were encouraged to connect movement to emotions, personal experiences, and broader cultural themes. This structure was designed to integrate physical movement with opportunities for social interaction and cultural dialogue. Engagement was informally monitored through instructor observation of participation in movement and discussion. No formal grading or structured assessment was used in order to maintain a low-pressure environment and support student comfort, autonomy, and participation.

In addition to in-class sessions, students were provided with a brief optional, “homework” handbook that included summaries of weekly content and visual references for key movements. Students were encouraged to engage in informal practice outside of class and to use the handbook to self-track their engagement (eg, frequency of practice, types of movements practiced, reflections experience). Homework was not formally assigned or reviewed as the intent was to encourage low-burden self-engagement rather than formally track adherence.

Given the high level of Bharatanatyam knowledge and skill needed, this program was taught by lead author SP in the school gym. It was also based on learning principles of Social Cognitive Theory, which considers how individuals’ actions are influenced by their social environment and vice versa.⁵¹ Principles of SCT were incorporated into the intervention through instructor-led modeling of dance movements, guided practice, and group-based format for peer engagement. While SCT was not directly measured, its principles guided intervention programming to support learning and engagement. For example, dance movements modeled by the instructor were followed by hands-on opportunities for guided and repeated practice. The 8-week program was designed to include postures specifically tailored for non-Bharatanatyam dancers and followed a developmentally sequenced pedagogy (Table 2). Overall, the course aimed to emphasize personal reflection, cultural exploration and dialogue, collaboration, and artistic expression.

Table 2.

8-Week Course Content

Week	Purpose	Bharatanatyam movements
1	Introduction to bharatanatyam. Introduce students to bharatanatyam, covering its history, and significance, and its impact on wellbeing as a mind-body practice. Encourage students to reflect on feelings, emotions, and thoughts & reflect on similarities, differences, and cultural dialogue from lesson elements.	Introduction to the basic bodily poses of bharatanatyam (standing or samam, half-sitting or araimandi, full-sitting or muzhimandi), along with breathing exercises in each pose.
2	Nritta: Footwork. Identify different ways to move parts of your feet and explore basic footwork. Encourage students to draw parallels between foundational foot movements and their own experiences (practicing or trying something new). Encourage students to reflect on feelings, emotions, and thoughts & reflect on similarities, differences, and cultural dialogues from lesson elements.	Advaus (without hands), examples include: Thatadavu, Thatumet, and Tha thai thei thas. Adavus are practiced in different talams (or rhythmic cycles).
3	Nritta: Hand gestures: Identify different ways to move your hands through hand gestures (see below), learning the meaning and cultural significance of each gesture. Learn to practice gestures intentionally with mindfulness exercises. Encourage reflection.	Single hand gestures (asymyuta hastas) & double hand gestures (samyuta hastas). Breathing exercises with different hastas or hand gestures.

4	Nritta: Footwork and hand gestures: Combine previously learned footwork with hand gestures to enhance mind-body connection. Encourage students to reflect on feelings, emotions, and thoughts & reflect on similarities, differences, and cultural dialogue from lesson elements.	Advanced advaus (with hands and feet): Kuthadavus, tha thai thei thas, and natadavus.

5	Natya: Understanding basic emotions: Learn to identify and express the nine basic emotions (navarasas), emphasizing the importance of self-expression. Encourage students to reflect on feelings, emotions, and thoughts & reflect on similarities, differences, and cultural dialogue from lesson elements.	More advanced adavus strung together to create a sequence; examples include: Kuthadavus, tha thai thei thas, and natadavu
6	Natya: Emotional expression: Explore ways to utilize hastas and navarasas to convey stories and experiences (ie, reading a book or celebrating a religious practice). Encourage students to reflect on feelings, emotions, and thoughts & reflect on similarities, differences, and cultural dialogue from lesson elements.	Guided story-telling using hand gestures and emotions.
7	Nritya: Narrative expression with movement: Exploration of stories and personal experiences, with both nritta and natya (ie, geometric movements and expressions). Encourage students to reflect on feelings, emotions, and thoughts & reflect on similarities, differences, and cultural dialogue from lesson elements.	Guided story-telling using hand gestures and emotions, with stories ranging from traditional stories from Bhavayami, an ancient Indian textbook to everyday scenarios (eg, schools with friends, at home with siblings, etc).
8	Nritya: Choreography: Collaborate with peers to create choreography that reflects their personal thoughts, emotions, feelings, and experiences. Encourage students to reflect on feelings, emotions, and thoughts & reflect on similarities, differences, and cultural dialogue from lesson elements.	Guided story telling with nritta and natya.

The course consisted of three main Bharatanatyam components: (1) nritta (ie, technical movements or geometric shapes created with bodily movements), (2) natya (ie, theatrical storytelling through the navarasas or emotions like sadness, happiness, and bravery, and mudras or hand gestures), and (3) nritya (ie, a combination of geometric bodily movements with theatrical storytelling; nritta + natya). In each weekly session, the course also consisted of information and discussion on the cultural significance and meaning of the Bharatanatyam principles. The intervention was designed to support the development of anti-bias skills by integrating storytelling, emotional exploration, and guided reflection.

During the first two weeks, students learned about how nritta focuses on geometric movements of the feet. During the third week, students learned the significance of Bharatanatyam hastas or hand gestures. Hastas come in two forms: single hand gestures, asymyuta hasta, and double hand gestures, samyuta hasta. Each hand gesture has several meanings and are chosen to be used by the context or environment. Taken together, hastas almost serve as another form of sign language. According to the Natya Shastra, there is no limit to creation and interpretation of new hastas.⁵² Each gesture carries multiple meanings depending on context and environment. Students were encouraged to explore hastas to describe their thoughts, feelings, and emotions.

During the fourth and fifth week, students practiced nritya by combining hand gestures and footwork to create a sequence of geometric steps. During the sixth week, students were introduced to narratives drawn from Indian classical texts and compositions (eg, Bhavayami Raguramam), which were used to explore themes of interpersonal conflict, bias, culture, relationships, and empathy. They also reenacted these stories by practicing natya or storytelling through the nine basic rasas or emotional states (ie, shringar or delight, hasya or laughter, karuna or sorrow, raudra or anger, veera or heroism, bhayanaka or fear, bibhatsa or disgust, adbuta or wonder, shanta or peace). Taken together, these activities promoted perspective-taking by encouraging students to interpret characters’ experiences and relate them to their lives.

Finally, during the eighth week, students were given choreography challenges, where they combined their knowledge of nritta, nritya, and natya to portray stories from their lives. These challenges offered students a new way of moving their body and supported cultural empathy skills by encouraging reflection and sharing of lived experiences within their culturally grounded context.

Importantly, in each section, the objective was not only to introduce new movements, but also to encourage students to approach unfamiliar situations with a mindful and nonjudgmental attitude, paying attention to their thoughts, emotions, and sensations. Similarly, it was equally important that the students each week engage in cultural dialogue, investigating similarities and differences in their experiences.

Results

Feasibility and Acceptability

Between baseline and 4 and 8 week follow up assessments, we observed retention rates of 83% and 89%, respectively. At 8 weeks, 65.7% of participants reported that the program had been helpful to them, with over two-thirds (64.7%) reporting satisfaction with the information provided. Between 62.9%-74.3% of participants reported the handbook was logical, the homework had clear instructions and was easy to complete, and the number of exercises, class duration, and pace of course materials taught was adequate. Full item-level response distributions are presented in Table S1.

Changes Between Baseline and Eight Weeks

Assumptions of the general linear model were evaluated prior to analysis. No substantial deviations from model assumptions were observed. Controlling for exercise frequency, statistically significant decreases (P < .05) were observed between baseline and 8 weeks in PROMIS Anxiety (mean difference/SD difference = −6.61/12.19; d = .80, P < .001), Depressive Symptoms (mean difference/SD difference = −10.75/13.70; d = .51, P = .002), Fatigue (mean/SD = −6.56/10.44; d = .61, P < .001), and Pain Intensity (mean difference/SD difference = −1.67/2.00; d = .77, P < .001), while significant increases were seen in Peer Relations (mean/SD = 8.04/10.88; d = 0.80, P < .001), body appreciation (mean difference/SD difference = 13.79/13.67; d = .97, P < .001), anti-bias (mean difference/SD difference = 18.55/16.22; d = 1.15, P < .001), state-mind (mean difference/SD difference = 2.97/5.10; d = .58, P < .001), and state-body (mean difference/SD difference = 4.31/5.03; d = .85, P < .001). No statistically significant changes were observed in physical function mobility and pain interference. See Table 3.

Table 3.

Difference Scores Between Pre-Post

Domain outcome measure	Experimental	T-test			95% CI		95% CI, Cohen’s D
Domain outcome measure	N M (SD)	T	DF	P (two sided)	Lower	Upper	Lower	Upper
Anxiety
Pre test	41 58.65 (11.93)
Midpoint	38 51.94 (10.65)
Post test	41 47.91 (11.03)
Difference	41 −6.16 (12.19)	−5.02	40	<.001	−15.07	−6.42	−1.13	−.43
Depression
Pre test	41 54.25 (10.67)
Midpoint	38 51.75 (11.78)
Post test	41 48.09 (11.04)
Difference	41 −10.75 (13.70)	−3.23	40	.002	−10.01	−2.31	−.82	−.17
Fatigue
Pre test	41 53.75 (10.12)
Midpoint	38 50.50 (10.58)
Post test	41 47.19 (9.83)
Difference	41 −6.56 (10.44)	−4.02	40	<.001	−9.86	−3.27	−.96	−.29
Pain intensity
Pre test	41 3.18 (1.94)
Midpoint	38 2.32 (2.37)
Post test	41 1.50 (1.89)
Difference	41 −1.67 (2.00)	−2.31	39	<.001	−2.31	−1.03	−1.19	−.47
Peer relations
Pre test	41 45.19 (9.05)
Midpoint	38 47.81 (8.10)
Post test	41 53.24 (8.11)
Difference	41 8.04 (10.88)	4.735	40	<.001	4.61	11.48	.39	1.08
Body appreciation
Pre test	39 39.10 (11.78)
Midpoint	38 44.62 (12.65)
Post test	39 52.89 (9.66)
Difference	39 13.79 (13.67)	6.30	38	<.001	9.36	18.22	.61	1.39
State mind
Pre test	39 15.71 (4.52)
Midpoint	40 16.39 (3.21)
Post test	39 18.69 (4.27)
Difference	39 2.97 (5.10)	3.64	38	<.001	1.32	4.62	.24	.92
State body
Pre test	38 18.36 (4.50)
Midpoint	34 20.84 (3.96)
Post test	38 22.68 (4.58)
Difference	38 4.31 (5.03)	5.28	37	<.001	2.66	5.96	.48	1.22
Anti bias
Pre test	40 49.50 (14.45)
Midpoint	38 53.70 (11.41)
Post test	40 68.05 (9.44)
Difference	40 18.55 (16.12)	7.27	39	<.001	13.39	23.70	.74	1.54

Note. Inferential testing results are between pre-test and post-test scores; midpoint means and standard deviations are for descriptive purposes only.

Correlation Analysis

Correlations among all study variables (anxiety, depressive symptoms, fatigue, pain intensity, peer relations, body appreciation, physical function mobility, anti-bias attitudes, and state mindfulness) were examined. Table 4 presents the Pearson correlation coefficients for the outcome variables. Correlations were conducted on change scores between baseline and 8 weeks. For all variables, change scores were coded so that positive values reflected improvement (eg, decreased anxiety and depressive symptoms were coded as positive change). For these measures, a positive relationship in the correlations means that both variables improved over time, while a negative correlation means that one variable improved while the other worsened. Significant positive correlations were found between anti-bias scores and anxiety symptoms (r = .385, P < .05), depressive symptoms (r = .448, P < .01), fatigue (r = .464, P < .01), and pain intensity (r = .431 P < .01). State-mind subscale of the state mindfulness scale showed a significant positive correlation with state-body subscale (r = .322, P < .05) and body appreciation (r = .346, P < .05). Similarly, state body subscale also showed a positive correlation with peer relations (r = .421, P < .05) and body appreciation (r = .641, P < .01), and state body showed a negative correlation with fatigue (r = −.407, P < .05). Similarly, physical function mobility showed a significant positive correlation with anxiety (r = .331, P < .05), depressive symptoms (r = .348, P < .05), and fatigue (r = .349, P < .05). Anxiety showed a significant positive correlation with pain intensity (r = .435, P < .01), fatigue (r = .582, P < .01), and depressive symptoms (r = .800, P < .01). Depressive symptoms additionally showed a significant positive correlation with fatigue (r = .72, P < .01) and pain intensity (r = .435, P < .01). Fatigue had a significant positive relationship with pain intensity (r = .428, P < .01). Peer relationships had a significant positive relationship with pain intensity (r = .358, P < .05).

Table 4.

Descriptive Statistics and Correlations for Outcome Variables

Variable	N	M	SD	Anti Bias	State mind	State body	PF mobility	Anxiety	Depression	Fatigue	Peer relations	Pain intensity	Body appreciation
Anti bias	40	18.6	16.1	—
State mind	39	2.97	5.1	0.28	—
State body	38	4.31	5.0	−0.12	.32*	—
PF mobility	41	2.89	8.1	−0.03	−0.04	−0.08	—
Anxiety	41	10.7	13.7	.38*	0.12	−0.17	.33*	—
Depression	41	6.16	12.2	.44**	0.02	−0.22	.34*	.80*	—
Fatigue	41	6.56	10.4	.46**	0.01	−0.4*	.34*	.58**	.72**	—
Peer relations	41	8.04	10.9	0.03	0.32	0.42*	0.08	0.24	.32*	0.14	—
Pain intensity	40	1.67	2.0	.43**	0.07	0.05	0.21	.43**	.47**	.42**	.35*	—
Body appreciation	39	13.8	13.7	0.16	.34*	.64**	−0.12	−0.01	0.11	−0.17	0.2	−0.006	—

Note. * = <.05; ** = <.01.

Linear Regression Analysis

Linear regression analysis was conducted to examine the associative relationship between increases in state mindfulness (both state mind and state body) and anti-bias with improvements in all other outcome variables (body appreciation, peer relation, pain intensity, fatigue, depression, and anxiety variables). Increased state body scores were significantly associated with improvements in body appreciation (β = .645, P < .001). Similarly, increased anti-bias scores were significantly associated with improvements in pain intensity (β = .567, P = .004), fatigue (β = .395, P = .031), depression (β = .510, P = .009), and anxiety (β = .485, P = .012). See Table 5.

Table 5.

Linear Regression of Outcome Improvement by Increased Mindfulness and Anti-bias Attitudes

	Standardized coefficient	T value	P Value
Improvement in body appreciation
Increase in anti-bias attitudes	.226	1.505	.143
Increase in state mind mindfulness	−.152	−1.007	.322
Increase in state body mindfulness	.645	4.347	<.001
Improvement in peer relations
Increase in anti-bias attitudes	.023	.114	.910
Increase in state mind mindfulness	.079	.391	.699
Increase in state body mindfulness	.295	1.447	.160
Improvement in pain intensity
Increase in anti-bias attitudes	.567	3.166	.004
Increase in state mind mindfulness	.014	.079	.938
Increase in state body mindfulness	.110	.596	.557
Improvement in fatigue
Increase in anti-bias attitudes	.395	2.274	.031
Increase in state mind mindfulness	.046	.266	.792
Increase in state body mindfulness	−.340	−1.947	.062
Improvement in depression
Increase in anti-bias attitudes	.510	2.802	.009
Increase in state mind mindfulness	−.125	−.687	.498
Increase in state body mindfulness	−.086	−.470	.643
Improvement in anxiety
Increase in anti-bias attitudes	.485	2.691	.012
Increase in state mind mindfulness	.089	.498	.623
Increase in state body mindfulness	−.107	−.592	.559

Bold indicates statistical significance.

Discussion

The purpose of this study was to describe the development, delivery, and initial effects of an 8-week Indian Classical dance program on physical, social, and mental wellbeing (ie, anxiety, depressive symptoms, peer relations, body satisfaction, anti-bias attitudes, mindfulness) among high school freshmen. We also aimed to explore potential associative variables among the outcome measures, which may provide insight for future iterations on the program and research experiments.

Overall, participation was feasible, with low attrition across assessment time points. Acceptability ratings were modest, with approximately two-thirds of the participants finding the program to be helpful and satisfactory. These findings may suggest the program was reasonably well-received, though the variability in ratings may reflect engagement fatigue. Future studies may benefit from optimizing program duration (eg, 4 weeks rather than 8 weeks), perceived relevance, and delivery models (eg, implement in non-classroom yet still school-based settings like after-school programs).

Statistically significant decreases in anxiety and depressive symptoms were observed upon program completion. These findings are consistent with previous dance-based intervention studies,^53-55 including an eight-month, after-school dance program that significantly reduced somatic symptoms in adolescent girls,⁵³ dance movement therapy programs that have decreased depressive symptoms,⁵⁶ and movement-based social-emotional wellness practices for students in classroom settings.^57-59 Next, results showed a significant decrease in pain intensity and fatigue, which is also in line with previous dance-based interventions that have demonstrated reductions in fatigue and improvements in physical functioning.^53,54,60 Several mechanisms may explain these effects. As students become more comfortable with their body, they may develop a greater awareness for dealing with pain and fatigue. Engagement in physical activity may support regulation of the stress response system and reduced physiological arousal, which is linked to pain and fatigue.^61,62 From a SCT perspective, the group-based and socially interactive nature of the intervention may have supported social reinforcement and embodied self-efficacy, which may have reduced perceived intensity of fatigue or pain.^63,64 Peer relations significantly increased with participation in all 8 weeks of the Bharatanatyam program. This may be attributable to peer acceptance gained through demonstrated excellence in physical activities.⁶⁵ The group-based activities also facilitate SCT principles such as observational learning, interpersonal skills, and social reinforcement.^66,67 Future research may investigate how program structure and delivery may influence peer-related outcomes. Results also showed a significant increase in body appreciation. Participation in movement-based activities is linked to strengthened body appreciation^68-71 as somatic practice in dance facilitates somatic exploration.⁷²

Our findings demonstrated significant increases in the state-body (eg, physical sensations, health, senses) factor of mindfulness. This is in line with research that has demonstrated the efficacy and feasibility of movement-based programs like Pilates, Taiji Quan, and gyrokinesis, to increase mindfulness scores and subscales.^73,74 Similar to these practices, Bharatanatyam movements emphasize core stability, concentration, breath, and overall awareness of physical and emotional bodily states. Additionally, the repetitive rhythms and bodily movements of nritta taught in weeks one and two may have enhanced body awareness and mindfulness.³⁶ We also found significant increases in the state-mind (emotional state, mood, attitude) factor of mindfulness. This may be because Bharatanatyam requires significant mental focus to learn complex movement patterns.⁷⁵ The cognitive demand to acquire unfamiliar movement may have facilitated present-moment awareness, a component of mindfulness, of emotions, feelings, and thoughts.⁴⁷ Storytelling with peers may have additionally contributed to participants’ heightened state of mind.⁷⁶ This may be because introspection on culture and identity encourages awareness of emotions and attitudes.

Results showed significant increases in levels of anti-bias, which echoes previous findings where cultural artforms in school-based dance programs have heightened cultural knowledge.⁷⁷ This may be attributed to our program’s team building exercises, which encouraged students to express their cultural stories and learn from the stories of others. These activities may have helped students foster a sense of mutual understanding and respect.⁷⁸ The weekly reflections and discussions on cultural dialogue may have helped create a more trusting, nonjudgmental, and supportive learning environment.⁷⁷ Future research on culturally grounded, movement-based programs may help expand the range of resources available in schools and encourage wider student participation.

Correlation analysis revealed significant relationships among study variables, as illustrated in Table 4. This analysis informed subsequent linear regression analyses, which examined the associative power between state mindfulness (both state-body and state-mind) and anti-bias attitudes with all other outcome variables. We found that state-body and state-mind mindfulness were significantly associated with greater body appreciation. The program’s emphasis to explore and reflect on novel bodily movements may have deepened their appreciation for their physical capabilities.⁷⁹ Additionally, the state-mind factor showed a significant associative relationship with peer relations.^80,81 The high frequency of group discussions to identify, process, and reflect on thoughts and emotions may have helped peers find shared experiences and strengthen bonds. Further, the anti-bias scale emerged as having a significant association with pain intensity, fatigue, depression, and anxiety, thereby heightening overall wellbeing. By focusing on building inclusive behaviors and attitudes (ie, anti-bias core skills), it may have strengthened coping and resilience strategies, which mitigate the impact of pain, fatigue, depression, and anxiety.^82,83 Similar research has shown that fostering inclusive environments can improve mental wellbeing.⁸⁴ Given the single-group pre–post design, findings should be interpreted as preliminary and associational. Observed relationships do not imply causality, and future controlled studies are needed to confirm directionality and mechanisms. Future studies may consider residualized change or longitudinal modeling approaches and may explore mindfulness and anti-bias skills as important targets for overall wellbeing in adolescents.

This study has several limitations. Due to the time constraints of when this course could be offered in the school’s block schedule, this course was delivered to only three separate classrooms. This scheduling constraint may have influenced acceptability scores, suggesting that the classroom-based delivery may not fully capture student participation in this intervention. The limited sample size of 46 students did not allow for as much diversity in the sample. Future studies should try to increase diversity and evaluate impacts of cultural differences on engagement with and outcomes from the intervention. Next, these findings should not be used to indicate efficacy of our program given the lack of experimental control. The single arm design of the study tailored for this early phase was appropriate for this initial pilot to examine patterns, trends, and relationships among variables, however any claims of efficacy at this point would be premature. Even though improvements in most outcomes were observed, these improvements could also be attributed to uncontrolled factors. Future investigations of this program should include experimental designs. Further, while SCT informed the design of the intervention, SCT-specific constructs (eg, self-efficacy, observational learning, social reinforcement) were not directly measured. Future research may incorporate these constructs to more explicitly evaluate the effectiveness of its mechanisms and more precisely inform program development. Lastly, given the requirement to obtain parental consent, this may have altered our sample to only include students coming from an environment that encouraged science, positive collaboration, and exploration. Future studies could investigate the role of an Indian Classical dance among students of different age groups, which may not require parental consent such as college students.

Conclusions

Our study suggests that an 8-week Indian Classical Dance intervention in an educational setting is feasible to deliver, modestly acceptable, and has the potential to improve physical, social, and emotional wellbeing. We found that anti-bias and mindfulness were significantly associated with these outcomes. These findings provide preliminary evidence to support continued refinement and implementation of school-based Bharatanatyam programs. Future research should examine underlying mechanisms and evaluate long-term benefits across diverse adolescents through experimental designs.

Supplemental Material

Supplemental material - Increasing Physical, Emotional, and Social Wellbeing in Adolescents Following a Multi-Week Indian Classical Dance Program: Results From a Single-Arm Pilot Study

Supplemental material for Increasing Physical, Emotional, and Social Wellbeing in Adolescents Following a Multi-Week Indian Classical Dance Program: Results From a Single-Arm Pilot Study by Shruti Parthasarathy, MPH, Christina Sauer, Bruriah Horowitz, David Victorson in Global Advances in Integrative Medicine and Health

Footnotes

ORCID iDs

Shruti Parthasarathy

David Victorson

Ethical Considerations

This study was approved by the Middleton-Cross Plains Area School District Deputy Superintendent of the Middleton-Cross Plains Area School District Ethics Board (ie, the district’s institutional review board) on October 16, 2019.

Consent to Participate

Written informed assent from participants and informed consent from their respective guardians were obtained.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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