Abstract
To prepare for research studies that would evaluate the impact of hula as part of a clinical intervention, including cardiovascular disease (CVD) prevention and management programs, kumu hula defined as “culturally recognized hula educators and experts,” were interviewed. Investigators sought to elicit their views regarding hula's traditional and contemporary connections to health and well-being, assess the cultural appropriateness of such projects, and suggest ways to maintain hula's cultural integrity throughout clinical intervention programs. Six prominent kumu hula from five different Hawaiian Islands participated in semi-structured key informant interviews lasting between 60 and 90 minutes. Each was asked open-ended questions regarding their attitudes, beliefs, and experiences regarding the connections of hula to health as well as their recommendations on maintaining the integrity of the dance's cultural traditions when developing and implementing a hula-based CVD program. All kumu hula endorsed the use of hula in a CVD intervention program and articulated the strong, significant, and enduring connections of hula to health and well-being. Each kumu hula also recognized that health is the full integration of physical, mental, emotional, and spiritual well-being. When care is taken to preserve its cultural integrity, hula may be an effective integrated modality for interventions designed to improve health and wellness.
Keywords: Native Hawaiians, Hula, Health, Well-being, Medical Interventions, Cardiovascular Disease
Background and Objectives
It is well established that Native Hawaiians disproportionately have numerous health disparities, including having the highest cardiovascular disease (CVD) mortality rate in Hawai‘i and one of the highest nationally.1–3 Despite recommendations to incorporate strategies to optimize patient adherence to CVD prevention programs,4,5 there are few CVD prevention and treatment interventions tailored for this high-risk population. Guided by a community-based participatory research (CBPR) approach, the Native Hawaiian dance form of hula was selected as the basis for developing and evaluating two CVD interventions: (1) post-hospitalization cardiac rehabilitation (CR), and (2) community-based hypertension management.6,7 Investigators, along with community and cultural informants, believed that Native Hawaiian cultural practices, such as hula, could be used effectively and appropriately as a part of CVD and other clinical interventions, but that it was important to gather insight from recognized cultural experts.
Hula, the indigenous dance of Hawai‘i, preserves significant aspects of Native Hawaiian culture, with strong ties to health and spirituality. Kumu hula which is defined as persons who are “culturally recognized hula experts and educators”, maintain and perpetuate this cultural tradition.8,9 Originally performed to convey history and spiritual beliefs, hula is now commonly practiced as a form of cultural and creative expression, and is comprised of specific controlled rhythmic movements that enhance or allude to the meaning or poetry of the accompanying songs or chants.10 While Native Hawaiians may have a cultural affinity for hula, dancers come from many different races and ethnicities, and hula is practiced by both men and women of all ages.11,12 There are at least 174 halau hula (hula schools) in Hawai‘i led by kumu hula and nearly 1,100 schools of dance teaching hula worldwide with enrollment ranging from a dozen to several hundred students.13,14
To prepare for a hula-based clinical intervention research and be consistent with CBPR principles and Native Hawaiian cultural protocols, key informant interviews were conducted with recognized and accomplished kumu hula. Specifically, the purpose of the interviews was to elicit kumu hula perspectives regarding hula's traditional and contemporary connections to health and well-being, assess the cultural appropriateness of the intervention, and to suggest ways to maintain hula's cultural integrity throughout the development and implementation of programs to prevent and manage CVD. To the investigators' knowledge, this is the first biomedical research study to scientifically examine the development of a clinical intervention based on hula.
Methods
Six prominent kumu hula were identified to participate in informant interviews. They were selected for gender balance, varied geographic location (5 different Hawaiian Islands) and hula lineage. Native Hawaiian culture gives special significance to genealogical heritage, and the transmission of knowledge within familial groups. This emphasis carries over to the cultural practice of hula where kumu hula strongly identify with the lineage of their training.15 Hula lineage can also have a connotation of particular expertise in specific dance repertoire, historic chants, and choreography. All kumu hula interviewed had extensive experience in providing hula training and education, were well-recognized authorities in hula, and acknowledged cultural resources for Native Hawaiian communities. Following accepted cultural norms, the kumu hula were first contacted by the investigators through a common acquaintance, if a current relationship did not exist.
Prior to the interview, the kumu hula were informed of the reason for the study: to use hula as basis for a CVD intervention. Each kumu hula was individually interviewed in person by a researcher and an assistant. Each interview included a series of open-ended questions soliciting opinions on (a) hula and health, (b) a hula-based CVD prevention and management program, (c) ways to preserve cultural integrity, (d) teaching students with illness/disability, (e) ways to improve retention, and (f) appropriate hula repertoire. With the permission of informants, all interviews were recorded, with participants given editing authority to exclude material that, upon reflection, they preferred not to share widely. The interview sessions lasted between 60 to 90minutes and were transcribed. Transcripts were evaluated using a thematic analysis method following standard qualitative methods.16 First, investigators reviewed all transcripts and established general domains determined from the context of the questions and the responses of the participants. Then, three members of the research team and a community member with hula training, independently reviewed the transcripts and identified repeating themes for each domain, and other themes that emerged with high frequency. Next, an investigator reviewed the transcripts to determine if additional themes or domains could be identified or clarified. Finally, the frequency of various themes was established through review of transcripts.
This paper presents a summary of findings from the first three areas of the interviews. While some of those interviewed expressed their views more succinctly than others, quotes in the discussion that follows are drawn from all those interviewed, with a minimum of two quotes and a maximum of five quotes drawn from any one interview. To preserve anonymity, each kumu hula is identified with a number in brackets. The study was approved by the University of Hawai‘i's Institutional Review Board.
Results
Interviews were conducted with 6 kumu hula, 1 male and 5 female with extensive experience teaching hula traditions, protocols, songs, chants and dances. All kumu hula were Native Hawaiian, most taught hula for 31–40 years, and one kumu hula had over 50 years of teaching experience (Table 1).
Table 1.
Kumu Hula Participants Demographic Characteristics
| Description | n (%) | |
| Gender | ||
| Female | 5 (83) | |
| Male | 1 (17) | |
| Ethnicity | ||
| Hawaiian | 6 (100) | |
| Non-Hawaiian | 0 (0) | |
| Age (Years) | ||
| 50–60 | 3 (50) | |
| 61 – 70 | 1 (17) | |
| 71 – 80 | 1 (17) | |
| 80+ | 1 (17) | |
| Years as Hula Educator (Years) | ||
| 31 – 40 | 5 (83) | |
| 41 – 50 | ||
| 50+ | 1 (17) | |
All kumu hula endorsed that hula could appropriately be used as part of a health intervention and conveyed that, with correct preparation and guidance, it could be conducted consistent within the parameters of the cultural practice. In addition, every kumu hula articulated that health is the full integration of the physical, mental, emotional, cultural, and spiritual facets of a person, a viewpoint that is consistent with traditional Hawaiian views of health. They expressed that the hula dance form affects all these health facets, particularly when hula is taught, practiced, and performed with traditional content and context in mind. One kumu hula, from Kaua‘i, put it very succinctly: No. 2 “Hula is not only dance, it's all of these things.” A second kumu hula elaborated: No. 5 “I see a really great relationship between hula and health in all aspects of health, not just physical health, but mental and emotional health, spiritual health; and I think hula is one of the few physical activities where you can—just the mere fact of what hula incorporates, automatically, you are addressing all, all aspects of the human being and the human being's health.”
However, acquiescing to the interview questions on specific sub-fields of health, kumu hula were willing to offer considerable insight into each area separately, allowing results to be discussed as somewhat distinct areas: (1) physical health; (2) mental health; (3) emotional and social support; (4) spiritual health; and (5) the importance of cultural integrity.
Physical Health
The first area discussed was physical health and hula. As one kumu hula described: No. 4 “Now, if we look at hula for its physical benefit, I don't think any hula dancer will say it doesn't benefit them physically. It gets them more in tune with their bodies, every aspect—where your elbows are, where your knees are, where are your toes pointed, where's your head, your chin up, your chin down, your eyes up, every part of your body is brought to your awareness…you get to know your body real quickly with hula…”
A kumu hula renowned for a dance style of vigorous physicality discussed how high levels of physical conditioning could be incorporated into hula training. One way described was through extended periods of continuous dancing; another was using weights on feet and hands. This kumu hula explained, No. 1 “Well, actually it started with sandbags, that was when I was taking hula, but I do that in other classes, they put on two pound weights.”
Others discussed various physical aspects of hula training including: breathing exercises, spine alignment, foot placement, and stretching. Clearly to all kumu hula, physical conditioning was only one basic, though necessary, level of hula: No. 2 “You have to start from scratch. When you build a house…you start from the foundation and the house got to build up. And that's how I teach.” Hula was seen explicitly as progressing through levels and stages: No. 4 “Like many things related to Hawaiian culture, there are levels and stages that you go through to acquire these three things and often times it starts with physical, it continues to intellectual, and then it continues to spiritual.”
Mental Health
Kumu hula explicitly recognized that dancers must clear their heads of No. 1 “mind chatter” and to “get outside” of oneself. “You turn yourself over to the story. So it's not a self thing, it's more about the story that you're translating.” This aspect of health with stress management implications, was explained in relation to simple rituals and routines: No. 5 “The mental health part of it to me, starts with leaving your slippers at the door. A routine, you know, which is what protocol is, it is a sequence of events that always happens the same way no matter what. So when you establish those routines, even if it's a routine of putting, leaving your slippers at the door, walking in and saying aloha, walking to the wall and putting your bag down, taking your pa‘u (skirt) out and putting it on your bag, sitting in a circle. And then the protocol of standing up, and going into a line… Just those little things, it's really mental health because it helps the children, the students, anybody. It forces them to have some organization in their lives.”
Most kumu hula commented on the cognition needed to properly learn hula. This involved not only remembering the sequence of foot patterns, body movements, and hand motions but also the appropriate understanding of the history, story, and poetry of each song or chant that accompanies each hula. The oldest kumu hula interviewed, who also had the longest teaching experience, emphasized that mental benefits were more important than physical benefits.
No. 6 “People think that hula is just physical and just exercise, but you have to know mentally what it means. It means many things. It means spiritual, all those kind of things. It makes you think a lot, if a student doesn't understand, I make them tell (ie, explain it to) me.”
The kumu hula went on to describe observed improvements in memory retention, especially in older dancers, and how that ties into motivation for participation.
Emotional Health and Social Support
Kumu hula were aware of the importance of their students' emotional health and the importance for halau hula members to unconditionally support one another in a comfortable, relaxed atmosphere. No. 3 “I think sitting there and doing a hula will bring a smile to your face.” This was seen as connecting emotional health to mental health: No. 5 “…when they come in, it has to feel like they're coming into a home… All the chants, all the preparation chants, that's to…morph you from your everyday self into your hula self, and…you transform slowly. And with everything you chant, and every piece of dressing that you put on, that's pulling you into your hula self, and that's letting go of your everyday self.”
This connection between dancers also had an effect on their collective dancing which in turn reinforces the bond. No. 1 “I personally like to see that kind of thread working throughout the rows [of dancers], that's when you know that they are clicking. And they're all together in that kind of mental state, which strengthens that bond.” Another kumu hula elaborated about the development of a supportive environment, No. 3 “They aloha you, you aloha them, you aloha what you doing, you aloha your teacher, you aloha the dance, you know. And then, when you finally get better, you aloha your health. And enjoy the journey, enjoy the journey.” The cultural value of aloha17,18 was widely recognized as instrumental in the relationship of hula to health, connecting the kumu hula to students, and students to each other.
This also reflects the traditional Hawaiian practice of conflict resolution, ho‘oponopono,19,20 a practice mentioned explicitly by one of the kumu hula: No. 2 “So when they were in any great trouble they would have ho‘oponopono and they would come to me and I would gather, well I had one family that was getting a divorce. But we had ho‘oponopono and got together and later on they stayed married for another 10 years; cause [now] they just got divorced and then she remarried. But all the time that the children and her was in the halau they put the family together.”
Another kumu hula formalized this concept of “leaving conflict outside the door” by incorporating a formal entrance chant, a practice in classic hula training to help bring the dancer into focus and clarity which would be presented each time dancers entered their training area.21
No. 6 “Some of them have arguments with their husbands at home and when they come I see them crying. I say ‘what happened to you?’ She tells me she had a big argument and I tell her ‘you know what, go leave it out my door. You come in clear, I don't want to hear about your husband, you leave that out there.’ Then she comes inside and she feels better. But what I do…I make them chant before they come inside.”
In the example mentioned, the entrance chant for the halau hula, reminds the students of their personal beauty, their relationship to the land on which they reside, their families, and to the value of aloha.
Spiritual Health
Regarding spiritual health, one kumu hula put it clearly: No. 5 “From a Hawaiian perspective, health isn't a scientific thing, it's a spiritual thing.” It was clear for everyone interviewed; “spiritual health” encompasses all the other areas of physical, mental, and emotional health, and therefore was the aspect of health that was most important. This perspective was reinforced by a kumu hula who observed: No. 3 “Spirituality encompassed the entire life of Hawaiians. You wake up - you pray, you go outside—you pray, you build a house—you pray, you go to get things in the garden—you pray. They would pule (pray) for every aspect, I mean, they were constantly praying and they were in tune… and so, when you were dancing, you were really dancing to akua (God, or the gods).”
A third kumu hula concluded: No. 2 “Spiritually, hula can be one of the most important parts of your life. If you believe in God and you believe that He heals you and takes you in his arms and caresses you and gives you knowledge of something that you are missing, hula does play an important spiritual role.”
Cultural Integrity
Every kumu hula interviewed believed that cultural integrity could be preserved in a hula-based CVD programs, and that retaining this integrity was critical for the success of such a program. Specific considerations were relayed to ensure the integrity of the cultural practice: focus should not be exclusively on the physicality of hula, and the importance for dancers to understand the literal and poetic aspects of the accompanying songs or chants should be emphasized.
No. 4 “The most important thing is not to trivialize the hula… Seeing that people do hula purely for the physical part of it, for me, does not fulfill its cultural mandate. And its cultural mandate is to maintain the poetry, and maintain the cultural memory of a people.”
All emphasized that the meaning and messages of the songs and the chants were far more significant than the physical aspects of dance itself.
No. 5 “The first thing is the class has to start with the understanding that the most important thing is the words and the chants, everything starts from the words. And so the stories have to be told, the explanation has to be given. It has to be…you have to teach more than a routine, more than motions…It's not the hula itself. It's all the other things you learn.”
Summing up the cultural side of hula and how it can work in a CVD prevention program, another concluded: No. 4 “If the whole program can be designed appropriately for the health benefits as well as the hula benefits, then I think it is a wonderful way to bring people back into their culture if they don't already have a strong connection. Because you know, again, for me, hula does touch upon all parts of Hawaiian culture, and dancing is universally a way that people express. Singing and dancing is a way people express their inner feelings more easily than painting or anything else.”
This kumu explicitly cautioned, No. 4 “If you focus on the hula you will get your outcomes, but if you focus only on the physical aspect of the dance, success is not so likely.”
Discussion
Experts of the cultural traditions and practice of hula emphasized the strong, significant, and enduring connections between hula and health. Each kumu hula interviewed supported the concept of integrating a hula-based program for preventing and managing CVD. All expressed the traditional purpose and integrity of this cultural practice should be preserved in such a program. More importantly, they all believed these factors would prove to be key components of a successful health intervention.
To address health disparities in Native Hawaiians and other ethnic populations, it has been suggested that innovative and culturally relevant approaches are needed to increase accessibility and adherence to disease prevention and management programs. When care is taken to preserve its cultural integrity, hula may be an effective modality for cardiac rehabilitation and hypertension management and perhaps for other health conditions. The discussion with kumu hula identified health implications including: physical activity, stress management, and social support. Most interviewed kumu hula discussed how hula training and performance integrated the different aspects of health. For example, many discussed the importance of the meanings, stories, and metaphors of accompanying songs or chants, which ties mental health benefits including memory retention and cognition with physical performance. Several kumu talked about how the health benefits from hula training are not always immediately evident. While the physical benefit is the first and most apparent, with consistent and persistent effort by the dancer, mental, emotional, and often spiritual benefits are also achieved.
There are limitations to our study. Only six kumu hula were included in the interviews. While participating kumu hula included both genders, multiple geographic locations within the Hawaiian Islands, and multiple hula lineages, they may not be representative of all kumu hula. Importantly, the interview focus was on utilization of hula for risk and recovery from cardiovascular disease; therefore kumu hula opinions regarding specific application of hula to other health programs were not explored.
The information and insights from these interviews were pivotal in the design and implementation of the Hula Empowering Lifestyle Adaptation (HELA) Study, a hula-based cardiac rehabilitation intervention study and a second pilot study, entitled Ola Hou: Hypertension and Hula Pilot study. Data from these studies are presently being analyzed and results will be reported soon.
Acknowledgements
The authors wish to extend their mahalo piha to the kumu hula for their cooperation with the interviews conducted for this study, and to Patience Namakauahoaokawena Bacon, Kekuni Blaisdell MD, and Fredric Pashkow MD, for their aloha, advice and guidance. Funding for this project was received from the National Institute on Minority Health and Health Disparities or the National Institutes of Health, grant P20MD000173. Dr. Seto is supported, in part, by the National Institute on Minority Health and Health Disparities (U54MD007584), National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIMHD or NIH.
Conflict of Interest
None of the authors identify any conflict of interest.
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