Lecture 10
Real-World Implementation and Cultural Diversity: Well-Being in Asia and the Problem of WEIRD Bias

(1) Framing of the issue of real-world implementation

Norie KAWAHARA opened the tenth lecture of the Spring 2026 semester of the Surviving Cancer in Asia: Cross-boundary Cancer Studies lecture series by introducing the week’s theme, Real-World Implementation and Cultural Diversity: Well-Being in Asia and the Problem of WEIRD Bias. 

She framed the session with a single question: when cancer prevention is designed, whose life is actually being designed for? 

Dr. Kawahara and Kika Z. Hotta are jointly conducting the Asia Well-Being Survey, with Malaysia as one of its major field sites, and Dr. Kawahara explained that she would first address the social value of prevention before handing over to Hotta, who would introduce what has been learned from the survey thus far. 

The limits of measurement

Measuring well-being is not simply to ask whether someone is happy. It requires understanding what a good life means to that person, who they can rely on, whether asking for help is socially and emotionally possible, and why protecting future health matters now. These are not peripheral questions: they determine what choices are available, what responsibilities come first, and what kind of future feels worth protecting. A well-being score can be precise and still miss the key points about the life it claims to measure.

Tremendous importance of stepping inside the household

This is why Dr. Kawahara began conducting household visits in Malaysia before translating life into numbers. This is because a household visit changes the unit of analysis. 

Whereas a questionnaire asks whether someone attended screening, a visit asks what made attending difficult in this particular life — this room, this schedule, this family, this route to care. The first question in each interview is simple: describe the flow of your day from waking to sleeping and the answer reveals a great deal: School time organizes the morning; prayer creates fixed points in the day; care-related work decides where a mother can and cannot go; meals, cleaning, television, and children’s return from school all come together to create the rhythm into which any health behavior must fit.

Being shown the contents of a family’s refrigerator and kitchen is not merely curiosity but a way to trace the pathway of daily life: what is bought, stored, saved, reserved for children or for illness, or what is simply absent. Food choice reflects family tastes, school food, budget, waste avoidance, shopping frequency, and time as much as it reflects nutrition knowledge. A single questionnaire item asking whether someone eats vegetables cannot show this practical logic. 

The physical qualities of a home — its smell, light, space, distance from the street, steps, heat, noise, and privacy — likewise shape what it means to go out, to wait, to travel, to ask for help, or to invite someone in, though none of this appears in a standard questionnaire. Well-being is not lived inside variables but inside rooms, relationships, routines, and atmosphere and this is what makes home visits so important to fully understanding well-being. 

A system of frictions

In Malaysia, failure to go for screening is rarely traced to a single missing piece of knowledge. Barriers accumulate that result in individuals putting off visits for screening, ranging from fear of finding disease, difficulty taking time from work, responsibility for children or older relatives, the cost of transport, tests, and follow-up, uncertainty about booking, and uncertainty about what happens after a result.

Although only one of such barriers may look small in isolation, as a whole they raise the threshold for action beyond what a household can manage. Preventive behavior, in this reading, is produced by a system of frictions rather than by knowledge or will alone, and it is shaped by a person’s position across several worlds at once: family duties at home, the norms and trusted people of work and community, and the access, cost, and trust that structure the health system itself. 

The same information can therefore produce different behavior in different households, because the person is not standing outside these systems making a clean choice but is located within them.

Towards a Prevention Culture Index

These observations lead directly to the Prevention Culture Index that Hotta would be introducing in his lecture. Rather than stopping at whether someone attended screening or exercised, the index asks why — whether the action was taken for the person, for the family, or because a workplace or community created a norm; whether someone recommended it; and whether the person could ask for advice, booking support, transport, or accompaniment, or had no one to ask. 

Dr. Kawahara added a further caution regarding the emerging concept of “proactive prevention” (seme no yobo), which is currently attracting considerable attention in Japan and has been formally incorporated into the Japanese government’s policy direction through a Cabinet decision. This new approach seeks to move beyond passive awareness-raising and to actively create social conditions and systems that enable people to protect their health, undergo screening, and take preventive action at an earlier stage.

She stressed, however, that proactive prevention must never become a language of individual blame. An index that measures only whether people have adopted recommended or desirable health behaviours risks rewarding those in more privileged circumstances while penalizing those who face financial, occupational, family-related, or social constraints. A culture of prevention should instead be evaluated by whether people are genuinely able to protect their health without being forced to bear excessive costs, isolation, or shame.

Prevention, on this view, means designing the path rather than only broadcasting information — connecting trusted information with consultation, booking, transport, and a workable time slot, and following attendance with explained results, referral, and support for returning to daily life, so that the intention to protect health can actually be completed. With that framing, Dr. Kawahara turned the lecture over to Hotta.

(2) Measuring the Good Life

Kika Z. HOTTA began by thanking Dr. Kawahara for a lecture that had addressed the qualitative side of their shared research — the direct lived experience of Malaysian households — before turning to its quantitative complement. 

He noted that the evening’s lecture, titled “Measuring the Good Life: Global Standards, Asian Perspectives, and Social Capital,” treats well-being as a problem of measurement in three movements: how the field’s instruments were built, why they fail outside the societies that built them, and what Hotta’s own research shows about the structure of social capital in Asia, before closing with a proposal for a new regional instrument.

Why measure well-being at all

Social research, Hotta observed, tends to measure what is easy to measure, including such metrics as income in economics, life expectancy in public health, years of schooling in education. All are useful, and none answers the question of whether a person’s life is actually going well — a person with a billion dollars, a doctorate, or a long life expectancy is not thereby guaranteed a good one. 

When a government asks whether its country is doing well, rising figures for income, education, or access to water and electricity do not settle the question, because none of them was designed to measure the thing itself. For roughly twenty years, researchers have been attempting to close this gap under the name well-being.

The clearest statement of the problem with measuring a country’s progress by the metric of GDP came from the Stiglitz Commission (2009), commissioned by the French government and including the Nobel laureate economist Amartya Sen among its members. The criticism of the commission, which therefore came from within the field of economics was simple: GDP measures what markets produce, not human progress, and a country can raise GDP while its people become worse off — a measurement failure, not a paradox. To see whether a society is healthy requires looking at households rather than at industrial output and corporate results. 

A closely related distinction separates quality of life from well-being. Quality of life describes the conditions around a person — housing, safety, environment; well-being describes how a person experiences those conditions. The two do not fully overlap: good conditions can coexist with low well-being, and modest conditions with high well-being, and it is this gap that the field studies.

Three components, not one

Subjective well-being, Hotta explained, is comprised not of a single part but three, each requiring its own question. Firstly, the evaluative component asks how a person rates their life as a whole, typically on a zero-to-ten Cantril ladder. Second, the hedonic component asks how a person actually felt yesterday — happy, sad, angry, stressed, etc. Thirdly, the eudemonic component asks whether a person’s life has meaning and purpose. 

None of the three includes the others: a country, or a person, can score high on one while scoring low on another, so a single combined number conceals more than it reveals.

Stable and defensible science

Well-being also has what Hotta referred to as a set point, drawing on Cummins (1996). Each person has a normal baseline level, around which day-to-day scores move up and down before returning. 

This raises a more basic question — whether subjective answers about happiness or sadness carry scientific meaning at all, or are merely opinion. Diener (1984) supplied the answer still relied upon today: self-reported well-being is stable over time, correlates with what a person’s friends independently say about them, and can be defined operationally as life satisfaction plus positive feeling minus negative feeling.

One point of technique, Hotta noted, is commonly misunderstood: positive and negative feelings are not opposite ends of one scale but two separate dimensions. A person can feel happy and stressed on the same day, about different things, so a well-being measure must ask about positive and negative feelings separately rather than inferring one from the other.

A further problem concerns memory: asking someone to summarize an entire year does not work well, because people forget the ordinary days along with the extreme ones. Two methods seek to address this. Ecological momentary assessment (EMA) asks respondents how they feel at intervals through the day, whereas the day reconstruction method (DRM) asks them to reconstruct yesterday hour by hour. For large samples, Hotta noted, simply asking about yesterday performs almost as well as either more elaborate method — the approach used by the Gallup World Poll (Kahneman et al., 2004).

Well-being can also be built up from its parts. A sixteen-domain framework developed by Professor Takashi Inoguchi, spans material domains such as housing, standard of living, income, education, and employment; personal domains such as health, friendship, marriage, family life, leisure, and spiritual life; and public domains such as neighbors, safety, environment, the social welfare system, and — the sixteenth domain — the democratic system itself, a political institution embedded directly within a well-being scale (Inoguchi, 2017; 2022; Figure 1).

The WEIRD problem

With the instruments themselves established, Hotta turned to the question of who they were built for. Aside from Inoguchi’s work and a small number of others, most well-being research carries a structural bias summarized by the acronym WEIRD — Western, Educated, Industrialized, Rich, Democratic (Henrich, Heine & Norenzayan, 2010) — describing both the societies in which most instruments were developed and the populations on which they were validated. 

A low score recorded by such an instrument outside a WEIRD population, Hotta suggested, may not indicate an unhappy life; it may indicate that the wrong question was asked of a different value system altogether.

The clearest expression of the difference lies in the structure of the self. Markus and Kitayama (1991) distinguish an independent self, more characteristic of the West, in which the self is a separate unit whose task is achievement and whose happiness is obtained and displayed, from an interdependent self, more characteristic of Asia, in which the self is constituted by its relationships, its concern is harmony with the surrounding environment and people, and happiness can be shared between people rather than held by one. Hotta described this West/Asia contrast as a simplification rather than an exact map, useful chiefly for illustrating that Western values do not represent everyone.

A 2015 scale built by Hitokoto and Uchida operationalizes the interdependent side directly, asking about harmony with the people around oneself, a peaceful life free of large worries, and ordinariness – hitonami, being the same as others. Where an achievement-based Western scale treats being average as a form of failure, for many respondents in Japan, and elsewhere in Asia, being ordinary is instead a normal and accepted source of peace.

Culture also shapes which feelings people want to have, independent of what they currently feel. Tsai (2007) terms this the ideal affect, distinct from a person’s current affect: Western respondents tend to prize high-arousal states such as excitement and pride, while East Asian respondents tend to prize low-arousal states such as calm and relief. An instrument built around high-arousal vocabulary will therefore tend to score calm people as unhappy.

A further bias concerns the belief that happiness is fragile. Joshanloo et al. (2015) found that, across many cultures, a high point is expected to invite a low point, and visible happiness is expected to invite the envy of others, so that respondents answer conservatively, choosing six or seven rather than nine or ten even when their life is going well. Japan illustrates the pattern clearly: survey respondents cluster in the three-to-seven range of a scale, while American respondents make more frequent use of the extremes, zero to two and eight to ten. Placed without correction into a single international ranking, this difference alone can make Japan appear less satisfied than a society reporting the same underlying level of well-being — a difference in how the scale is used, not in how satisfied people are. (See Figure 2 for summary of the above)

The correction to WEIRD bias, developed by Kapteyn, Smith and Van Soest (2007), asks every respondent to first rate the same fictional stranger, described in a short vignette — a healthy and wealthy Person A who has no one to call, or an ill and poor Person B surrounded by a loving family. Because every respondent rates the identical case, the score they assign reveals how that person uses the scale; self-reports can then be adjusted to a shared baseline before two societies are compared.

Measuring social capital in Asia - AsiaBarometer

Hotta then turned to research conducted with Professor Inoguchi roughly twenty years ago, surveying 29 Asian societies between 2004 and 2006 as the AsiaBarometer project (Hotta & Inoguchi, 2009). Because social capital has no single agreed definition, the study began without one, asking eleven questions about actual behavior rather than general opinions about trust, and used statistical analysis to see what dimensions the answers themselves produced. 

Three of the eleven questions illustrate the method: whether a company president would hire a marginally lower-scoring relative over an unrelated top candidate; how a household would maintain its budget if the main breadwinner died or became unable to work — through relatives, neighbors, social welfare, a retirement allowance, or an insurance policy; and whether a passer-by would stop to help someone who appeared lost on the street. 

Where a general question about valuing family produces an agreeable answer at no cost to the respondent, each of these questions attaches a concrete cost to the answer, and so reveals more of the underlying structure.

The analysis produced four dimensions that had not been specified in advance:1)  altruism, general willingness to help others and to trust people; 2) utilitarianism, trust extended on merit rather than relationship; 3) communitarianism, reliance on relatives and neighbors, whose opposite is self-provision; and 4) regime concordance, trust in the social system itself — welfare, institutions, and fairness. Placed among the 29 societies, Japan ranked sixth on altruism (high), fourteenth on regime concordance (middle), twenty-eighth on communitarianism (very low), and twenty-ninth — last — on utilitarianism, a striking result for a society organized around competitive examination. 

Hotta offered a Confucian explanation behind the pairing of high altruism and low utilitarianism, namely that giving is treated as a personal virtue, which raises altruism, while asking for help is treated as a personal failure, which lowers communitarianism, and an exchange logic of service-for-service or money-for-money is itself looked down upon, which places Japan last on utilitarianism. Japan clusters in this respect with Taiwan and Korea.

Cluster analysis grouped the 29 societies into seven shapes rather than a single ranking (Figure 3). 

Japan, Taiwan, and Korea show high altruism with the lowest utilitarianism and very low community reliance. China and Turkmenistan show altruism as high as Japan’s, but without Japan’s reluctance to rely on others. Pakistan, Afghanistan, and the Maldives combine high altruism with high community reliance and low trust in government. Singapore, India, Sri Lanka, and Nepal — the formerly British group — show low community reliance and low trust in government. Hong Kong and the Philippines combine low community reliance with high trust in government. Brunei, Malaysia, Indonesia, Vietnam, Bhutan, and Mongolia show the highest utilitarianism alongside low altruism. Thailand, Cambodia, Laos, Myanmar, Bangladesh, Kazakhstan, Uzbekistan, Tajikistan, and Kyrgyzstan combine high community reliance with low altruism. 

Two comparisons make the point most sharply: China ranks close to Japan on altruism but does not share Japan’s refusal to rely on others, and Malaysia ranks second of 29 on utilitarianism, where Japan ranks last — two Asian societies at opposite ends of the same scale, a result a single number for “social capital” could never show.

Isolation, ageing, and purpose

Hotta connected this structural finding to Japan’s isolation figures. An OECD survey found that 15.3 percent of Japanese respondents report rare or no contact with friends, colleagues, or other social groups, the highest share among the countries surveyed (OECD, 2005, cited in Nakagomi et al., 2023) — a figure that, Hotta noted, cannot be shown to cause or be caused by a culture in which asking for help is treated as a personal failure, though the two facts sit together within the same society.

A large Japanese cohort study, JAGES, followed 34,187 older adults from 2016 into 2019 and compared the most isolated group against the least isolated on an isolation index. The comparison found higher odds of mortality (odds ratio 1.89), of dementia (1.60), and of functional disability (1.47) among the most isolated, alongside lower attendance at health screening (risk ratio 0.88, twelve percent less likely to attend), more depressive symptoms, and less trust in other people (Nakagomi et al., 2023). Notably, the association traced specifically to poor interaction with friends rather than with children or other relatives, and the authors were careful to describe these as associations rather than proof of a causal effect.

Hotta linked this to kodokushi (dying alone at home and being found only later). More than 30 percent of people aged 60 and over report a fear of it, prompting the Japanese government to appoint a Minister of Loneliness in 2021, following an earlier appointment in the United Kingdom (Cabinet Office Japan, 2021). The fear involved, Hotta suggested, is not a fear of death itself but of being disconnected from others before it.

The well-known U-shape of well-being across the lifespan — high in youth, lowest around ages 45–54, rising again in old age — turns out not to be universal. Gallup World Poll data spanning more than 160 countries show the U-shape confined largely to high-income English-speaking countries; well-being declines steadily with age across the former Soviet Union, Eastern Europe, and Latin America and the Caribbean, and remains essentially flat across sub-Saharan Africa (Steptoe, Deaton & Stone, 2015). Malaysia shows a gradual decline with no second rise in old age; a regression analysis of Gallup data found satisfaction with standard of living, household income satisfaction, and social support to be the strongest predictors of life satisfaction, with confidence in government contributing a smaller but still significant effect, while age itself carried only a small — though statistically significant — negative coefficient once these material factors were included (Park & Joshanloo, 2019). Malaysia’s declining life satisfaction with age, in other words, reflects economic and social conditions more than ageing itself.

A final study addressed whether a sense of purpose protects the body. The English Longitudinal Study of Ageing followed 9,050 people for eight and a half years, dividing them into quartiles by eudaimonic well-being. In the lowest quartile, 29.3 percent died over the study period, against 9.3 percent in the highest; after full adjustment for age, sex, wealth, education, baseline illness, depression, smoking, and physical activity, the hazard ratio remained 0.70 (Steptoe, Deaton & Stone, 2015). Hotta urged caution against reading this as proof that purpose prevents death: were the causal claim to be overstated, a seriously ill person might conclude they were somehow to blame for not finding meaning in their own life. The result stands as an association, not a proof.

What is known, and what is not

Summarizing, Hotta set out what the field currently knows in contrast to what remains unresolved. What is known can be enumerated thus: isolation predicts death, dementia, and fewer health checks; the U-shape of ageing is not universal; and social capital has a measurable shape rather than a single amount. 

The unknowns were set out in this way: why countries differ once income is controlled for; how much ethnicity matters, and how much of that effect is confounded with income; how religion functions — as belief, as community, or as both; whether social capital causes well-being or follows from it; whether culture changes the underlying experience or only the way it is reported; and whether a sense of purpose protects the body or only marks a life that is already healthier. 

Hotta observed that the unknown, resolved column is, in effect, most of the field.

Towards an Asian Well-being Barometer

Hotta closed by describing a project underway with Dr. Kawahara: an Asian Well-being Barometer, as yet unnamed. Existing instruments, built around the independent self, ask what a person has achieved and how excited they feel, but do not ask about harmony, ordinariness, or the shape of a person’s social capital. 

A pilot study is planned in Japan and Malaysia — two societies chosen precisely because they differ on almost every relevant dimension, including the direction in which ageing runs and where trust sits on the utilitarianism scale. It is plausible, therefore, that an instrument that works in both of these societies could be expected to be a fit for other Asian countries. 

A third component, the Prevention Culture Index introduced earlier in the lecture by Dr. Kawahara, would extend the barometer beyond current well-being to ask who protects their own future health, and why — through attributes such as ethnicity, gender, and income, or through beliefs, culture, religion, and social capital. None of this work, Hotta noted, has yet been carried out.

Hotta closed the lecture by returning to his opening observation, namely that social science measures what is easy to measure, and for a long time no one attempted to measure whether people’s lives were actually going well. 

That has begun to change over the past two decades, imperfectly but genuinely, and once a society can measure something, it can decide to change it. Measuring, in Hotta’s closing words, is the very first step, and not the last.

(3) Assignment

Students were asked to complete the following assignment: 

Today's lecture explored how well-being is shaped by culture rather than by universal assumptions.

Reflect on your own country or cultural background and answer the following questions. 

1. What is one cultural value or practice in your society that you believe strongly influences people's well-being?

2. How does this differ from what is often emphasized in Western societies?

3. In your view, does this cultural perspective promote prevention, resilience, or social well-being? Why?

4. What is one question about your own culture that today's lecture made you reconsider?

Please use one concrete example from your own experience, family, or community to support your discussion.

(4) Discussion

Dr. Kawahara noted how clearly the lecture had connected theory, measurement, and public policy, adding that Hotta’s framework helped explain what her household visits had actually been observing in the field, and that measuring well-being is not itself the end goal — the goal is to improve people’s lives through better prevention and policy. 

She asked how the next generation of Asian well-being surveys should be designed to capture the cultural realities her visits have consistently uncovered, namely decisions made not by isolated individuals but under the strong influence of family relationships, community expectations, and cultural norms, given that many existing well-being scales were originally developed in WEIRD societies.

Hotta responded with four practical rules for designing such a survey, noting that questions need to be modelled based on exactly the kind of background investigation that Dr. Kawahara’s household visits supply so well. 

First, a survey should ask about the group, not only the person, on the model of the interdependent happiness scale, which asks whether a respondent is as happy as the people around them — a question that most Western items, built around the person as the unit of analysis, cannot ask. 

Second, a survey should ask about cost rather than settle for value statements that invite an automatically agreeable answer: asking whether someone values family produces a uniform yes, but asking who would keep a household running if its breadwinner could no longer work — relatives, neighbors, the state, or insurance — reveals the actual structure of reliance and value. 

Third, giving and asking should be measured separately, since Hotta’s own research had found that in Japan a willingness to help was not matched by a willingness to ask for help, a distinction that most well-being questionnaires miss by asking only whether people in a society help each other in general. 

Fourth, a survey should correct for response style, using the same Person A/Person B vignette method described earlier in the lecture, since Japanese and Western respondents do not use a numerical scale in the same way. 

Hotta concluded that most of what such a survey needs to ask only becomes visible through home visits of the kind Dr. Kawahara conducts, since survey designers rarely know what to ask until they have seen the pressures a household actually faces.

Dr. Kawahara closed the session by describing the lecture as having supplied an important foundation for thinking about well-being in Asia, and as a caution against applying any single model of well-being to every society. 

She previewed the following week’s lecture, the final lecture in the series, which moves from the question of well-being to the question of prevention and how it can be implemented within real social systems. The lecturer from PERKESO (Social Security Organization of Malaysia) would present the logic of implementation, showing how prevention connects to workplaces, rehabilitation, return to work, and social security, while the lecturer from Astellas Pharma would present the logic of making value visible, showing how the value created by prevention can be made visible to patients, families, companies, and society. 

Brought together, she suggested, prevention could be understood not simply as an entrance to medical care but as a principle for designing society and a public investment supporting people’s lives, work, dignity, and well-being, thus framing the question to be addressed in the series’ final session: how prevention can become a shared social value for the future of ageing societies in Asia.

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