Health literacy in substance use

disorder treatment_ A latent profile

analysis Tayla J. Degan & Peter J. Kelly
& Laura D. Robinson & Frank P. Deane
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 Journal of Substance Abuse Treatment 96 (2019) 46–52

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Journal of Substance Abuse Treatment

journal homepage: www.elsevier.com/locate/jsat

Health literacy in substance use disorder treatment: A latent profile analysis T

⁎
Tayla J. Degan , Peter J. Kelly, Laura D. Robinson, Frank P. Deane
Illawarra Institute for Mental Health, School of Psychology, University of Wollongong, Australia

A R T I C LE I N FO A B S T R A C T

Keywords: Introduction and aims: Health literacy refers to the degree to which people can access and understand health
Health Literacy Questionnaire information, as well as communicate their health needs to service providers. Whilst health literacy is increas-
Mental health ingly being examined within general community samples, there is limited research focused on substance use
Physical health disorders where the need for health literacy is likely to be high. The aim of this study was to examine the health
Quality of life
literacy profiles of people attending substance use disorder treatment and to examine how these profiles were
Substance use disorder
related to measures of quality of life, mental health, and physical health.
Residential rehabilitation
The Salvation Army Design and methods: Participants were attending specialist non-government substance use disorder treatment
across New South Wales, Queensland, and the Australia Capital Territory, Australia (N = 298). Participants
completed the Health Literacy Questionnaire, a multi-dimensional measure of health literacy. Latent profile
analysis was conducted to identify profiles of health literacy within the sample.
Results: Three distinct health literacy profiles were identified, and termed low (24.2%), moderate (62.8%) and
high health literacy (13.1%). Participants with lower levels of health literacy had lower levels of social support
in their home environment outside of treatment, as well as lower levels of quality of life, higher levels of
psychological distress, and poorer mental health. There was no difference between the three profiles on mea-
sures of physical health.
Discussion and conclusion: The current study found that low to moderate health literacy levels were common for
those attending residential substance abuse treatment. Participants with lower health literacy tended to have
poorer quality of life and mental health. Future research should examine strategies to improve health literacy
amongst people attending alcohol and other drug treatment. It may also be useful for service providers to
consider ways to minimise the impact of low health literacy on the health needs and outcomes of this vulnerable
population.

1. Introduction Yin et al., 2015). A meta-analysis conducted by Zhang, Terry, and

Health literacy is defined as “the degree to which people are able to
access, understand, appraise, and communicate information” (Zumbo
et al., 2006, p. ii). It refers to the ability to actively engage in different
health contexts and use information to promote and maintain adequate
health throughout the life-course (World Health Organization [WHO],
2009; Zumbo et al., 2006). Individuals' with low health literacy tend to
find it difficult to voice their opinions or make successful decisions
regarding their healthcare, minimising their access, knowledge and
quality of care (Australian Bureau of Statistics [ABS], 2006; Andrus &
Roth, 2002). The majority of health literacy research has focused on the
general population. Using measures of literacy and numeracy as an
indicator of health literacy, research has established a clear relationship
between lower scores on health literacy and poorer health outcomes
(Osborn, Paasche-Orlow, Bailey, & Wolf, 2011; Rowlands et al., 2015;
McHorney (2014) showed that health literacy influenced peoples'
physical health, health behaviours and treatment adherence. In addi-
tion, poor health literacy has been correlated with poor health beha-
viours, higher rates of hospitalization, poor aftercare engagement, poor
social support, and negative attitudes and actions towards seeking
treatment (Andrus & Roth, 2002; Guntzviller, King, Jensen, & Davis,
2017; Parikh, Parker, Nurss, Baker, & Williams, 1996; Smith, Curtis,
Wardle, Von Wagner, and Wolf, 2013).
There has been a recent move away from measuring health literacy
as a unidimensional construct captured by measures of literacy or nu-
meracy, towards measuring health literacy in a multi-dimensional way
(Beauchamp et al., 2015; Bo, Friis, Osborne, & Maindal, 2014; Institute
of Medicine, 2009). Accompanying this shift is the development of the
Health Literacy Questionnaire (Osborne, Batterham, Elsworth,
Hawkins, & Buchbinder, 2013), a recently established measure that

⁎
Corresponding author at: School of Psychology, University of Wollongong, Wollongong, Australia.
E-mail address: tjd589@uowmail.edu.au (T.J. Degan).

https://doi.org/10.1016/j.jsat.2018.10.009
Received 5 June 2018; Received in revised form 22 October 2018; Accepted 22 October 2018
0740-5472/ © 2018 Elsevier Inc. All rights reserved.
T.J. Degan et al. Journal of Substance Abuse Treatment 96 (2019) 46–52

captures nine domains of health literacy (e.g. social support for health Table 1
and navigating the healthcare system). Studies that have used the HLQ Demographic and clinical characteristics.
have revealed that gender, age, educational levels, and social support n %
are strongly related to health literacy (Beauchamp et al., 2015; Brabers
et al., 2017). For example, Beauchamp et al. (2015) used the HLQ to Gender (n = 297)
Male 206 69.4
examine the health literacy of adults living in both urban and rural
Female 91 30.6
Victoria, Australia (n = 813). Results showed that participants' with Country of Birth (n = 297)
low health literacy levels had “difficulties actively engaging with Australia 258 86.9
healthcare providers, navigating the healthcare system, finding or un- Other 39 13.1
derstanding health information and finding adequate social support for Education level (n = 298)
High School 169 56.7
health” (p. 6). The purpose of the HLQ was to develop a measure that
Non-tertiary 99 33.2
detects a range of health literacy needs across multiple profiles and Tertiary 30 10.1
populations in order to advance the health literacy field (Batterham Marital status (n = 296)
et al., 2014; Osborne et al., 2013). Researchers' are now beginning to Single 173 58.4
Partnered 45 15.2
see the value of using multidimensional measures of health literacy, as
Separated/Widowed 78 26.4
it provides a comprehensive summary of the health literacy needs of Living arrangement before entering treatment (n = 294)
individuals. Alone 81 27.6
Although there has been an extensive amount of research conducted Family or significant other 137 46.6
on the health literacy of general populations, health literacy research Other 76 25.9
Reading Ability (n = 297)
amongst people living with mental illness is limited. This is concerning,
Terrible/poor 14 4.7
due to their high health service needs (Odlaug et al., 2015; WHO, Okay/good 119 40.1
2014). In a United States sample of 71 adults with serious mental ill- Excellent 164 55.2
ness, rates of inadequate literacy were high, although it was acknowl- Previous treatment for a substance use disorder 189 64.1
edged that the rates of inadequate health literacy varied amongst the Currently on medication for a mental health condition 167 56.8
Previous treatment for a mental health condition 200 67.6
three health literacy measures used (42.3% = Single Item Literacy Chronic disease 62 21.0
Screener; 51.7% = Rapid Assessment of Adult Literacy in Medicine, Daily cigarette smoking 230 78.0
66.2% = Newest Vital Sign (Clausen, Wantanabe-Galloway, Mean age years (SD) 37.5 9.72
Baerentzen, & Britigan, 2016). In contrast, another study that examined
the health literacy of people living with mental illness, found that the Note. Sample sizes vary across characteristics due to incomplete responses.
SD = standard deviation.
sample had good functional health literacy in general, but the study
used a single health literacy measure which captured a unidimensional
2. Methods
construct (Galletly, Neaves, Burton, Liu, & Denson, 2012). Despite these
preliminary studies, populations living with mental illness are still
2.1. Participants
significantly understudied. We are unaware of any previous research
that has examined the health literacy of people living with alcohol or
All participants were attending residential alcohol and other drug
other substance use disorders. As with those who have other mental
treatment facilities provided by The Salvation-Army and We Help
disorders, individuals with a substance use disorder present with a
Ourselves (WHOS) across the Australian states of New South Wales and
range of serious health conditions comprising both physical and mental
Queensland, and the Australian Capital Territory (9 facilities). In total,
illnesses, accompanied by diminished quality of life (Odlaug et al.,
346 self-report surveys were handed out and 298 were sufficiently
2015; Vancampfort et al., 2016). Individuals' with a substance use
completed, providing an 86% participation rate. The participating
disorder are also less likely to seek health care when needed and are
sample was comprised of mostly males (69.4%, n = 206), and the age of
often non-adherent to healthcare recommendations (Weiss, McCoy,
participants ranged from 19 to 69 years (M = 37.5, SD = 9.72; see
Kluger & Finkelstein, 2004).
Table 1). The most common substance of dependence was alcohol
The current exploratory study is the first to examine the health
(32.2%). A total of 12.8% of participants (n = 36) identified as Abori-
literacy of people attending treatment for a substance use disorder.
ginal or Torres Strait Islander. The majority (93.2%, n = 275) identified
Participants attending treatment across multiple Australian states were
their primary income as a government pension/benefit.
asked to complete the HLQ and a series of physical health, mental
health, and quality of life measures. As there is little prior health lit-
eracy research with these populations, an exploratory approach was 2.2. Measures
adopted to examine if distinct sub-groups or profiles of health literacy
exist amongst people attending substance use disorder treatment. In 2.2.1. Background characteristics and determinants
line with recommendations from the developers of the HLQ (Dodson, General socio-demographic, background information, substance
Beauchamp, Batterham, & Osborne, 2014), latent profile analysis (LPA) use, and medical history were collected from participants based on
was used to determine the number of possible profiles present within items used in past surveys conducted with The Salvation Army and
this sample. They argue that this approach allows unmasking of “sub- WHOS services (see Deane et al., 2014; Kelly et al., 2012).
groups of people who have particular strengths that can be built upon,
or sub-groups with limitations, which services might need to provide 2.2.2. Health literacy
support to improve” (p. 2). It was therefore hypothesised that: (1) Based The Health Literacy Questionnaire was used to measure the multi-
on the nine domains of the HLQ, there will be distinct health literacy dimensional health literacy of the sample (Osborne et al., 2013). The
profiles identified within the sample through the use of LPA. (2) These HLQ contains 44 distinct items and is scored on nine subscales. Items
profiles will differ on various determinants and characteristics (educa- for the first 5 of the 9 scales use a 4-point Likert scale, ranging from
tion, social support and reading ability), quality of life, mental health, ‘strongly disagree’ to ‘strongly agree’, and items for scales 6 to 9 use a 5-
and physical health. point Likert scale, ranging from ‘cannot do’ to ‘very easy’. Examples of
the HLQ subscales and items are included in Table 2. Higher scores
indicate higher health literacy levels. In the current study, the Cronbach
α for the nine HLQ subscales ranged from 0.49 to 0.90. All scales had

47
T.J. Degan et al.
Table 2
Health Literacy Questionnaire subscales, item examples and Cronbach α.
HLQ subscales
1. Feeling understood and supported by healthcare providers
2. Having sufficient information to manage my health
3. Actively managing my health
4. Social support for health
5. Appraisal of health information
6. Ability to actively engage with healthcare providers
7. Navigating the healthcare system
8. Ability to find good health information
9. Understand health information well enough to know what to do
Note. HLQ = Health literacy questionnaire; α = Cronbach alpha.
satisfactory internal reliability with the exception of subscale five
which showed low internal consistency (Cronbach α = 0.49). However,
Cronbach α can underestimate reliability if a scale is of a multi-
dimensional nature (Schmitt, 1996). Internal consistency is also context
dependent in that measures such as knowledge questionnaires can have
low internal consistency if they endeavour a wide range of knowledge
domains. Given that subscale five ‘Appraisal of Health Information’
captures the extent that respondents check the accuracy of health in-
formation (2 items) and also different sources of information (3 items),
it is possible this resulted in lower internal consistency ratings. How-
ever, both components are strategies for appraising health information
and so they were retained in the analyses.
To account for the differences in reading ability on health literacy, a
standard one item measure was used; ‘How would you rate your ability
to read?’, with a 5-point Likert scale ranging from ‘terrible or very poor’
to ‘excellent or very good’ (Institute of Medicine, 2009). This item
provides the researchers with a general idea of participants reading
ability.
2.2.3. Quality of life
The EUROHIS Quality of Life 8-item index measures the quality of
life of participants. This measure was originally developed by the World
Health Organisation Quality of Life group (WHOQOL), derived from the
WHOQOL-100 and the WHOQOL-BREF, both of which have established
psychometric properties (The WHOQOL Group, 1998a, 1998b). The
self-report measure encompasses 8-items on a 5-point Likert scale,
which make up an overall QOL score; higher scores indicate better QOL
(Schmidt, Muhlan, & Power, 2006). In the current study the QOL
measure had high internal consistency (Cronbach's α = 0.85), which is
consistent with previous research (e.g. Schmidt et al., 2006).
2.2.4. Psychological distress
The Kessler Psychological Distress 6-Scale (K6) measures psycho-
logical distress over the 4-weeks prior to its completion. The 6-items are
on a 5-point Likert scale, with a response range from ‘none of the time’
(5) to ‘all of the time’ (1). Items include the following item content;
nervousness, hopelessness, restlessness or fidgety, depressed, every-
thing was an effort, and worthlessness (Kessler et al., 2002). All are
summed to gain an overall K6 score ranging from 6 to 30, where higher
scores indicate less psychological distress. In the current study, the K6
had high internal consistency (Cronbach's α = 0.91).
2.2.5. Self-reported health
Self-reported health and health related quality of life was measured
using the 12-item Short Form Health Survey (SF-12) (Ware, Kosinski, &
Keller, 1996). This self-report measure includes 12-items, from which
eight health outcome domains are produced and two final summary
composite scores are obtained; physical health component score (PCS),
and mental health component score (MCS) (Turner-Bowker & Hogue,
2014). Higher scores indicate better self-reported health (Grendas et al.,
2017). In the current sample, the SF-12 measure shows sufficient
Journal of Substance Abuse Treatment 96 (2019) 46–52
Example item α
“I have at least one healthcare provider who knows me well” 0.82
“I have enough information to help me deal with my health problems” 0.82
“There are things that I do regularly to make myself more healthy” 0.85
“If I need help, I have plenty of people I can rely on” 0.63
“I compare health information from different sources” 0.49
“Have good discussions about your health with doctors” 0.90
“Decide which healthcare provider you need to see” 0.73
“Get information by yourself” 0.87
“Read and understand all the information on medication labels” 0.88
internal consistency for research purposes (PCS Cronbach's α = 0.66;
MCS Cronbach's α = 0.68).
2.3. Procedures
Survey data was collected between May and August 2017. All pro-
cedures were reviewed and approved by the University Human
Research Ethics Committee (HE2017/115). Individuals attending the
residential facilities were invited by service treatment staff to attend a
meeting on site and it was explained that this was to provide them with
information about a research study. Participants could choose not to
attend the meeting and based on the total number of residents at each
facility, it is estimated that between 5 and 10% of people attending the
treatment centres did not attend these sessions. This is partly due to
people having pre-standing appointments (e.g. off-site medical ap-
pointments) or being involved in onsite work activities (e.g. kitchen
preparation). The recruitment sessions were run by two researchers.
Individuals who attended these sessions were given copies of the par-
ticipant information sheet and surveys. After an explanation of the
study was provided by the researchers, potential participants were
provided time to review the participant information sheet and had the
opportunity to ask further questions. Those who chose to participate
then completed the survey. Those who chose not to participate were
able to leave the session. Support was provided by the researchers to
participants who had difficulties with reading or writing. The partici-
pant information form indicated to participants that consent was im-
plied if they chose to complete the survey and return it to the re-
searchers. They were not required to complete a separate signed
consent form.
2.4. Analytic strategy
The Statistical Package for the Social Sciences (SPSS) Version 21
(IBM Corp, 2012) was used to examine the sample and its descriptive
and demographic information. Confirmatory factor analysis (CFI) was
conducted in Mplus (Version 8; Muthen & Muthen, 2012–2017), for
each of the nine HLQ subscales. Model fit indices showed good fit, CFI
ranged from 0.90 to 0.99, TLI from 0.90 to 0.999 and the SRMR from
0.01 to 0.03. Consistent with previous studies (e.g. Osborne, Batterham,
Elsworth, Hawkins, and Buchbinder, 2013), the model chi-square fit
statistics ranged from p = .001 to p = .44, however the CFI, TLI and
SRMR are considered better fit indices (Hooper, Coughlan & Mullen,
2008. Using Mplus software (Version 8; Muthen & Muthen,
2012–2017), LPA was used to identify distinct profiles of the sample
population based on the HLQ, that are otherwise unmeasured using
continuous observed variables. Model fit was identified through model
fit indices. This determines the most optimal number of profiles,
starting from a 2-profile solution. This included the Bayesian informa-
tion criterion (BIC), the Akaike information criterion (AIC), boot-
strapped Lo-Mendell-Rubin parametric likelihood ratio test (BLMRT)
and Entropy (Kelly et al., 2017; Lubke & Neale, 2006; Nylund,
48
T.J. Degan et al.
Asparouhov, & Muthen, 2007).
Chi square analysis was used for categorical variables and a one-way
Analysis of Variance (ANOVA) was used for continuous variables to
measure differences between identified profiles on demographic and
clinical characteristics, and their health outcomes. There is evidence
that some demographic characteristics and determinants influence
health literacy (ABS, 2006; Diemer et al., 2017; Parikh et al., 1996;
Sørensen et al., 2012; Zoellner et al., 2011). Based on Sørensen et al.
(2012) health literacy framework, the following determinants were
included; age, gender (male, female), education (high school, non-ter-
tiary, tertiary), living arrangement (alone, family, other), marital status
(single, partnered, separated/widowed) and reading ability (poor/ter-
rible, okay/good, excellent). Furthermore, to determine the related
health outcomes within each identified profile, general linear model
analyses were conducted. Following testing for assumptions of regres-
sion analyses, four general linear model analyses were performed for
each of the continuous dependent variables. These were, quality of life,
psychological distress, mental health and physical health. In each
model, the following variables were controlled for; age, gender, edu-
cation, living arrangement, marital status and reading ability. If sig-
nificant findings were identified from the general linear model ana-
lyses, these were investigated further using Tukey's multiple
comparisons correction.
3. Results
3.1. Latent profile analysis
The model fit statistics for the LPA are shown in Table 3, which
range from a 2-profile solution to a 5-profile solution. The findings
indicate that the 3-profile solution was deemed as the best model fit
based on its minimum LMRT and BLRT value, significant BLRT p-value
and maximum entropy compared to all other profile solutions.
The LPA was run on the full data set (n = 298) which had all
missing data on the HLQ items excluded. The LPA identified three
distinct health literacy profiles. Profile 1 was characterized as ‘low
health literacy’, due to the average scores the participants had on each
HLQ subscale being low (n = 72, 24.2%). Profile 2 was characterized as
‘moderate health literacy’, due to the average scores the participants
had on each HLQ subscale being moderate (n = 187, 62.8%). Further,
profile 3 was characterized as ‘high health literacy’, due to the average
scores the participants had on each HLQ subscale being high (n = 39,
13.1%). All three profiles had significantly different scores on each HLQ
subscale (See Table 4). Results show that subscale 1 ‘feeling understood
and supported by healthcare providers’, 2 ‘having sufficient information
to manage my health’, as well as 6 ‘ability to actively engage with
healthcare providers’ and 7 ‘navigating the healthcare system’ show the
strongest differences across the three profiles.
3.2. Characteristics of each profile
Table 5 shows the characteristics of individuals in the three profiles.
Age, gender, education, marital status and the residential treatment site
Table 3
Fit statistics of the latent profile analysis.
Profiles df AIC BIC Entropy BLMRT
2 profile 28 4202.780 4306.298 0.913 −2478.805⁎
3 profile 38 3731.700 3872.189 0.947 −2073.390⁎
4 profile 48 3751.700 3929.160 0.644 −1827.850
5 profile 58 3702.507 3921.790 0.944 −1797.281⁎
Note. AIC = Akaike information criterion; BIC = Bayesian information cri-
terion; BLMRT = bootstrapped Lo-Mendell-Rubin parametric likelihood ratio
test; df = degrees of freedom.
⁎
p < .05 (two-tailed).
49
Journal of Substance Abuse Treatment 96 (2019) 46–52
participants attended, did not significantly differ across the three health
literacy profiles. The profiles differed significantly on their living ar-
rangements prior to treatment χ2(1, 4) = 14.09, p < .01. Individuals
with ‘moderate health literacy’ and ‘high health literacy’ were more
likely to have lived with family prior to treatment compared to those
with ‘low health literacy’. Reading ability differed significantly across
health literacy profiles, χ2(1, 4) = 21.79, p < .001. It was found that
‘Low health literacy’ and ‘moderate health literacy’ individuals were
more likely to rate as having okay/good reading ability compared to the
‘high health literacy’ profile. ‘Low health literacy’ individuals were less
likely to report excellent reading ability compared to ‘moderate health
literacy’ and ‘high health literacy’ individuals.
The following variables; quality of life, psychological distress,
mental health and physical health, were continuous variables and
therefore the dependent variables in the general linear model. Results
of the general linear model show that, after controlling for age, gender,
education, marital status, living arrangements and reading ability,
quality of life was significantly (F(2,273) = 21.12, p < .001) higher in
‘high health literacy’ (M = 30.64, SD = 6.46) than ‘low health literacy’
(M = 23.49, SD = 5.14) and ‘moderate health literacy’ profiles
(M = 26.36, SD = 5.14). Psychological distress was found to be sig-
nificantly different across the profiles (F(2,271) = 19.52, p < .001),
with significantly lower scores for individuals in the ‘high health lit-
eracy’ profile (M = 24.28, SD = 4.70) compared to those in ‘low health
literacy’ (M = 18.25, SD = 4.84) and ‘moderate health literacy’ profiles
(M = 22.21, SD = 4.61). ‘Low health literacy’ was found to be sig-
nificantly higher than ‘moderate health literacy’ profiles on psycholo-
gical distress. Similarly, self-reported mental health differed sig-
nificantly (F(2,277) = 5.62, p < .01), with higher scores amongst
individuals in the ‘high health literacy’ profile (M = 40.04, SD = 9.04)
compared to those in the ‘low health literacy’ (M = 34.21, SD = 8.61)
and ‘moderate health literacy’ profiles (M = 35.00, SD = 8.90). Self-
reported physical health did not significantly differ across profiles (F
(2,278) = 1.003, p = .368).
4. Discussion
This study was the first to use the HLQ to explore the presence of
distinct sub-groups or profiles of health literacy amongst people at-
tending substance use disorder treatment. Using exploratory LPA, three
distinct profiles of multi-dimensional health literacy were identified.
We termed these three profiles as, profile 1 ‘low health literacy’, profile
2 as ‘moderate health literacy’ and profile 3 as ‘high health literacy’.
Despite each profile scoring either ‘low’, ‘moderate’ or ‘high’ on the
HLQ overall, the LPA allowed unique profile trends and patterns to be
observed for each of the HLQ domains. Individuals in the low health
literacy profile performed best on their ability to actively manage their
health (HLQ3) as well as understand health information well enough to
know what to do (HLQ9). Those in the moderate health literacy profile
and the high health literacy profile showed lowest average scores on
their ability to actively manage their health (HLQ3), as well as being
able to appraise health information (HLQ5). In addition, since the
strongest differences across the three profiles were for domains 1, 2, 6
and 7 (see results section for details), it is likely that the capacity of
individuals in the sample to engage with healthcare providers or the
health system particularly distinguish the profile groups.
Given the lack of prior research that has assessed health literacy of a
substance use disorder population, comparisons with other populations
provides a point of reference for understanding the results. The current
study's moderate and low health literacy profiles have low health lit-
eracy scores on average when compared to other populations. For ex-
ample, a study conducted in Melbourne, Australia identified that pa-
tients in public hospitals (n = 384) had ‘lower health literacy’
compared to those in private hospitals (n = 3121) (Jessup, Osborne,
Beauchamp, Bourne & Buchbinder, 2018). However, participants in the
moderate and low health literacy profiles of the current study had even
T.J. Degan et al. Journal of Substance Abuse Treatment 96 (2019) 46–52

Table 4
Health literacy questionnaire subscales across the three health literacy profiles.
Health Literacy Questionnaire subscales Low health literacy Moderate health literacy High health literacy F or χ2 p

a
HLQ1 2.39 (0.50) 2.89 (0.34) 3.59 (0.43) 122.17 .00
HLQ2a 2.40 (0.49) 2.87 (0.33) 3.51 (0.41) 105.88 .00
HLQ3a 2.47 (0.54) 2.69 (0.42) 3.23 (0.62) 31.72 .00
HLQ4a 2.40 (0.60) 2.88 (0.64) 3.39 (0.46) 34.86 .00
HLQ5a 2.31 (0.42) 2.54 (0.38) 3.32 (0.95) 53.63 .00
HLQ6b 2.78 (0.56) 3.91 (0.30) 4.80 (0.26) 413.94 .00
HLQ7b 2.78 (0.48) 3.76 (0.34) 4.62 (0.40) 308.87 .00
HLQ8b 2.86 (0.52) 3.85 (0.33) 4.63 (0.35) 293.84 .00
HLQ9b 3.27 (0.70) 4.07 (0.37) 4.80 (0.29) 149.86 .00

HLQ = Health Literacy Questionnaire.

a
Likert scale of 1–4.
b
Likert scale of 1–5.

lower average health literacy scores across the HLQ domains in com-
parison with these public hospital patients. Furthermore, in Beauchamp
et al.'s (2015) study, average health literacy scores across their sample
of 813 individuals attending health and community care services in
Victoria, Australia, were higher than that of our current study's mod-
erate and low health literacy profiles average scores. These comparisons
suggest particularly low health literacy amongst many of the partici-
pants in the current study attending treatment for a substance use
disorder. In contrast, a study of 11,930 young Swiss men, found that
risky substance use behaviours are associated with higher health lit-
eracy (Dermota et al., 2013). Although it is important to recognise that
these individuals were not in treatment for a substance use disorder, it
is interesting to note that these substance users had greater access to
and understanding of substance related information (Dermota et al.,
2013). It is worth reiterating that the current sample comprised those
who ‘made it’ to treatment. Approximately two thirds of people in
Canada who met criteria for a substance abuse disorder did not receive
any care and those with lower education were even less likely to receive
care (Urbanoski, Inglis & Veldhuizen, 2017). Although there are likely
to be a multitude of reasons contributing to this unmet need, it is highly
likely that a significant proportion of people with substance use dis-
orders have not engaged in treatment as a result of difficulties navi-
gating the health system. It may therefore be important for future
studies to determine the health literacy abilities and needs of a sub-
stance use disorder population not currently in treatment and those that
have not been able to ever access treatment.
The present study examined various determinants guided by the
broader health literacy literature (ABS, 2006; Diemer et al., 2017;
Parikh et al., 1996; Zoellner et al., 2011). Prior research indicates
mixed findings regarding the relationships between gender and age on
health literacy (ABS, 2006; Diemer et al., 2017; Parikh et al., 1996;
Zoellner et al., 2011). The current study found no differences in gender
or age across the profiles. This finding may be a function of the low
numbers of females and older aged individuals in the sample. Although
there were fewer females in the sample, the proportion was re-
presentative of those typically found in these services, where males
attending residential treatment typically constitute around 79% of
participants (Deane, Blackman, & Kelly, 2015). It is not completely
clear why there are no differences across health literacy profiles and
participants gender and age, however this is consistent with previous
studies whom show variances in the significance of gender and age
across health literacy levels (e.g. Diemer et al., 2017; Parikh et al.,
1996). The lack of difference may have something to do with this po-
pulation and their similarities in accessing NGO treatment, having
lower socio-economic status and often being disadvantaged, however
this may need further investigation. Furthermore, lower educational
attainment was also not associated with the ‘low health literacy’ profile
as hypothesised. This finding could be explained by floor effects, with
samples who have substance use disorders having very low levels of
educational attainment overall (Diemer et al., 2017; Parikh et al.,

Table 5
Determinants and health outcomes of the three profiles and their differences.
Total Low health literacy Moderate health literacy High health literacy F or χ2 p Profile differences

Class size (n (%)) 298 72 (24.2) 187 (62.8) 39 (13.1) – –

Individual characteristics
Age (M (SD)) 396 38.14 (11.33) 36.74 (8.63) 39.92 (11.09) 1.95 .15 ns
Gender (n (%)) 0.17 .92 ns
Male 206 50 (70.4) 130 (69.5) 26 (66.7)
Female 91 21 (29.6) 57 (30.5) 13 (33.3)
Education 4.19 .38 ns
High School 169 36 (50.0) 113 (60.4) 20 (51.3)
Non-tertiary 99 30 (41.7) 55 (29.4) 14 (35.9)
Tertiary 30 6 (8.3) 19 (10.2) 5 (12.8)
Marital Status 2.33 .68 ns
Single 173 39 (54.9) 113 (60.8) 21 (53.8)
Partnered 45 14 (19.7) 24 (12.9) 7 (17.9)
Separated/Widowed 78 18 (25.4) 49 (26.3) 11 (26.4)
Living arrangement 14.09 .01
Alone 81 19 (27.1) 47 (25.3) 15 (39.5) ns
Family 137 23 (32.9) 97 (52.2) 17 (44.7) Low < moderate, high
Other 76 28 (40.0) 42 (22.6) 6 (15.8) ns
Reading ability
Terrible/poor 14 8 (11.1) 5 (2.7) 1 (2.6) ns
Okay/good 119 38 (52.8) 72 (38.7) 9 (23.1) 21.79 .00 Low, moderate > high
Excellent 164 26 (36.1) 109 (58.6) 29 (74.4) Low < moderate, high

Note. M = Mean; SD = standard deviation; ns = non-significant; low = low health literacy; moderate = moderate health literacy; high = high health literacy;

50
T.J. Degan et al.
1996). Furthermore, those in the lower health literacy profiles had
poorer reading ability, a finding that is consistent with previous re-
search (e.g., Andrus & Roth, 2002; Parikh et al., 1996; Zhang et al.,
2014), linking poorer health literacy with lower reading ability. Finally,
those in the low health literacy group tended to have different living
arrangements from those in the moderate and high health literacy
groups. The moderate and high health literacy groups more frequently
lived with family. In some health literacy domains better family com-
munication has been found to be related to improved health literacy
(e.g., cervical cancer literacy, Zambrana et al., 2015). This has led to
suggestions that family networks may be an important source of health
literacy information and there are increasing calls for research to better
understand how families communicate health information. To date
most of this work has centred on cancer literacy with the ambition
being to better understand how communication within families re-
garding cancer family history, risk, and prevention contribute to cancer
awareness and literacy (Campbell & McLain, 2013). Results from the
current study raise similar questions regarding the role that family may
play in the development of health literacy amongst those seeking
treatment for a substance use disorder. The benefits of having stable
housing and family networks are well-established within the literature
regarding substance use treatment (Siddall & Conway, 1988; Zhou
et al., 2016). The development of a social support system, having
greater family involvement and good perceived social support, has been
associated with greater successful completion of treatment as well as
being a notable predictor of stronger retention rates (Siddall & Conway,
1988; Zhou et al., 2016). Future research should explore whether fa-
mily history of particular health conditions and intergenerational or
current family communication contribute to health literacy in these
populations.
As well as the determinants examined, participants with low health
literacy reported having poorer quality of life, higher psychological
distress and poorer mental health, which is consistent with previous
findings that associate lower health literacy with poor health outcomes
(Osborn et al., 2011; Rowlands et al., 2015; Yin et al., 2015). There was
a trend for participants with lower levels of health literacy to have
lower levels of physical health as measured on the SF-12 (‘low health
literacy’ M = 45.0, ‘moderate health literacy’ M = 46.8, ‘high health
literacy M = 47.9), but these differences were not statistically sig-
nificant. Despite this, all three profiles had lower mean scores on the
physical health subscale compared to the Australian National Survey of
Mental Health and Wellbeing (n = 10,641, M = 48.9, Andrews, 2002)
and those referred to the Clinical Research Unit for Anxiety and De-
pression in Sydney, Australia (n = 1, 725, M = 49.7, Andrews, 2002).
In comparison to the norms for the general U.S population (M = 50.1,
Ware, Kosinski, & Keller, 1995), our sample also presented with lower
mean physical health. The similarity across the profiles and their phy-
sical health scores are consistent with the literature that acknowledge
the high rates of co-existing poor physical health needs of these in-
dividuals (Mental Health Commission of NSW, 2016).
There were a number of limitations of the current study. All of the
data collected in the current project were self-report, a cross-sectional
design was used, and all participants were attending residential ser-
vices. Although consistent with the demographic population of people
attending residential services (Kelly et al., 2012; Kelly et al., 2017),
there was an under representation of women and older age groups in
the sample. Furthermore, it is estimated that 5–10% of the residential
population sampled were absent at the time of study recruitment. An-
ecdotal reports from staff indicated this was usually because people
were off-site attending pre-standing appointments or were engaged in
onsite work activities that were difficult to reschedule (e.g. kitchen
preparation). However, it is also possible that a proportion of partici-
pants decided to not attend the recruitment meeting. In addition, sub-
scale five of the HLQ showed low internal consistency. However, this
subscale was retained in the analyses since it has face validity, as ap-
praisal of health information is considered an important component of
51
Journal of Substance Abuse Treatment 96 (2019) 46–52
health literacy. Strengths of the current project include participants
attending multiple treatment services and coming from multiple Aus-
tralian States and Territories. This study was also the first of its kind,
contributing new evidence to the health literacy and substance use
disorder field. This sample had various profiles of health literacy, with
most of the sample presenting with low to moderate health literacy
levels. Reading ability was poor for those with lower health literacy, as
well there being less family presence and support to those with lower
health literacy prior to treatment entry. Future research should examine
relationships across the determinants examined in the current study
using a longitudinal approach. Furthermore, suggestions for improving
the health literacy of this population are urgent. For those who make it
to substance use disorder treatment, there are opportunities to provide
psychoeducation and skills to increase health literacy. For example, in
general populations, presenting essential information, using self-man-
agement strategies, emphasising skill-building, and pilot-testing, were
some components of successful interventions that improved health lit-
eracy levels (Berkman et al., 2011). It is possible that these types of
approaches might be appropriate for people attending residential sub-
stance use disorder treatment. Our findings suggest that reading diffi-
culties in those with the lowest health literacy would indicate the need
for visual or verbal strategies in providing psychoeducation. Skills to
promote health literacy might involve preparation (list of questions),
role plays and coaching to improve communication with health pro-
fessionals (e.g., Talen, Muller-Held, Eshleman, & Stephens, 2011).
Health literacy training of staff who deal with these vulnerable popu-
lations is also paramount. It is also important to recognise that it is
likely that people with lower levels of health literacy will be particu-
larly vulnerable once they leave residential treatment, when required to
start navigating the health system independently. It is possible that
existing continuing care interventions (e.g. McKay, Van Horn, &
Morrison, 2010) that provide lower intensity treatment when people
are leaving residential programs, might help to buffer against the effects
of lower health literacy levels and/or help to mentor people in the skills
needed to navigate the health system. This would potentially help drug
and alcohol clinicians to better understand and engage with service
users' various health literacy needs. Further, adopting a no wrong door
policy may help to improve the populations difficulty in accessing and
interacting with service providers and the health system. By improving
the health literacy of this population, improvement of their current
poor health outcomes and poor recovery rates could be possible.
Acknowledgements
The current study was partially funded by research consultancies
from The Salvation Army and We Help Ourselves. We would like to
thank the managers and staff at the sites for helping to coordinate the
data collection.
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dress.
“Do you remember,” she said, “how the blinds used to flap at
Bourton?”
“They did,” he said; and he remembered breakfasting alone, very
awkwardly, with her father; who had died; and he had not written to
Clarissa. But he had never got on well with old Parry, that querulous,
weak-kneed old man, Clarissa’s father, Justin Parry.
“I often wish I’d got on better with your father,” he said.
“But he never liked any one who—our friends,” said Clarissa; and
could have bitten her tongue for thus reminding Peter that he had
wanted to marry her.
Of course I did, thought Peter; it almost broke my heart too, he
thought; and was overcome with his own grief, which rose like a
moon looked at from a terrace, ghastly beautiful with light from the
sunken day. I was more unhappy than I’ve ever been since, he
thought. And as if in truth he were sitting there on the terrace he
edged a little towards Clarissa; put his hand out; raised it; let it fall.
There above them it hung, that moon. She too seemed to be sitting
with him on the terrace, in the moonlight.
“Herbert has it now,” she said. “I never go there now,” she said.
Then, just as happens on a terrace in the moonlight, when one
person begins to feel ashamed that he is already bored, and yet as
the other sits silent, very quiet, sadly looking at the moon, does not
like to speak, moves his foot, clears his throat, notices some iron
scroll on a table leg, stirs a leaf, but says nothing—so Peter Walsh
did now. For why go back like this to the past? he thought. Why
make him think of it again? Why make him suffer, when she had
tortured him so infernally? Why?
“Do you remember the lake?” she said, in an abrupt voice, under the
pressure of an emotion which caught her heart, made the muscles of
her throat stiff, and contracted her lips in a spasm as she said “lake.”
For she was a child, throwing bread to the ducks, between her
parents, and at the same time a grown woman coming to her parents
who stood by the lake, holding her life in her arms which, as she
neared them, grew larger and larger in her arms, until it became a
whole life, a complete life, which she put down by them and said,
“This is what I have made of it! This!” And what had she made of it?
What, indeed? sitting there sewing this morning with Peter.
She looked at Peter Walsh; her look, passing through all that time
and that emotion, reached him doubtfully; settled on him tearfully;
and rose and fluttered away, as a bird touches a branch and rises
and flutters away. Quite simply she wiped her eyes.
“Yes,” said Peter. “Yes, yes, yes,” he said, as if she drew up to the
surface something which positively hurt him as it rose. Stop! Stop! he
wanted to cry. For he was not old; his life was not over; not by any
means. He was only just past fifty. Shall I tell her, he thought, or not?
He would like to make a clean breast of it all. But she is too cold, he
thought; sewing, with her scissors; Daisy would look ordinary beside
Clarissa. And she would think me a failure, which I am in their sense,
he thought; in the Dalloways’ sense. Oh yes, he had no doubt about
that; he was a failure, compared with all this—the inlaid table, the
mounted paper-knife, the dolphin and the candlesticks, the chair-
covers and the old valuable English tinted prints—he was a failure! I
detest the smugness of the whole affair he thought; Richard’s doing,
not Clarissa’s; save that she married him. (Here Lucy came into the
room, carrying silver, more silver, but charming, slender, graceful she
looked, he thought, as she stooped to put it down.) And this has
been going on all the time! he thought; week after week; Clarissa’s
life; while I—he thought; and at once everything seemed to radiate
from him; journeys; rides; quarrels; adventures; bridge parties; love
affairs; work; work, work! and he took out his knife quite openly—his
old horn-handled knife which Clarissa could swear he had had these
thirty years—and clenched his fist upon it.
What an extraordinary habit that was, Clarissa thought; always
playing with a knife. Always making one feel, too, frivolous; empty-
minded; a mere silly chatterbox, as he used. But I too, she thought,
and, taking up her needle, summoned, like a Queen whose guards
have fallen asleep and left her unprotected (she had been quite
taken aback by this visit—it had upset her) so that any one can stroll
in and have a look at her where she lies with the brambles curving
over her, summoned to her help the things she did; the things she
liked; her husband; Elizabeth; her self, in short, which Peter hardly
knew now, all to come about her and beat off the enemy.
“Well, and what’s happened to you?” she said. So before a battle
begins, the horses paw the ground; toss their heads; the light shines
on their flanks; their necks curve. So Peter Walsh and Clarissa,
sitting side by side on the blue sofa, challenged each other. His
powers chafed and tossed in him. He assembled from different
quarters all sorts of things; praise; his career at Oxford; his marriage,
which she knew nothing whatever about; how he had loved; and
altogether done his job.
“Millions of things!” he exclaimed, and, urged by the assembly of
powers which were now charging this way and that and giving him
the feeling at once frightening and extremely exhilarating of being
rushed through the air on the shoulders of people he could no longer
see, he raised his hands to his forehead.
Clarissa sat very upright; drew in her breath.
“I am in love,” he said, not to her however, but to some one raised up
in the dark so that you could not touch her but must lay your garland
down on the grass in the dark.
“In love,” he repeated, now speaking rather dryly to Clarissa
Dalloway; “in love with a girl in India.” He had deposited his garland.
Clarissa could make what she would of it.
“In love!” she said. That he at his age should be sucked under in his
little bow-tie by that monster! And there’s no flesh on his neck; his
hands are red; and he’s six months older than I am! her eye flashed
back to her; but in her heart she felt, all the same, he is in love. He
has that, she felt; he is in love.
But the indomitable egotism which for ever rides down the hosts
opposed to it, the river which says on, on, on; even though, it admits,
there may be no goal for us whatever, still on, on; this indomitable
egotism charged her cheeks with colour; made her look very young;
very pink; very bright-eyed as she sat with her dress upon her knee,
and her needle held to the end of green silk, trembling a little. He
was in love! Not with her. With some younger woman, of course.
“And who is she?” she asked.
Now this statue must be brought from its height and set down
between them.
“A married woman, unfortunately,” he said; “the wife of a Major in the
Indian Army.”
And with a curious ironical sweetness he smiled as he placed her in
this ridiculous way before Clarissa.
(All the same, he is in love, thought Clarissa.)
“She has,” he continued, very reasonably, “two small children; a boy
and a girl; and I have come over to see my lawyers about the
divorce.”
There they are! he thought. Do what you like with them, Clarissa!
There they are! And second by second it seemed to him that the wife
of the Major in the Indian Army (his Daisy) and her two small children
became more and more lovely as Clarissa looked at them; as if he
had set light to a grey pellet on a plate and there had risen up a
lovely tree in the brisk sea-salted air of their intimacy (for in some
ways no one understood him, felt with him, as Clarissa did)—their
exquisite intimacy.
She flattered him; she fooled him, thought Clarissa; shaping the
woman, the wife of the Major in the Indian Army, with three strokes
of a knife. What a waste! What a folly! All his life long Peter had been
fooled like that; first getting sent down from Oxford; next marrying
the girl on the boat going out to India; now the wife of a Major in the
Indian Army—thank Heaven she had refused to marry him! Still, he
was in love; her old friend, her dear Peter, he was in love.
“But what are you going to do?” she asked him. Oh the lawyers and
solicitors, Messrs. Hooper and Grateley of Lincoln’s Inn, they were
going to do it, he said. And he actually pared his nails with his
pocket-knife.
For Heaven’s sake, leave your knife alone! she cried to herself in
irrepressible irritation; it was his silly unconventionality, his
weakness; his lack of the ghost of a notion what any one else was
feeling that annoyed her, had always annoyed her; and now at his
age, how silly!
I know all that, Peter thought; I know what I’m up against, he
thought, running his finger along the blade of his knife, Clarissa and
Dalloway and all the rest of them; but I’ll show Clarissa—and then to
his utter surprise, suddenly thrown by those uncontrollable forces
thrown through the air, he burst into tears; wept; wept without the
least shame, sitting on the sofa, the tears running down his cheeks.
And Clarissa had leant forward, taken his hand, drawn him to her,
kissed him,—actually had felt his face on hers before she could
down the brandishing of silver flashing—plumes like pampas grass
in a tropic gale in her breast, which, subsiding, left her holding his
hand, patting his knee and, feeling as she sat back extraordinarily at
her ease with him and light-hearted, all in a clap it came over her, If I
had married him, this gaiety would have been mine all day!
It was all over for her. The sheet was stretched and the bed narrow.
She had gone up into the tower alone and left them blackberrying in
the sun. The door had shut, and there among the dust of fallen
plaster and the litter of birds’ nests how distant the view had looked,
and the sounds came thin and chill (once on Leith Hill, she
remembered), and Richard, Richard! she cried, as a sleeper in the
night starts and stretches a hand in the dark for help. Lunching with
Lady Bruton, it came back to her. He has left me; I am alone for ever,
she thought, folding her hands upon her knee.
Peter Walsh had got up and crossed to the window and stood with
his back to her, flicking a bandanna handkerchief from side to side.
Masterly and dry and desolate he looked, his thin shoulder-blades
lifting his coat slightly; blowing his nose violently. Take me with you,
Clarissa thought impulsively, as if he were starting directly upon
some great voyage; and then, next moment, it was as if the five acts
of a play that had been very exciting and moving were now over and
she had lived a lifetime in them and had run away, had lived with
Peter, and it was now over.
Now it was time to move, and, as a woman gathers her things
together, her cloak, her gloves, her opera-glasses, and gets up to go
out of the theatre into the street, she rose from the sofa and went to
Peter.
And it was awfully strange, he thought, how she still had the power,
as she came tinkling, rustling, still had the power as she came
across the room, to make the moon, which he detested, rise at
Bourton on the terrace in the summer sky.
“Tell me,” he said, seizing her by the shoulders. “Are you happy,
Clarissa? Does Richard—”
The door opened.
“Here is my Elizabeth,” said Clarissa, emotionally, histrionically,
perhaps.
“How d’y do?” said Elizabeth coming forward.
The sound of Big Ben striking the half-hour struck out between them
with extraordinary vigour, as if a young man, strong, indifferent,
inconsiderate, were swinging dumb-bells this way and that.
“Hullo, Elizabeth!” cried Peter, stuffing his handkerchief into his
pocket, going quickly to her, saying “Good-bye, Clarissa” without
looking at her, leaving the room quickly, and running downstairs and
opening the hall door.
“Peter! Peter!” cried Clarissa, following him out on to the landing. “My
party to-night! Remember my party to-night!” she cried, having to
raise her voice against the roar of the open air, and, overwhelmed by
the traffic and the sound of all the clocks striking, her voice crying
“Remember my party to-night!” sounded frail and thin and very far
away as Peter Walsh shut the door.
Remember my party, remember my party, said Peter Walsh as he
stepped down the street, speaking to himself rhythmically, in time
with the flow of the sound, the direct downright sound of Big Ben
striking the half-hour. (The leaden circles dissolved in the air.) Oh
these parties, he thought; Clarissa’s parties. Why does she give
these parties, he thought. Not that he blamed her or this effigy of a
man in a tail-coat with a carnation in his buttonhole coming towards
him. Only one person in the world could be as he was, in love. And
there he was, this fortunate man, himself, reflected in the plate-glass
window of a motor-car manufacturer in Victoria Street. All India lay
behind him; plains, mountains; epidemics of cholera; a district twice
as big as Ireland; decisions he had come to alone—he, Peter Walsh;
who was now really for the first time in his life, in love. Clarissa had
grown hard, he thought; and a trifle sentimental into the bargain, he
suspected, looking at the great motor-cars capable of doing—how
many miles on how many gallons? For he had a turn for mechanics;
had invented a plough in his district, had ordered wheel-barrows
from England, but the coolies wouldn’t use them, all of which
Clarissa knew nothing whatever about.
The way she said “Here is my Elizabeth!”—that annoyed him. Why
not “Here’s Elizabeth” simply? It was insincere. And Elizabeth didn’t
like it either. (Still the last tremors of the great booming voice shook
the air round him; the half-hour; still early; only half-past eleven still.)
For he understood young people; he liked them. There was always
something cold in Clarissa, he thought. She had always, even as a
girl, a sort of timidity, which in middle age becomes conventionality,
and then it’s all up, it’s all up, he thought, looking rather drearily into
the glassy depths, and wondering whether by calling at that hour he
had annoyed her; overcome with shame suddenly at having been a
fool; wept; been emotional; told her everything, as usual, as usual.
As a cloud crosses the sun, silence falls on London; and falls on the
mind. Effort ceases. Time flaps on the mast. There we stop; there we
stand. Rigid, the skeleton of habit alone upholds the human frame.
Where there is nothing, Peter Walsh said to himself; feeling hollowed
out, utterly empty within. Clarissa refused me, he thought. He stood
there thinking, Clarissa refused me.
Ah, said St. Margaret’s, like a hostess who comes into her drawing-
room on the very stroke of the hour and finds her guests there
already. I am not late. No, it is precisely half-past eleven, she says.
Yet, though she is perfectly right, her voice, being the voice of the
hostess, is reluctant to inflict its individuality. Some grief for the past
holds it back; some concern for the present. It is half-past eleven,
she says, and the sound of St. Margaret’s glides into the recesses of
the heart and buries itself in ring after ring of sound, like something
alive which wants to confide itself, to disperse itself, to be, with a
tremor of delight, at rest—like Clarissa herself, thought Peter Walsh,
coming down the stairs on the stroke of the hour in white. It is
Clarissa herself, he thought, with a deep emotion, and an
extraordinarily clear, yet puzzling, recollection of her, as if this bell
had come into the room years ago, where they sat at some moment
of great intimacy, and had gone from one to the other and had left,
like a bee with honey, laden with the moment. But what room? What
moment? And why had he been so profoundly happy when the clock
was striking? Then, as the sound of St. Margaret’s languished, he
thought, She has been ill, and the sound expressed languor and
suffering. It was her heart, he remembered; and the sudden
loudness of the final stroke tolled for death that surprised in the midst
of life, Clarissa falling where she stood, in her drawing-room. No! No!
he cried. She is not dead! I am not old, he cried, and marched up
Whitehall, as if there rolled down to him, vigorous, unending, his
future.
He was not old, or set, or dried in the least. As for caring what they
said of him—the Dalloways, the Whitbreads, and their set, he cared
not a straw—not a straw (though it was true he would have, some
time or other, to see whether Richard couldn’t help him to some job).
Striding, staring, he glared at the statue of the Duke of Cambridge.
He had been sent down from Oxford—true. He had been a Socialist,
in some sense a failure—true. Still the future of civilisation lies, he
thought, in the hands of young men like that; of young men such as
he was, thirty years ago; with their love of abstract principles; getting
books sent out to them all the way from London to a peak in the
Himalayas; reading science; reading philosophy. The future lies in
the hands of young men like that, he thought.
A patter like the patter of leaves in a wood came from behind, and
with it a rustling, regular thudding sound, which as it overtook him
drummed his thoughts, strict in step, up Whitehall, without his doing.
Boys in uniform, carrying guns, marched with their eyes ahead of
them, marched, their arms stiff, and on their faces an expression like
the letters of a legend written round the base of a statue praising
duty, gratitude, fidelity, love of England.
It is, thought Peter Walsh, beginning to keep step with them, a very
fine training. But they did not look robust. They were weedy for the
most part, boys of sixteen, who might, to-morrow, stand behind
bowls of rice, cakes of soap on counters. Now they wore on them
unmixed with sensual pleasure or daily preoccupations the solemnity
of the wreath which they had fetched from Finsbury Pavement to the
empty tomb. They had taken their vow. The traffic respected it; vans
were stopped.
I can’t keep up with them, Peter Walsh thought, as they marched up
Whitehall, and sure enough, on they marched, past him, past every
one, in their steady way, as if one will worked legs and arms
uniformly, and life, with its varieties, its irreticences, had been laid
under a pavement of monuments and wreaths and drugged into a
stiff yet staring corpse by discipline. One had to respect it; one might
laugh; but one had to respect it, he thought. There they go, thought
Peter Walsh, pausing at the edge of the pavement; and all the
exalted statues, Nelson, Gordon, Havelock, the black, the
spectacular images of great soldiers stood looking ahead of them, as
if they too had made the same renunciation (Peter Walsh felt he too
had made it, the great renunciation), trampled under the same
temptations, and achieved at length a marble stare. But the stare
Peter Walsh did not want for himself in the least; though he could
respect it in others. He could respect it in boys. They don’t know the
troubles of the flesh yet, he thought, as the marching boys
disappeared in the direction of the Strand—all that I’ve been through,
he thought, crossing the road, and standing under Gordon’s statue,
Gordon whom as a boy he had worshipped; Gordon standing lonely
with one leg raised and his arms crossed,—poor Gordon, he
thought.
And just because nobody yet knew he was in London, except
Clarissa, and the earth, after the voyage, still seemed an island to
him, the strangeness of standing alone, alive, unknown, at half-past
eleven in Trafalgar Square overcame him. What is it? Where am I?
And why, after all, does one do it? he thought, the divorce seeming
all moonshine. And down his mind went flat as a marsh, and three
great emotions bowled over him; understanding; a vast philanthropy;
and finally, as if the result of the others, an irrepressible, exquisite
delight; as if inside his brain by another hand strings were pulled,
shutters moved, and he, having nothing to do with it, yet stood at the
opening of endless avenues, down which if he chose he might
wander. He had not felt so young for years.
He had escaped! was utterly free—as happens in the downfall of
habit when the mind, like an unguarded flame, bows and bends and
seems about to blow from its holding. I haven’t felt so young for
years! thought Peter, escaping (only of course for an hour or so)
from being precisely what he was, and feeling like a child who runs
out of doors, and sees, as he runs, his old nurse waving at the wrong
window. But she’s extraordinarily attractive, he thought, as, walking
across Trafalgar Square in the direction of the Haymarket, came a
young woman who, as she passed Gordon’s statue, seemed, Peter
Walsh thought (susceptible as he was), to shed veil after veil, until
she became the very woman he had always had in mind; young, but
stately; merry, but discreet; black, but enchanting.
Straightening himself and stealthily fingering his pocket-knife he
started after her to follow this woman, this excitement, which seemed
even with its back turned to shed on him a light which connected
them, which singled him out, as if the random uproar of the traffic
had whispered through hollowed hands his name, not Peter, but his
private name which he called himself in his own thoughts. “You,” she
said, only “you,” saying it with her white gloves and her shoulders.
Then the thin long cloak which the wind stirred as she walked past
Dent’s shop in Cockspur Street blew out with an enveloping
kindness, a mournful tenderness, as of arms that would open and
take the tired—
But she’s not married; she’s young; quite young, thought Peter, the
red carnation he had seen her wear as she came across Trafalgar
Square burning again in his eyes and making her lips red. But she
waited at the kerbstone. There was a dignity about her. She was not
worldly, like Clarissa; not rich, like Clarissa. Was she, he wondered
as she moved, respectable? Witty, with a lizard’s flickering tongue,
he thought (for one must invent, must allow oneself a little diversion),
a cool waiting wit, a darting wit; not noisy.
She moved; she crossed; he followed her. To embarrass her was the
last thing he wished. Still if she stopped he would say “Come and
have an ice,” he would say, and she would answer, perfectly simply,
“Oh yes.”
But other people got between them in the street, obstructing him,
blotting her out. He pursued; she changed. There was colour in her
cheeks; mockery in her eyes; he was an adventurer, reckless, he
thought, swift, daring, indeed (landed as he was last night from India)
a romantic buccaneer, careless of all these damned proprieties,
yellow dressing-gowns, pipes, fishing-rods, in the shop windows; and
respectability and evening parties and spruce old men wearing white
slips beneath their waistcoats. He was a buccaneer. On and on she
went, across Piccadilly, and up Regent Street, ahead of him, her
cloak, her gloves, her shoulders combining with the fringes and the
laces and the feather boas in the windows to make the spirit of finery
and whimsy which dwindled out of the shops on to the pavement, as
the light of a lamp goes wavering at night over hedges in the
darkness.
Laughing and delightful, she had crossed Oxford Street and Great
Portland Street and turned down one of the little streets, and now,
and now, the great moment was approaching, for now she
slackened, opened her bag, and with one look in his direction, but
not at him, one look that bade farewell, summed up the whole
situation and dismissed it triumphantly, for ever, had fitted her key,
opened the door, and gone! Clarissa’s voice saying, Remember my
party, Remember my party, sang in his ears. The house was one of
those flat red houses with hanging flower-baskets of vague
impropriety. It was over.
Well, I’ve had my fun; I’ve had it, he thought, looking up at the
swinging baskets of pale geraniums. And it was smashed to atoms—
his fun, for it was half made up, as he knew very well; invented, this
escapade with the girl; made up, as one makes up the better part of
life, he thought—making oneself up; making her up; creating an
exquisite amusement, and something more. But odd it was, and
quite true; all this one could never share—it smashed to atoms.
He turned; went up the street, thinking to find somewhere to sit, till it
was time for Lincoln’s Inn—for Messrs. Hooper and Grateley. Where
should he go? No matter. Up the street, then, towards Regent’s
Park. His boots on the pavement struck out “no matter”; for it was
early, still very early.
It was a splendid morning too. Like the pulse of a perfect heart, life
struck straight through the streets. There was no fumbling—no
hesitation. Sweeping and swerving, accurately, punctually,
noiselessly, there, precisely at the right instant, the motor-car
stopped at the door. The girl, silk-stockinged, feathered, evanescent,
but not to him particularly attractive (for he had had his fling),
alighted. Admirable butlers, tawny chow dogs, halls laid in black and
white lozenges with white blinds blowing, Peter saw through the
opened door and approved of. A splendid achievement in its own
way, after all, London; the season; civilisation. Coming as he did
from a respectable Anglo-Indian family which for at least three
generations had administered the affairs of a continent (it’s strange,
he thought, what a sentiment I have about that, disliking India, and
empire, and army as he did), there were moments when civilisation,
even of this sort, seemed dear to him as a personal possession;
moments of pride in England; in butlers; chow dogs; girls in their
security. Ridiculous enough, still there it is, he thought. And the
doctors and men of business and capable women all going about
their business, punctual, alert, robust, seemed to him wholly
admirable, good fellows, to whom one would entrust one’s life,
companions in the art of living, who would see one through. What
with one thing and another, the show was really very tolerable; and
he would sit down in the shade and smoke.
There was Regent’s Park. Yes. As a child he had walked in Regent’s
Park—odd, he thought, how the thought of childhood keeps coming
back to me—the result of seeing Clarissa, perhaps; for women live
much more in the past than we do, he thought. They attach
themselves to places; and their fathers—a woman’s always proud of
her father. Bourton was a nice place, a very nice place, but I could
never get on with the old man, he thought. There was quite a scene
one night—an argument about something or other, what, he could
not remember. Politics presumably.
Yes, he remembered Regent’s Park; the long straight walk; the little
house where one bought air-balls to the left; an absurd statue with
an inscription somewhere or other. He looked for an empty seat. He
did not want to be bothered (feeling a little drowsy as he did) by
people asking him the time. An elderly grey nurse, with a baby
asleep in its perambulator—that was the best he could do for
himself; sit down at the far end of the seat by that nurse.
She’s a queer-looking girl, he thought, suddenly remembering
Elizabeth as she came into the room and stood by her mother.
Grown big; quite grown-up, not exactly pretty; handsome rather; and
she can’t be more than eighteen. Probably she doesn’t get on with
Clarissa. “There’s my Elizabeth”—that sort of thing—why not “Here’s
Elizabeth” simply?—trying to make out, like most mothers, that
things are what they’re not. She trusts to her charm too much, he
thought. She overdoes it.
The rich benignant cigar smoke eddied coolly down his throat; he
puffed it out again in rings which breasted the air bravely for a
moment; blue, circular—I shall try and get a word alone with
Elizabeth to-night, he thought—then began to wobble into hour-glass
shapes and taper away; odd shapes they take, he thought. Suddenly
he closed his eyes, raised his hand with an effort, and threw away
the heavy end of his cigar. A great brush swept smooth across his
mind, sweeping across it moving branches, children’s voices, the
shuffle of feet, and people passing, and humming traffic, rising and
falling traffic. Down, down he sank into the plumes and feathers of
sleep, sank, and was muffled over.
The grey nurse resumed her knitting as Peter Walsh, on the hot seat
beside her, began snoring. In her grey dress, moving her hands
indefatigably yet quietly, she seemed like the champion of the rights
of sleepers, like one of those spectral presences which rise in twilight
in woods made of sky and branches. The solitary traveller, haunter of
lanes, disturber of ferns, and devastator of great hemlock plants,
looking up, suddenly sees the giant figure at the end of the ride.
By conviction an atheist perhaps, he is taken by surprise with
moments of extraordinary exaltation. Nothing exists outside us
except a state of mind, he thinks; a desire for solace, for relief, for
something outside these miserable pigmies, these feeble, these ugly,
these craven men and women. But if he can conceive of her, then in
some sort she exists, he thinks, and advancing down the path with
his eyes upon sky and branches he rapidly endows them with
womanhood; sees with amazement how grave they become; how
majestically, as the breeze stirs them, they dispense with a dark
flutter of the leaves charity, comprehension, absolution, and then,
flinging themselves suddenly aloft, confound the piety of their aspect
with a wild carouse.
Such are the visions which proffer great cornucopias full of fruit to
the solitary traveller, or murmur in his ear like sirens lolloping away
on the green sea waves, or are dashed in his face like bunches of
roses, or rise to the surface like pale faces which fishermen flounder
through floods to embrace.
Such are the visions which ceaselessly float up, pace beside, put
their faces in front of, the actual thing; often overpowering the
solitary traveller and taking away from him the sense of the earth,
the wish to return, and giving him for substitute a general peace, as if
(so he thinks as he advances down the forest ride) all this fever of
living were simplicity itself; and myriads of things merged in one
thing; and this figure, made of sky and branches as it is, had risen
from the troubled sea (he is elderly, past fifty now) as a shape might
be sucked up out of the waves to shower down from her magnificent
hands compassion, comprehension, absolution. So, he thinks, may I
never go back to the lamplight; to the sitting-room; never finish my
book; never knock out my pipe; never ring for Mrs. Turner to clear
away; rather let me walk straight on to this great figure, who will, with
a toss of her head, mount me on her streamers and let me blow to
nothingness with the rest.
Such are the visions. The solitary traveller is soon beyond the wood;
and there, coming to the door with shaded eyes, possibly to look for
his return, with hands raised, with white apron blowing, is an elderly
woman who seems (so powerful is this infirmity) to seek, over a
desert, a lost son; to search for a rider destroyed; to be the figure of
the mother whose sons have been killed in the battles of the world.
So, as the solitary traveller advances down the village street where
the women stand knitting and the men dig in the garden, the evening
seems ominous; the figures still; as if some august fate, known to
them, awaited without fear, were about to sweep them into complete
annihilation.
Indoors among ordinary things, the cupboard, the table, the window-
sill with its geraniums, suddenly the outline of the landlady, bending
to remove the cloth, becomes soft with light, an adorable emblem
which only the recollection of cold human contacts forbids us to
embrace. She takes the marmalade; she shuts it in the cupboard.
“There is nothing more to-night, sir?”
But to whom does the solitary traveller make reply?

So the elderly nurse knitted over the sleeping baby in Regent’s Park.
So Peter Walsh snored.
He woke with extreme suddenness, saying to himself, “The death of
the soul.”
“Lord, Lord!” he said to himself out loud, stretching and opening his
eyes. “The death of the soul.” The words attached themselves to
some scene, to some room, to some past he had been dreaming of.
It became clearer; the scene, the room, the past he had been
dreaming of.
It was at Bourton that summer, early in the ’nineties, when he was so
passionately in love with Clarissa. There were a great many people
there, laughing and talking, sitting round a table after tea and the
room was bathed in yellow light and full of cigarette smoke. They
were talking about a man who had married his housemaid, one of
the neighbouring squires, he had forgotten his name. He had
married his housemaid, and she had been brought to Bourton to call
—an awful visit it had been. She was absurdly over-dressed, “like a
cockatoo,” Clarissa had said, imitating her, and she never stopped
talking. On and on she went, on and on. Clarissa imitated her. Then
somebody said—Sally Seton it was—did it make any real difference
to one’s feelings to know that before they’d married she had had a
baby? (In those days, in mixed company, it was a bold thing to say.)
He could see Clarissa now, turning bright pink; somehow
contracting; and saying, “Oh, I shall never be able to speak to her
again!” Whereupon the whole party sitting round the tea-table
seemed to wobble. It was very uncomfortable.
He hadn’t blamed her for minding the fact, since in those days a girl
brought up as she was, knew nothing, but it was her manner that
annoyed him; timid; hard; something arrogant; unimaginative;
prudish. “The death of the soul.” He had said that instinctively,
ticketing the moment as he used to do—the death of her soul.
Every one wobbled; every one seemed to bow, as she spoke, and
then to stand up different. He could see Sally Seton, like a child who
has been in mischief, leaning forward, rather flushed, wanting to talk,
but afraid, and Clarissa did frighten people. (She was Clarissa’s
greatest friend, always about the place, totally unlike her, an
attractive creature, handsome, dark, with the reputation in those
days of great daring and he used to give her cigars, which she
smoked in her bedroom. She had either been engaged to somebody
or quarrelled with her family and old Parry disliked them both equally,
which was a great bond.) Then Clarissa, still with an air of being
offended with them all, got up, made some excuse, and went off,
alone. As she opened the door, in came that great shaggy dog which
ran after sheep. She flung herself upon him, went into raptures. It
was as if she said to Peter—it was all aimed at him, he knew—“I
know you thought me absurd about that woman just now; but see
how extraordinarily sympathetic I am; see how I love my Rob!”
They had always this queer power of communicating without words.
She knew directly he criticised her. Then she would do something
quite obvious to defend herself, like this fuss with the dog—but it
never took him in, he always saw through Clarissa. Not that he said
anything, of course; just sat looking glum. It was the way their
quarrels often began.
She shut the door. At once he became extremely depressed. It all
seemed useless—going on being in love; going on quarrelling; going
on making it up, and he wandered off alone, among outhouses,
stables, looking at the horses. (The place was quite a humble one;
the Parrys were never very well off; but there were always grooms
and stable-boys about—Clarissa loved riding—and an old coachman
—what was his name?—an old nurse, old Moody, old Goody, some
such name they called her, whom one was taken to visit in a little
room with lots of photographs, lots of bird-cages.)
It was an awful evening! He grew more and more gloomy, not about
that only; about everything. And he couldn’t see her; couldn’t explain
to her; couldn’t have it out. There were always people about—she’d
go on as if nothing had happened. That was the devilish part of her
—this coldness, this woodenness, something very profound in her,
which he had felt again this morning talking to her; an
impenetrability. Yet Heaven knows he loved her. She had some
queer power of fiddling on one’s nerves, turning one’s nerves to
fiddle-strings, yes.
He had gone in to dinner rather late, from some idiotic idea of
making himself felt, and had sat down by old Miss Parry—Aunt
Helena—Mr. Parry’s sister, who was supposed to preside. There she
sat in her white Cashmere shawl, with her head against the window
—a formidable old lady, but kind to him, for he had found her some
rare flower, and she was a great botanist, marching off in thick boots
with a black collecting-box slung between her shoulders. He sat
down beside her, and couldn’t speak. Everything seemed to race
past him; he just sat there, eating. And then half-way through dinner
he made himself look across at Clarissa for the first time. She was
talking to a young man on her right. He had a sudden revelation.
“She will marry that man,” he said to himself. He didn’t even know
his name.
For of course it was that afternoon, that very afternoon, that
Dalloway had come over; and Clarissa called him “Wickham”; that
was the beginning of it all. Somebody had brought him over; and
Clarissa got his name wrong. She introduced him to everybody as
Wickham. At last he said “My name is Dalloway!”—that was his first
view of Richard—a fair young man, rather awkward, sitting on a
deck-chair, and blurting out “My name is Dalloway!” Sally got hold of
it; always after that she called him “My name is Dalloway!”
He was a prey to revelations at that time. This one—that she would
marry Dalloway—was blinding—overwhelming at the moment. There
was a sort of—how could he put it?—a sort of ease in her manner to
him; something maternal; something gentle. They were talking about
politics. All through dinner he tried to hear what they were saying.
Afterwards he could remember standing by old Miss Parry’s chair in
the drawing-room. Clarissa came up, with her perfect manners, like a
real hostess, and wanted to introduce him to some one—spoke as if
they had never met before, which enraged him. Yet even then he
admired her for it. He admired her courage; her social instinct; he
admired her power of carrying things through. “The perfect hostess,”
he said to her, whereupon she winced all over. But he meant her to
feel it. He would have done anything to hurt her after seeing her with
Dalloway. So she left him. And he had a feeling that they were all
gathered together in a conspiracy against him—laughing and talking
—behind his back. There he stood by Miss Parry’s chair as though
he had been cut out of wood, he talking about wild flowers. Never,
never had he suffered so infernally! He must have forgotten even to
pretend to listen; at last he woke up; he saw Miss Parry looking
rather disturbed, rather indignant, with her prominent eyes fixed. He
almost cried out that he couldn’t attend because he was in Hell!
People began going out of the room. He heard them talking about
fetching cloaks; about its being cold on the water, and so on. They
were going boating on the lake by moonlight—one of Sally’s mad
ideas. He could hear her describing the moon. And they all went out.
He was left quite alone.
“Don’t you want to go with them?” said Aunt Helena—old Miss Parry!
—she had guessed. And he turned round and there was Clarissa
again. She had come back to fetch him. He was overcome by her
generosity—her goodness.
“Come along,” she said. “They’re waiting.”
He had never felt so happy in the whole of his life! Without a word
they made it up. They walked down to the lake. He had twenty
minutes of perfect happiness. Her voice, her laugh, her dress
(something floating, white, crimson), her spirit, her adventurousness;
she made them all disembark and explore the island; she startled a
hen; she laughed; she sang. And all the time, he knew perfectly well,
Dalloway was falling in love with her; she was falling in love with
Dalloway; but it didn’t seem to matter. Nothing mattered. They sat on
the ground and talked—he and Clarissa. They went in and out of
each other’s minds without any effort. And then in a second it was
over. He said to himself as they were getting into the boat, “She will
marry that man,” dully, without any resentment; but it was an obvious
thing. Dalloway would marry Clarissa.
Dalloway rowed them in. He said nothing. But somehow as they
watched him start, jumping on to his bicycle to ride twenty miles
through the woods, wobbling off down the drive, waving his hand
and disappearing, he obviously did feel, instinctively, tremendously,
strongly, all that; the night; the romance; Clarissa. He deserved to
have her.
For himself, he was absurd. His demands upon Clarissa (he could
see it now) were absurd. He asked impossible things. He made
terrible scenes. She would have accepted him still, perhaps, if he
had been less absurd. Sally thought so. She wrote him all that
summer long letters; how they had talked of him; how she had
praised him, how Clarissa burst into tears! It was an extraordinary
summer—all letters, scenes, telegrams—arriving at Bourton early in
the morning, hanging about till the servants were up; appalling tête-
à-têtes with old Mr. Parry at breakfast; Aunt Helena formidable but
kind; Sally sweeping him off for talks in the vegetable garden;
Clarissa in bed with headaches.
The final scene, the terrible scene which he believed had mattered
more than anything in the whole of his life (it might be an
exaggeration—but still so it did seem now) happened at three o’clock
in the afternoon of a very hot day. It was a trifle that led up to it—
Sally at lunch saying something about Dalloway, and calling him “My
name is Dalloway”; whereupon Clarissa suddenly stiffened,
coloured, in a way she had, and rapped out sharply, “We’ve had
enough of that feeble joke.” That was all; but for him it was precisely
as if she had said, “I’m only amusing myself with you; I’ve an
understanding with Richard Dalloway.” So he took it. He had not
slept for nights. “It’s got to be finished one way or the other,” he said
to himself. He sent a note to her by Sally asking her to meet him by
the fountain at three. “Something very important has happened,” he
scribbled at the end of it.
The fountain was in the middle of a little shrubbery, far from the
house, with shrubs and trees all round it. There she came, even
before the time, and they stood with the fountain between them, the
spout (it was broken) dribbling water incessantly. How sights fix
themselves upon the mind! For example, the vivid green moss.
She did not move. “Tell me the truth, tell me the truth,” he kept on
saying. He felt as if his forehead would burst. She seemed
contracted, petrified. She did not move. “Tell me the truth,” he
repeated, when suddenly that old man Breitkopf popped his head in
carrying the Times; stared at them; gaped; and went away. They
neither of them moved. “Tell me the truth,” he repeated. He felt that
he was grinding against something physically hard; she was
unyielding. She was like iron, like flint, rigid up the backbone. And
when she said, “It’s no use. It’s no use. This is the end”—after he
had spoken for hours, it seemed, with the tears running down his
cheeks—it was as if she had hit him in the face. She turned, she left
him, went away.