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Uncertain Terms: Message Features of

Online Cancer News
Ryan J. Hurley , Kami A. Kosenko & Dale Brashers
Published online: 25 Jul 2011.

To cite this article: Ryan J. Hurley , Kami A. Kosenko & Dale Brashers (2011) Uncertain Terms:
Message Features of Online Cancer News, Communication Monographs, 78:3, 370-390, DOI:
10.1080/03637751.2011.565061

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 Communication Monographs
Vol. 78, No. 3, September 2011, pp. 370
390

Uncertain Terms: Message Features of

Online Cancer News
Ryan J. Hurley, Kami A. Kosenko & Dale Brashers
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About 113 million Americans have reported seeking health information online; however,
little is known about the quality (or qualities) of the information being retrieved. Users
have reported seeking information about health issues in an attempt to reduce negatively
appraised uncertainties (Brashers, 2007), but less is known about the ability of the
retrieved information to increase or produce unwanted uncertainty. A content analysis of
online cancer news was conducted and suggests that 65% of Internet-based cancer news
contains message features previously linked to the production of uncertainty (e.g.,
ambiguous or complex information). Though future research is required regarding
uncertainty-related content and its effects, this project provides a foundation for such
future endeavors.

Keywords: Uncertainty; Cancer; Internet News; Google; Content Analysis

Uncertainty, defined as the inability to make sense of, assign value to, or predict the
outcomes of events or situations because of a lack of sufficient cues (Mishel, 1990), is
a focal concept in communication research. Scholars have demonstrated the relevance
and importance of uncertainty in a wide range of communicative and relational
contexts, including initial interactions (e.g., Berger & Calabrese, 1975), dating and
marital relationships (e.g., Knobloch, 2007, 2008), organizations (e.g., Gallagher &
Sias, 2009), community-level change (e.g., Brummans & Miller, 2004), intercultural
interactions (e.g., Gudykunst, 2005), families (e.g., Afifi & Schrodt, 2003), and
individuals and couples coping with illness (e.g., Goldsmith, 2009). Various theories,
including uncertainty reduction theory (Berger & Calabrese, 1975), uncertainty

Ryan J. Hurley and Kami A. Kosenko are in the Department of Communication, North Carolina State
University; Dale Brashers was in the Department of Communication, University of Illinois at Urbana-
Champaign. Sadly, we lost our good friend and coauthor, Dale Brashers, before completing this manuscript. We
will always be thankful for the guidance and friendship he provided. The authors also would like to thank Scott
Althaus, Travis Dixon, and David Tewksbury for their insights on previous versions of this manuscript and Jeff
Rauch, Julius Riles, and Angeline Sangalang for their diligent coding and sampling assistance. Correspondence
to: Ryan J. Hurley, Department of Communication, North Carolina State University, 201 Winston Hall, Campus
Box 8104, Raleigh, NC 27695-8104, USA. E-mail: rjhurley@ncsu.edu

ISSN 0363-7751 (print)/ISSN 1479-5787 (online) # 2011 National Communication Association

DOI: 10.1080/03637751.2011.565061
 Message Features of Online Cancer News 371

management theory (Brashers, 2001), anxiety/uncertainty management theory

(Gudykunst, 2005), problematic integration theory (Babrow, 2001), and the theory
of motivated information management (Afifi & Weiner, 2004), conceive of
communication as a cause of and response to uncertainty. For example, many of
these theories predict that individuals will seek information through interpersonal
and mediated channels to reduce or eliminate uncertainty appraised as threatening
(e.g., Berger & Calabrese, 1975; Brashers, 2001). A primary assumption of much
communication research, in fact, has been that acquiring information leads to less
uncertainty (Berger & Calabrese, 1975; Gudykunst, 1975). Less studied is the
potential for new information to increase uncertainty in the seeker (Kivits, 2009).
Despite the potential for media content and use to serve as both a cause and
consequence of uncertainty (Jones, Denham, & Springston, 2007), the concept
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remains relatively unexplored by mass communication scholars (for an exception, see

Friedman, Dunwoody, & Rogers, 1999). The present study examines the potential for
mediated information to serve as a source of uncertainty by identifying potentially
uncertainty-provoking content in online news stories. The following sections detail
the unique context of the present investigation, online cancer news, and the
theoretical and conceptual framework of the study.

Online Cancer News

Cancer has had a devastating and pervasive impact on society; therefore, the
physical, psychological, and social effects of the disease have garnered significant
scholarly attention. Chief among the concerns of those affected by cancer and those
studying its psychosocial effects is the management of uncertainty (Clayton, Dudley,
& Musters, 2008; Thompson & O’Hair, 2008). Research indicates that uncertainty
plays an important role in all stages of the cancer continuum, from prevention to
diagnosis and treatment to survival or end-of-life care. As Cohen (2009) noted,
‘‘[c]ancer screening, diagnosis, and treatment situations are ripe with complex,
unpredictable, and probabilistic uncertainties that may be managed by commu-
nication practices’’ (p. 398). Several studies have explored the use of and potential
for communication practices, such as information seeking and social support, to
manage cancer-related uncertainty (Andreassen, Randers, Näslund, Stockeld, &
Mattiasson, 2006), but relatively few have examined the quality (and qualities) of
the information that individuals affected by cancer seek and find (Longo et al.,
2009).
The advent of new technologies and the proliferation of Internet health resources
have altered the landscape of cancer information and cancer-related information
seeking (Bass et al., 2006). Though individuals affected by cancer rely heavily on
interpersonal resources, such as medical professionals, for information and support
(Longo et al., 2009), people increasingly report seeking health information online.
An estimated 80% of Americans (113 million) use the Internet to gather health-
related information (Pew Internet & American Life Project, 2006), and cancer is one
of the most commonly searched health topics (Shim, 2008). Data from the 2003
 372 R. J. Hurley et al.

Health Information Trends Survey indicated that, despite preferring interpersonal

resources, a majority of the cancer survivors surveyed relied on the Internet to meet
their informational needs (Tian & Robinson, 2009).
Health-related Internet searches yield websites and news stories (Lapinski, 2006),
but researchers have focused more on the former than the latter. Various studies
explore the features of cancer websites (e.g., Ream, Blows, Scanlon, & Richardson,
2009; Whitten, Smith, Munday, & LaPlante, 2008); however, the content of Internet-
based cancer news remains relatively unexamined. News websites and aggregators
disseminate a wealth of health information, in general, and cancer-related
information, in particular, providing a fertile ground for study. According to
Habel, Liddon, and Stryker (2009), ‘‘[o]n a typical day, 50 million Americans use
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the Internet for news information, and approximately 70% of adult Americans
report getting news online’’ (p. 402). Data from Google Zeitgeist and Google
Trends, both of which document trends in Google searches, indicate that many
online newsreaders are interested specifically in cancer-related news content (Google
Inc., 2007). In 2006, cancer was the third most frequently searched term on Google
News (behind Paris Hilton and Orlando Bloom). Cancer remained a popular health
search term in the US from 2008 to present, second only to the flu (Google Inc.,
2010). Given the popularity and importance of cancer-related Internet searches and
the potential for online cancer news to serve as an information resource for a large
audience (Habel et al., 2009), further investigation of Internet-based cancer news
content is warranted.
Although the quality (and qualities) of online cancer news remains relatively
unexamined, a large body of work explores the content of traditional cancer news
(e.g., newspaper, magazines, or television). For example, researchers have done
content analytic work on the amount and nature of cancer news coverage in Black
versus general-audience newspapers (Cohen et al., 2008), the relative attention to
prevention, detection, causes, and effects in a national sample of news coverage in the
United States (Slater, Long, Bettinghaus, & Reineke, 2008), and frequently cited
sources in cancer news (Moriarty, Jensen, & Stryker, 2010). Several studies of cancer
news content point to features of news stories that might create uncertainty in a
reader. In Gill and Babrow’s (2007) analysis of breast cancer articles in women’s
interest magazines, ‘‘uncertainty and ambivalence were near constant themes’’
(p. 139). Clarke and Everest (2006) concluded that cancer news was ripe with
‘‘contradictions and confusion and a consequent sense of uncertainty’’ (p. 2596), and
Lantz and Booth (1998) worried that the conflicting advice found in their content
analysis of 15 years of magazine coverage of breast cancer would create confusion and
frustration for magazine readers. Although several studies point to the presence of
uncertainty-related content in traditional cancer news, additional research is needed
to determine its forms and frequency in online cancer news. Codifying and
identifying uncertainty-related message features in cancer news stories requires
further consideration of how uncertainty in illness is conceptualized and operatio-
nalized in theory and research.
 Message Features of Online Cancer News 373

Theoretical and Conceptual Framework

Conceptualizations of uncertainty in illness vary across theories and studies, with
many adopting a psychological approach to uncertainty. For example, some theories
such as uncertainty management theory (Brashers, 2001) and Mishel’s (1988, 1990)
theories of uncertainty in acute and chronic illness focus on an individual’s
experience with and appraisal of uncertainty. In these theories, communication
is construed as a cause of and response to uncertainties appraised by an individual as
threatening or opportune. The role of communication in the management of
uncertainty has received considerable scholarly attention (e.g., Brashers et al., 2000;
Martin, Stone, Scott, & Brashers, 2010); less studied is the potential for messages to
reflect, convey, and create uncertainty. Despite the emphasis in the literature on the
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individual and how individuals make sense of, interpret, and/or appraise uncertain-
ties, some scholars signal the need for further research on the messages that might
reflect or shape the individual’s experience of uncertainty. As Babrow, Kasch, and
Ford (1998) argue, ‘‘[t]hough it is common to view uncertainty as an essentially
individual-psychological state, it is important to recognize that, by their very nature,
uncertainties about health and illness are constituted socially through discourse’’
(p. 9). In addition to promoting greater recognition and understanding of the social
construction of uncertainty, studies of messages that convey or create uncertainty are
needed to ‘‘trace the ways that people convey and deploy their relative uncertainty’’
(Michael, 1994, p. 383). Despite this potential for messages to reflect, convey, or
create uncertainties about health and illness, few theoretical or conceptual frame-
works specify the properties or forms of uncertainty-related messages.
Although the individual, and not the message, is usually the focus in uncertainty
research, uncertainty theory and research can be used to inform a study of message
content. In particular, Babrow’s (1995) problematic integration theory and Mishel’s
(1988, 1990) theory of uncertainty in chronic illness offer insight into the kinds of
messages that might convey or create uncertainty. Like many of the uncertainty-
related theories previously mentioned, problematic integration (PI) theory builds on
the assumption that humans experience the world as an uncertain place. PI assumes
that an individual develops both probabilistic and evaluative orientations to the
world and that integrating these orientations (one’s beliefs, attitudes, and values) is
frequently problematic (Babrow, 2007).
In a systematic review of the meanings of uncertainty in illness (including Mishel,
1988, 1990), Babrow et al. (1998) argued that information quality contributed to
probabilistic orientations regarding the illness experience. The authors described
several dimensions of information quality, including clarity, volume, consistency, and
ambiguity, that could impact one’s probabilistic orientation (and, consequently,
uncertainty). For example, unclear messages, such as those that are exceedingly
complex or laden in medical jargon, can convey or create uncertainty because they do
not contribute to meaning making. Too little or too much information and
inconsistent or conflicting messages similarly can confuse and overwhelm readers.
 374 R. J. Hurley et al.

Also, ambiguous information, which can be interpreted in multiple ways, contributes

to uncertainty in the illness experience.
These features of information quality provide a useful lens through which to
identify and evaluate potentially uncertainty-related message content. They have been
used, for example, to label uncertainty for people living with HIV (Brashers et al.,
2003), for those who are waiting for, or who have received, an organ transplant
(Martin et al., 2010), and for family members of Alzheimer’s disease patients (Stone
& Jones, 2009). Given that the volume, clarity, consistency, and ambiguity of
information can cause or exacerbate uncertainty in the illness experience, and given
the project goal of identifying uncertainty-related content in online cancer news, the
following research questions were posed:
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RQ1: How frequently do articles indicate that too little information exists
regarding a cancer topic?
RQ2: How frequently do articles indicate that too much information exists
regarding a cancer topic?
RQ3: How frequently do articles indicate that ambiguous information exists
regarding a cancer topic?
RQ4: How frequently do articles indicate that complex information exists
regarding a cancer topic?
RQ5: How frequently do articles indicate that conflicting information exists
regarding a cancer topic?
Mishel’s theory of uncertainty in chronic illness provides additional insight into
uncertainty-related message content. Mishel (1988) developed uncertainty in illness
theory to account for the unique complexities and ambiguities of the illness
experience. Convinced that the theory needed to be reformulated to better account
for uncertainty experienced by those with chronic illness, Mishel renamed her initial
theory, uncertainty in acute illness theory, and developed a theory of uncertainty in
chronic illness (UCI). Mishel (1999) argued that, unlike acute illnesses, in which
uncertainty is ‘‘somewhat localized in the issues of diagnosis, treatment, and
recovery’’ (p. 269), individuals with chronic illnesses must live with constant
uncertainty. UCI describes uncertainty as permeating the existence of those with
chronic illnesses, such as cancer, and dismantling ‘‘the person’s view of self and of
reality’’ (p. 270). Out of this chaos comes order, as the person comes to understand
and accept the uncertainties of life and illness.
The application of Mishel’s (1999) UCI theory suggests a trajectory model of
uncertainty (e.g., see Brashers, Neidig, Reynolds, & Haas, 1998; Martin et al., 2010)
that changes over the course of risk and illness. According to Mishel’s theory,
uncertainty is part and parcel of the cancer control continuum, which includes
prevention, detection, diagnosis, treatment, survival, and end-of-life. To determine if
this chronic uncertainty is reflected in online cancer news, the following research
question was posed:
RQ6: How frequently are the dimensions of information quality (i.e., volume,
consistency, ambiguity, and clarity) associated with each stage in the cancer
continuum (e.g., prevention, detection)?
 Message Features of Online Cancer News 375

Although this project is concerned with the content of online news, differences in
retrieval methods used by online newsreaders are of note. Recent evolutions in media
technologies have given rise to search engines for news called news aggregators (e.g.,
Google News). These programs cull news articles from significantly larger pools than
focused provider websites (e.g., NYTimes.com, CNN.com) and employ algorithms
that prefer information from their political and economic supporters (Introna &
Nissenbaum, 2000). Because the process of news aggregation differs from traditional
news retrieval methods, it could be that aggregators capture different cancer content
than their nonaggregation-based counterparts. As such, potential differences in the
coverage and content of cancer news retrieved from aggregation and nonaggregation
news websites should be examined.
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RQ7: Do the uncertainty-related qualities of information differ between news

aggregator websites and nonnews aggregator websites?

Method
One of the main goals of this project was to identify and quantify uncertainty-related
messages in online cancer news articles. Several previous studies have indicated
that uncertainty-related messages are present in the news (e.g., Campion, Martins, &
Wilhelm, 2009), yet relatively few studies have codified and quantified such
messages. Developing a quantitative analysis of uncertainty-related message features
to address this gap necessitated the development of a sampling frame and coding
procedures, concept explication, operationalization, and reliability checks. This
section discusses each element of the research design and method, in turn.

Sampling
According to the Pew Research Center for the People and the Press (2006, 2009),
MSNBC, Yahoo! News, CNN, and Google News (in that order) are the world’s most
popular and frequented news websites. As such, these four popular news websites
were used to construct a sample, consisting of four contiguous months (March, April,
May, and June 2008) of news coverage. From each month’s news coverage, a week of
stories was constructed (for a total of four weeks of stories). Stratifying by day of the
week (starting with Monday), seven dates were randomly selected from each
sampling month (e.g., Monday, March 10th; Tuesday March 25th; and so on). On
each date, a researcher conducted four searches (one of each news website) in six-
hour intervals (e.g., searched one website at 6 a.m. and another website at 12 p.m.,
etc.). The researchers varied the time and day that websites were searched such that
the sample was representative of searches from each of the four websites on each day
of the week at each of the four search times (i.e., 6 a.m., 12 p.m., 6 p.m., 12 a.m.).
These times were chosen because they were four equally spaced temporal points that
represented the morning, noon, evening, and midnight hours.
The first three pages that resulted from each search (e.g., 6 p.m., Yahoo! News)
yielded 30 stories (10 per page). Previous research indicates that people rarely
 376 R. J. Hurley et al.

proceed past the first 20 items (usually two pages) in an Internet search (Molassiotis
& Xu, 2004). To increase the likelihood that the most viewed stories were captured in
the sample, the first three pages of results (i.e., the first 30 stories) were selected.
Using simple random sampling without replacement to ensure equal probability of
selection for each article, 10 articles were selected from the 30 stories produced by
each search. This procedure, repeated with each search conducted, yielded a total of
1120 cancer news articles.
Sampling online news stories necessitates attention to search term use. Although
search term selection is of concern, consistency in search term use across websites is
also of importance. To keep searches comparable across websites and time periods
and to produce a broad selection of cancer news stories, cancer was used as the sole
search term. Cancer was deemed an appropriate search term because of its popularity
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with Internet users (Google Inc., 2007) and because of the potential for the use of any
other qualifying word or phrase to skew the search results and/or make the search
phrase too cumbersome to be externally valid.

Coding Procedure
To identify uncertainty-related messages in online cancer news stories, a coding
scheme, based on some of Babrow et al.’s (1998) dimensions of information quality,
was developed. Significant adaptation of Babrow et al.’s dimensions of information
quality was necessary because the dimensions were not designed for the express
purpose of codifying and quantifying uncertainty-related messages. This coding
scheme was developed to identify uncertainty-related message features in online
cancer news; however, it was formulated to be broad enough for use in other contexts
and to be applicable to other texts and forms of discourse. Paragraphs were selected
as the unit of analysis because they represented units that were more easily
identifiable (i.e., 100% agreement) and manageable than sentences.
Pilot tests conducted with a set of articles (not part of the final sample) were used
to modify and finalize the coding scheme and to calibrate coders. This approach,
adopted by other content analysts (e.g., Moriarty & Stryker, 2007), helped ensure that
the measures were employed in a valid and reliable manner. To calculate intercoder
reliability, 10% of the sample was coded, and Krippendorff ’s (2004) alpha, a relatively
conservative reliability assessment that accounts for chance agreement, was used.
All reliabilities calculated with Krippendorff ’s alpha were greater than .85. Once
reliability was established, the two coders were randomly assigned half of the days
sampled (28 total days in the sample, 14 days per analyst) to code.
In pilot tests, researchers observed and concluded that qualities of information
could be identified in various ways. Although coders were asked to focus on manifest
content, coders identified both explicit and implicit references to uncertainty. This
realization resulted in the formation of the following four-step process for coding the
uncertainty-related message features. First, each coder was asked to determine
whether an uncertainty-related message was present in a single paragraph and,
second, to determine whether that category was explicitly or implicitly referenced in
 Message Features of Online Cancer News 377

manifest content. Any instance in which the article overtly mentioned a category was
coded as explicit; conversely, implicit references contained manifest content that was
suggestive of but did not explicitly mention a category. Coders reliably made these
presence/absence determinations on the paragraph level. Krippendorff ’s alpha for
determining whether an uncertainty-related message was present was .93, and the
alpha for determining whether it was explicit or implicit was .92. Step three involved
both coders making judgments about the presence/absence of each quality of
information (e.g., ambiguity, complexity), and, in step four, coders were asked to link
the uncertainty-related message to a stage in the cancer continuum (reliabilities for
which are reported in the following section).
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Variables
Coders were tasked with identifying what counted as an article about cancer and with
identifying the variables, described below.

Cancer article. Not all stories that are produced by a search using the term cancer
are actually about cancer. As such, coders first determined if a story returned in a
search was about cancer. Pilot data and previous research (e.g., Stryker, Emmons, &
Viswanath, 2007) helped in the development of decision rules used by coders to
determine if a story was valid. For example, coders were directed to discount stories
that only mentioned cancer once or twice (i.e., if the main focus of the story was
not cancer) or stories that used cancer figuratively (e.g., ‘‘he was like a cancer in the
clubhouse’’). Stories about feline cancer or the sign of the zodiac similarly were not
considered valid. Coders were able to consistently apply and follow these rules as
indicated by 100% (a 1.0) agreement in the reliability testing. The final sample of
articles included 862 articles (77%) of the 1120 originally retrieved from the four
news websites.

Uncertainty variables. The dimensions of information quality derived from Babrow

et al.’s (1998) review of sources of uncertainty in illness and Mishel’s (1988) forms of
uncertainty were adapted in order to identify uncertainty-related messages within
online cancer news articles. Volume of information, one dimension of information
quality, involves having too much or too little information. Babrow et al. considered
volume (having too much information) and completeness (having too little
information) to be information qualities linked to uncertainty. Coders identified
explicit references to information volume with ease, but identifying implicit
references to information volume proved problematic, ultimately leading to this
category’s removal from the coding scheme. Explicit references to a lack of
information included sentences, such as ‘‘There had been early anecdotal evidence
about people with cancer being cured by this bug or that bug, but not much hard
evidence.’’ Such phrases as ‘‘not much hard evidence exists’’ were counted as explicit
references to a lack of information. Explicit references to too much information
 378 R. J. Hurley et al.

consisted of sentences or phrases, such as ‘‘I was getting so much information that
I had to stop reading about it.’’ Measures of explicit references to volume of
information were reliable, with an alpha of .93 for references to too little information
and an alpha of 1.0 for references to too much information. Coders also reliably
identified the stage of the cancer continuum referenced with regard to volume of
information (a .94).
Clarity, another information quality identified by Babrow et al. (1998), was defined
and operationalized as complex information. Writing and speaking about cancer often
necessitates the use of medical jargon and other complex terms; therefore, paragraphs
that relied heavily on these words and phrases were coded as complex. Synonyms for
complexity (e.g., complicated, difficult, etc.) were considered manifest indicators of
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this category and used to locate explicit mentions of complexity within an article. For
example, complex information was coded as present if a story contained a statement
such as ‘‘navigating the complex treatment maze can be frightening.’’ Complex terms
(as opposed to explicit references to complex, difficult, or complicated information)
were considered manifest indicators of implicit complexity. For example, a paragraph
containing the statement that ‘‘they identified genes of interest in 28 related tumor
samples and 18 cell lines using array-comparative genomic hybridization profiling on
Agilent’s 60-mer 44K or 244K density microarrays’’ was coded as containing implicit
complexity. This measure proved more difficult than others to employ, but coders
reliably identified complexity in cancer news articles (a .87) and the stage of the
cancer continuum that was being depicted as complex (a.88).
Ambiguity, a third dimension of information quality, refers to the difficulties
involved in interpreting or determining the meaning of an event or situation when
multiple interpretations are possible (Babrow et al., 1998). Any statement that
explicitly referenced these interpretation difficulties or the potential for information
to be interpreted in multiple ways was coded as explicit ambiguity. Coders looked for
manifest indicators of explicit ambiguity. For example, the statement, ‘‘the first sign is
a painless bump, often reddish to purple, that can resemble a benign cyst, confusing
even dermatologists about whether a biopsy’s needed,’’ was counted as an explicit
reference to ambiguity. Confusion, in this case, was identified as a manifest indicator
that a particular symptom could be interpreted in multiple ways (i.e., ambiguity).
Research on hedging, a concept similar to ambiguity, was used to develop a
measure of implicit ambiguity. Hedging research indicates that word choice can be
used to identify implied ambiguity or uncertainty. As such, terms such as ‘‘may’’ or
‘‘might’’ and ‘‘possible’’ or ‘‘potential’’ were considered manifest indicators of implicit
ambiguity (Crismore & Vande Kopple, 1997; Jensen, 2008). For example, a statement,
such as ‘‘we cannot say any specific studies are wrong, but we can say that the analysis
used in many of the papers suggests that some of them probably were overstating the
significance of their findings,’’ would be coded as hedging, or implicit ambiguity.
Indicating that someone ‘‘probably overstated their findings’’ highlights the potential
for multiple interpretations of the information but does not explicitly mention the
possibility of multiple interpretations. Coders reliably identified manifest indicators
 Message Features of Online Cancer News 379

of both explicit and implicit ambiguity (a .91) in sample stories and the stage of the
cancer continuum described as ambiguous (a.89).
The final category of uncertainty-related messages was dubbed conflicting
information and attended to issues of consistency within individual articles. When
an article stated that a conflict existed between two or more pieces of information,
that paragraph was coded as containing an explicit reference to conflicting
information. For example, the phrase, ‘‘doctors disagree about the effect of
chemotherapy on this type of cancer,’’ was counted as explicit conflicting informa-
tion. This message states that conflicting perspectives exist as opposed to multiple
interpretations (which would be ambiguity). If it read, ‘‘doctors could interpret the
results differently,’’ then the statement instead would be counted as an explicit
ambiguity reference.
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Statements that suggested but did not explicitly state that information was
conflicting were coded as containing implicit references to conflicting information.
For example, a statement, such as ‘‘Dr. Moore said that using chemo increased
patients’ chances of survival, but Dr. Anderson stated that chemotherapy has little to
no effect,’’ establishes a conflict without actually stating that a conflict exists. In other
words, cases of implicit conflicting information force the reader to determine if a
conflict is present; whereas, in instances of explicit conflicting information, the
journalist tells the reader that a conflict is present. Inconsistencies within articles also
were counted as implicit conflicting information. As such, if an article contained
contradictory information (but did not explicitly reference the existence of
conflicting ideas or information), then implicit conflicting information was coded.
Inconsistencies between articles were not examined; inconsistencies within and
between paragraphs were captured but only counted once. For example, if paragraph
one of a news story presented a fact that was contradicted in paragraph three of the
same story, then implicit conflicting information was considered present in
paragraph three. Krippendorff ’s alpha for conflicting information within articles
was sufficient (a.93), and coders were able to determine the stage of the cancer
continuum reliably, as well (a .87).

Results
Uncertainty-related message features were measured using individual paragraphs as
the unit of analysis. Paragraph-level data were transformed to reflect the number of
uncertainty-related messages per article. In this four-month sample of online news,
over 65% (562 of 862) of the articles contained messages that might convey or create
uncertainty regarding the cancer experience. In other words, nearly two-thirds of
online cancer news articles contained at least one paragraph with uncertainty-related
messages about cancer prevention, detection, treatment, survivorship, or end-of-life.
An analysis of uncertainty-related messages by website showed that the frequencies of
these messages differed between individual websites, x2(3, n862) 21.80, p B.001.
The frequencies and percentage of stories within a particular website revealed that
MSNBC presented the most uncertainty-related messages in their cancer news in this
 380 R. J. Hurley et al.

Table 1 Instances of Uncertainty-related Messages by Website

Nonaggregation Aggregators

MSNBC CNN Google News Yahoo! News All sites

Story level 175 (77.4)a 63 (66.3)b 160 (60.6)b 164 (59.2)b 562 (65.2)
Story n 226 95 264 277 862
Paragraph level 571 (13.6)a 208 (10.1)b 447 (13.4)a 430 (11.6)b 1656 (12.4)
Paragraph n 4214 2061 3326 3717 13,318

Note: Percentages in rows (indicated in parentheses) that do not share superscripts differ at pB.05 using a
chi-square test.

sample (see Table 1). Of the 562 cancer news articles that contained uncertainty-
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related content, the average amount was 2.95 uncertainty-related messages per article
(ranging from one to 15 messages in a single article; SD 2.08).
Articles could contain multiple forms of uncertainty-related messages (e.g.,
conflicting and ambiguous messages) and/or the same form multiple times (e.g.,
several ambiguous messages). For this reason, specific forms of uncertainty-related
messages were coded at the paragraph level. The average article length for this sample
was 15.47 paragraphs per cancer article (SD 9.65). A total of 13,318 paragraphs
were coded in the sample, and 1656 paragraphs contained some uncertainty-related
message. In other words, about 12.4% of the paragraphs in this sample contained
uncertainty-related message. A chi-square test revealed a significant difference
between paragraph-level uncertainty-related messages and cancer news websites,
x2(3, n 13,318) 20.85, p B.001. At the paragraph level, both Google News and
MSNBC contained more uncertainty-related messages than Yahoo! News and CNN
(see Table 1).
The first formal research question asked how frequently articles indicated that too
little information existed regarding some cancer topic. Two hundred and seven
paragraphs of the 13,318 coded (1.6%) contained explicit mentions of a lack of
information (see Table 2). A chi-square test revealed a significant difference
(answering part of RQ7) between news aggregator and nonaggregation websites
with regard to too little information, x2(1, n 13,318) 12.77, pB.001, such that
nonaggregation news websites indicated a lack of information more often than
aggregation news websites (see Table 2). MSNBC presented the most instances of a
lack of information.
The second research question asked how frequently articles indicated that too
much information existed regarding some cancer topic. Only 27 paragraphs of the
13,318 coded (0.2%) contained explicit mentions of having too much information
(or information overload). A chi-square test revealed a significant difference between
news aggregator and nonaggregation websites, x2(1, n 13,318) 30.37, p B.001.
Google News and Yahoo! News did not contain any instances of uncertainty-related
messages of this kind.
The third research question asked how frequently articles indicated that ambiguous
information existed regarding some cancer topic. Of the 13,318 paragraphs coded,
 Message Features of Online Cancer News 381

Table 2 Frequencies of Paragraph-level Uncertainty-related Messages by Website

Nonaggregation Aggregators

MSNBC CNN Google News Yahoo! News All sites

Lack of info. 92 (2.2)a 31 (1.5)ab 48 (1.4)b 36 (1)b 207 (1.6)

Too much info. 21 (0.5)a 6 (0.3)a 0 (0.0)b 0 (0.0)b 27 (0.2)
Explicit ambiguity 14 (0.3)a 0 (0.0)b 21 (0.6)a 14 (0.4)a 49 (0.4)
Implicit ambiguity 404 (9.6)a 153 (7.4)b 254 (7.6)b 265 (7.1)b 1076 (8.1)
Both ambiguities 15 (0.4)a 2 (0.1)a 7 (0.2)a 6 (0.2)a 30 (0.2)
Explicit complexity 0 (0.0)a 0 (0.0)a 3 (0.1)a 3 (0.1)a 6 (B0.1)
Implicit complexity 5 (0.1)a 11 (0.5)b 81 (2.4)c 85 (2.3)c 182 (1.4)
Explicit conflict 7 (0.2)ac 0 (0.0)c 16 (0.5)b 14 (0.4)ab 37 (0.3)
Implicit conflict 10 (0.2)ab 5 (0.2)ab 16 (0.5)a 7 (0.2)b 38 (0.3)
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Both conflicts 3 (0.1)a 0 (0.0)a 1 (B0.1)a 0 (0.0)a 4 (B0.1)

Totals 571 (13.6)a 208 (10.1)b 447 (13.4)a 430 (11.6)b 1656 (12.4)
Paragraph n 4214 2061 3326 3717 13318

Note: Percentages in rows (indicated in parentheses) that do not share superscripts differ at pB.05 using a
chi-square test.

1155 (8.7%) contained some form of ambiguous information. Of those, explicit

ambiguity was present in 49 paragraphs, implicit ambiguity was coded in 1076
paragraphs, and 30 paragraphs contained both explicit and implicit presentations of
ambiguity. Table 2 presents frequencies and percentages regarding the presence of
ambiguity by website. A chi-square test revealed a significant difference between
news aggregator and nonaggregation websites and presentations of ambiguity,
x2(1, n13,318)  7.30, p B.01, such that that nonaggregation news websites
presented ambiguous information slightly more than aggregation news websites in
this sample. MSNBC presented more instances of ambiguity than any of the other
three websites sampled.
The fourth research question asked how frequently articles indicated that complex
information existed regarding some cancer topic. Of the 13,318 coded, 188
paragraphs (1.4%) contained some form of complex information. Explicit complex
information only was present in six paragraphs, whereas implicit complexity was
coded in 182 (about 97%) of the 188 cancer news paragraphs containing complex
information (see Table 2). A chi-square test revealed a significant difference between
news aggregator and nonaggregation websites regarding all types of complexity, x2(1,
n 13,318) 114.06, p B.001. Specifically, news aggregation websites presented
substantially more complex information than nonaggregation news websites.
The fifth research question asked how frequently articles indicated that conflicting
information existed regarding some cancer topic. Seventy-nine (0.6%) of the 13,318
coded paragraphs contained some form of conflicting information. Explicit
conflicting information was present in 37 of the paragraphs, implicit conflicting
information was coded in 38 paragraphs, and four of the cancer news paragraphs
both explicitly and implicitly presented conflicting information (see Table 2). A chi-
square test revealed a significant difference between news aggregator and nonag-
gregation websites concerning conflicting information, x2(1, n 13,318) 7.63,
 382 R. J. Hurley et al.

Table 3 Frequencies of Uncertainty-related Messages in the Cancer Continuum

Prevention Detection Treatment Survivor End of life

a b b c
Lack of 75 (17.4) 20 (7.7) 56 (8.2) 20 (27.4) 14c (37.8)
Too much 0a (0.0) 0a (0.0) 27b (4.0) 0ab (0.0) 0ab (0.0)
Ambiguous 293a (68.0) 206b (79.2) 432a (63.6) 53ab (72.6) 23a (62.2)
Complex 33a (7.7) 9b (3.5) 142c (20.9) 0b (0.0) 0ab (0.0)
Conflicting 30ad (7.0) 25a (9.6) 22bc (3.2) 0c (0.0) 0cd (0.0)
All uncertainties 431 260 679 73 37

Note: Percentages in rows (indicated in parentheses) that do not share superscripts differ at pB.05 using a
chi-square test.

p B.01. News aggregation websites contained significantly more conflicting informa-

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tion than their nonaggregation counterparts.

The sixth research question asked how frequently each stage of the cancer
continuum was referenced as being uncertain (see Table 3). Uncertainty-related
messages about treatment were most common followed, in order, by prevention,
detection, survivorship, and end-of-life issues. These findings regarding the cancer
continuum suggest that the stage of cancer being described is related to the presence
of uncertainty-related messages. Table 3 also highlights the differences between the
frequencies of each dimension of information quality, such that ambiguous cancer
information clearly was the most common. Table 3 depicts clear differences in
frequencies between the dimensions of information quality across each of the stages
of the cancer continuum. Treatment ambiguity was the most common dimension of
information quality mentioned with regard to a stage in the continuum.

Discussion
The current investigation was guided by multiple goals: (1) to identify uncertainty-
related message content and track its frequency in online cancer news, (2) to examine
how uncertain terms are dispersed across the stages of the cancer continuum, and (3)
to determine if news aggregator and focused provider websites differ in cancer news
coverage and content. Findings indicate that uncertainty-related terms appear in 65%
of Internet-based cancer news and that, of these terms, ambiguity is the most
frequent in cancer news stories. Uncertainty-related messages are used most
frequently in reference to the treatment stage of the cancer continuum. For example,
ambiguous messages are often about the efficacy and side-effects of cancer
treatments. Finally, significant differences between the uncertainty-related content
of news aggregator and focused provider websites and between individual websites
exist. These findings, and their implications for communication theory and research,
are discussed in turn.
Almost two-thirds of all cancer stories contain some uncertainty-related messages
that could contribute to probabilistic orientations about cancer (Babrow, 1995). The
frequency with which uncertainty-related content appears in online cancer news
might be tied to a number of factors. The scientific and medical uncertainties
 Message Features of Online Cancer News 383

inherent to the disease and the disease experience (Gill & Babrow, 2007) might be
reflected in journalistic writing on the subject, resulting in news stories with
uncertainty as a common theme. Uncertainty-related content in cancer news also
might reflect journalistic choice and agenda setting. Some research suggests that
writers strategically employ ambiguity in their writing to engage readers and increase
cognitive interest. For example, in a series of experiments examining the differential
impact of various messages on the cognitive interest of readers, Campion et al. (2009)
found that the presence of inconsistencies and other uncertainty-provoking content
in texts was associated with increased cognitive interest. Gill and Babrow noted a
tendency in breast cancer magazine articles for writers to encourage readers to ‘‘‘read
on’ with the promise of enlightenment in the pages ahead . . . under the pretext that
uncertainty can, should, and will be reduced’’ (2007, p. 143). Critical research on
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health journalism offers an alternative explanation for the presence of uncertainty-

related content in health news. Journalists and scientists have been accused of
‘‘manufacturing uncertainty’’ on certain topics, such as global warming and the link
between smoking and cancer, due to pressure from private industry (Michaels, 2005;
see also McGarity & Wagner, 2008; Oreskes & Conway, 2010). Studies examining the
nature of uncertainty-related message production are needed to more fully explain
why these message features appear with such regularity in cancer news.
The frequency with which uncertainty-related content appears in online cancer
news also provides some insight into findings from media effects studies. Seemingly
contradictory findings in studies of effects of cancer information seeking and
exposure might be explained by differences in cancer information content, such as
the relative frequency of uncertainty-related messages. For example, online health
information and information seeking has been associated with an array of beneficial
behaviors and outcomes, including increased self-efficacy and self-advocacy; however,
an inverse relationship between Internet health information seeking and treatment
compliance has been documented (Bass et al., 2006). Ambiguous messages about
treatment, common in this study of online cancer new articles, might help explain
why Internet health information is associated with a lack of compliance with doctors’
recommendations. Also, the complexity of treatment names, regimes, side-effects,
and options has the potential to create concern and a sense of reduced self-efficacy,
which might affect compliance. Han, Moser, and Klein (2006) found that perceived
ambiguity in cancer prevention recommendations affected readers’ perceptions and
emotions. Perceived ambiguity of cancer prevention information was negatively
related to perceptions of cancer preventability and positively associated with cancer-
related worry. It is possible that individuals with cancer who encounter ambiguous or
uncertain messages about treatment experience similar fears and a diminished sense
of self-efficacy or response efficacy. Further research is needed to examine and explain
the relationship between cancer news content and effects.
Uncertainty-related messages referenced various stages of the cancer continuum.
Although the coding scheme developed and employed in this project did not allow us
to calculate percentages regarding uncertainty-related messages within each stage
(e.g., the percentage of survivorship articles that contain uncertainty), it did allow us
 384 R. J. Hurley et al.

to determine which stages of the cancer continuum were more and less likely to be
associated with various uncertain terms. For example, ambiguity regarding treatment
was more frequent within online cancer news than ambiguity regarding end of life;
however, we cannot say that the percentage of treatment stories containing ambiguity
is greater than the percentage of end-of-life articles containing ambiguity. Still, these
findings complement and extend work on cancer portrayals in the media. For
example, in a content analysis of two years’ worth of magazine, newspaper, and
television coverage of cancer, Slater et al. (2008) found that treatment received the
most coverage of any cancer topic. In a study of breast cancer magazine articles, Gill
and Babrow (2007) noted that uncertainties regarding treatment options were
commonly voiced concerns. Ambiguous messages about treatment in cancer news
stories might be reflective of the difficult and complex decisions facing those
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diagnosed with cancer or might simply reflect the nature of cancer treatments,
themselves. Cancer drugs and treatment protocols are continually evolving, and
cancer news coverage tends to emphasize new and/or experimental treatments of
which even doctors are uncertain. As Corbett and Mori (1999) noted, ‘‘[h]ealth
reporters’ favorite stories concern new drugs and treatments’’ (p. 230). Given this
emphasis on treatment in cancer news stories and the frequency with which
ambiguous messages about treatment appear in cancer news, further research is
necessary to understand the origins and effects of the uncertain terms used to
describe cancer treatments.
The lack of uncertainty-related messages about end-of-life decisions and care is
also worthy of note. The dearth of uncertain messages about end-of-life issues might
be linked to the certainty of death, immortalized in Ben Franklin’s comments about
death and taxes (Miller, 2005); however, end-of-life decision making and planning
is rife with uncertainty. That fact that, compared to the other categories in this study,
uncertainty-related messages were least frequently associated with end-of-life issues
might contribute to ‘‘fundamental inaccurate assumptions about the nature of
uncertainties confronting dying persons’’ noted in the literature on advance planning
for those with terminal illness (Hines, 2001, p. 509). In addition, some suggest that
expressing uncertainty with regard to end-of-life issues offers hope to patients (Trice
& Prigerson, 2009). Additional research is necessary to determine the effects of
uncertainty-related messages (or the lack of these messages) about end-of-life issues
in cancer news stories.
Effects studies also are needed to further explicate the role of media use and
content in the experience and management of uncertainty. Mishel’s (1988) theory of
uncertainty in illness specifies three antecedents of uncertainty in the illness
experience: stimuli frame, which includes one’s symptom pattern, familiarity with
the event, and consistency between expectations and experiences; cognitive capacity,
or information-processing ability; and, structure providers, or available resources.
Although media outlets serve as resources for ill individuals, structure providers are
most commonly conceived of as medical professionals and other interpersonal
resources. The potential role of media as an antecedent to uncertainty in illness
warrants further investigation, including theory testing and development.
 Message Features of Online Cancer News 385

The results of this study, and the coding scheme described herein, might be
applicable to studies of how other illnesses*and other phenomena more generally*
are represented in the media. Many illnesses are marked by high levels of uncertainty:
for example, life-threatening illnesses such as HIV or hepatitis, degenerative
conditions such as Parkinson’s or Alzheimer’s disease, or illnesses that quickly gain
public attention such as the H1N1 flu. As we build our understanding of the
relationship between information (e.g., media messages) and uncertainty, it is
important to determine if the clarity, volume, consistency, or ambiguity of that
information influences how people experience these illnesses. For example, when the
H1N1 flu (originally labeled swine flu) first emerged in the spring of 2009,
uncertainty was apparent about who was at risk, about how easily the virus was
transmitted, and, ultimately, about risks associated with the vaccine. The coding
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scheme presented in this paper could help researchers track the sources and types of
uncertainty that unfolded during that time and perhaps to make recommendations
about more or less effective ways for readers to understand the complexity, or
ambiguity, of the situation. Other phenomena, such as climate change or economic
crisis, might also be reported in ways that acknowledge or increase uncertainty rather
than reduce it.
The methodological implications of these findings also warrant consideration.
Significant differences between the uncertainty-related content of news stories
retrieved from news aggregator versus focused provider websites might be the result
of these two search tools, commonly used in Internet news content analysis,
capturing different types of cancer news stories (Introna & Nissenbaum, 2000).
Studies have indicated that news aggregation websites might capture different types
of articles than their nonaggregation counterparts (Hurley, Sangalang, & Muddiman,
2009); however, the reasons behind these selection differences remain relatively
unexplained. Because websites like Google and Yahoo! News are sources of
information for millions of health information seekers (Pew Internet & American
Life Project, 2006), future work should examine why news aggregation and
nonaggregation content differs. Furthermore, researchers should note that content
retrieved using different search tools might vary.
No study is without limitations, and this project is no exception. This study was
designed to explore news articles that were retrieved via some search technology;
however, a body of research is developing around information ‘‘scanning.’’ Part of
understanding how people react to information might be based in whether they are
intentionally seeking information about cancer when they read the news or merely
scanning the news and happening upon stories about cancer (see Niederdeppe et al.,
2007). These data cannot be used to make claims about the content to which
information scanners might be exposed; however, the information landscape
presented to cancer information-seekers on these four news websites should be
adequately represented.
The methodological limitations of this project, including potential validity threats,
also should be considered. First, content validity issues might exist given our
substantial adaptation of Babrow et al.’s (1998) dimensions of information quality.
 386 R. J. Hurley et al.

Future applications of our coding scheme and/or Babrow et al.’s categories might
benefit from a consideration of alternative ways of conceptualizing and operationa-
lizing uncertainty-related message content. The use of mutually exclusive categories
and a focus on manifest (rather than latent) content also serve as potential validity
threats. Some might argue that the complexities and subtleties of the uncertainty
construct and experience preclude the use of mutually exclusive categories and
manifest content analysis; however, in a project focused on codifying and quantifying
uncertain terms (as opposed to an individual’s meanings of uncertainty), the use of
mutually exclusive categories and manifest content analysis is warranted. Although
these features of the project enabled the coders to achieve high inter-coder reliability,
the potential threats to validity should be noted. The use of quantitative measures
and methods might be considered problematic, as well. Some researchers (e.g., Gill &
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Babrow, 2007) have argued that qualitative methods are uniquely suited to the
analysis of uncertainty, given its complexities and the potential for individuals’
meanings of uncertainty to be chained or interrelated. Although qualitative
approaches might offer further insight into the forms of uncertainty-related
messages, the quantitative content analytic approach adopted in this study allowed
for an analysis of the frequency with which those forms appear in cancer news stories.
Finally, construct validity issues should be noted. Although difficult to assess given
the lack of extant theory and research on message-level uncertainty, the nomological
validity of this coding scheme and these findings remains unexplored. Work that
applies, extends, or refines the categories or coding scheme developed for this project
should consider these and other potential methodological limitations of the present
study.
Despite its limitations, the present study suggests several directions for future
research. Messages that might convey values and, thus, contribute to evaluative
orientations were outside the scope of this investigation but should be considered in
future examinations of uncertainty-related message content. Also, examining
uncertainty-related information across news stories would serve as a useful and
insightful extension of this work. Applications of this coding scheme and/or Babrow
et al.’s (1998) dimensions of information quality to other forms of cancer
information such as cancer-related websites and traditional cancer news stories
could provide additional insight into the landscape of cancer information and might
reveal different forms of uncertainty-related messages than those identified in this
study. Furthermore, cancer represents only one context among many that requires
examination. Researchers should explore uncertainty-related content in news cover-
age of other health issues (e.g., HIV, HPV) and in nonhealth-related contexts (e.g.,
political news coverage). Finally, additional research is needed to determine how
aspects of the Internet search process such as the sheer volume of search results
yielded might convey or create uncertainty.
Individuals are increasingly reliant on the Internet for health information, and
Internet health information seeking is associated with myriad perceptual and
behavioral effects (Shim, 2008). What is missing from the discussion of online
health information is attention to content and to the potential for online health
 Message Features of Online Cancer News 387

resources to cause or exacerbate uncertainty in information seekers. This study serves

as a step toward greater understanding and recognition of the message features of
online health information, which patients and their loved ones are so reliant upon,
that might cause, exacerbate, or help manage uncertainty. A greater understanding of
the production and effects of these uncertainty-related messages is needed to help
clarify the role of media in uncertainty-related theory and research.

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