At 111 online, we’ve started to add images to our triage questions. Not very many, just selected ones where we've had feedback from our users that they need more help with understanding the question.

We’ve added images to questions that ask about different body parts that our users have told us are tricky to understand – for example, your ‘flank’. Using illustrations, photographs and videos ensures our users can use an online assessment, unguided and answer the questions correctly and get the right clinical outcome.

111 online has a feedback form on almost every page and a common comment has been around checking skin rashes, where “show me a photo” is a running theme. One of the most important questions we ask is about ruling out a meningococcal sepsis rash – the skin rash that might suggest meningitis.

Sourcing medically approved imagery was challenging. We scoured medical websites, reference books, medical stock images sites and reached out to medical photography departments. Photographs that are inclusive, and show many different skin tones, are difficult to come by – but we did manage to find what we needed.

The first image shown is the very early stages of the rash. The spread of spots and marks illustrate how challenging it can be to identify when the rash first starts. This image is shown on white skin, which visually is easier to see for people who have low contrast vision. It also corresponds with data from the user research team. The latest ethnicity stats for people who fill in our survey shows 90% of users select are white.

We had previously looked at using the images on the meningitis symptom pages of the NHS website. However, our clinical team pointed out that while the lead image on this page was dramatic and easily spotted, it was probably too advanced to be useful for people using the 111 online service.

The images we were looking for needed to accurately show the meningitis rash in its earlier stages, so we needed images that were similar to ones that GPs or other clinicians might be using when making a diagnosis.

Consulting with the UK Sepsis Trust, as well as our own NHS Pathways clinicians, we found some images which were published online from the British Medical Journal. Thankfully the journal has an easy-to-use licensing model, so it didn’t take long to arrange.

We knew from earlier work on cyanosis (lips or skin turning blue) that it is also important to describe or show how a symptom can look on brown or black skin, especially where it might be different or harder to spot than on white skin.

After another long search, we decided to use the same image that is on the NHS website to show what the rash looks like on brown or black skin. Partly for consistency, and partly because it is widely used across the internet and licensable through our regular science stock library.

Finally, we wanted to show something more than a single still image of how to perform the blanching skin test, commonly known as a glass test. This is where some pressure on the rash will cause it to fade or remain.

We looked at a series of diagrams or other methods, but this short clip from a video from St John Ambulance seemed to very quickly show how to do it. We asked for permission to use it and were happy to be able to include it with appropriate attribution.

As with all the content on 111 online, we have been doing of plenty of user research as we have gone through the design process to see how people react, understand, and use images and media on a page in an online assessment.

All of the imagery was ratified and approved by a clinical panel, from NHS 111 online and NHS Pathways, who approved that the images were appropriate to match with the questions we selected.

For the actual build, the image gallery and the video player have been through a lot of accessibility research with people who use a variety of assistive technology, like screen readers and magnifiers.

The images and video are now live on the service, and we plan to follow the analytics of user behaviour as they use these questions online. Where we added images to 111 online before, we saw no negative responses so we expect that adding photos to the meningitis symptom pages will have a positive outcome too.