Pineapples and stethoscopes. The problem with stock images

In this blog, Cochrane UK’s Knowledge Broker, Sarah Chapman, reflects on the challenges of using stock images to illustrate blogs and other social media products about health evidence. Since writing this blog, in October 2020, Cochrane UK, with the help of a global advisory group and other colleagues, has produced for Cochrane Choosing images for sharing evidence: a guide, which is free for anyone to access and use.

Page last updated 14 February 2023.

Let’s start with a little quiz. In which of the following circumstances would a health professional wear a stethoscope round their neck?

  1. Dressing a wound
  2. Delivering a baby
  3. On the doorstep of a patient’s home
  4. Sitting at a desk
  5. Retrieving record files from a shelf
  6. None of the above
  7. All of the above

Creators of stock images seem to think that the correct answer is 7) and that the wearing of a stethoscope is essential for the performance of all health-related tasks. Or, rather, that this prop is essential to convey the idea of a health-related activity. The trouble is, this immediately makes the image inauthentic. If the first thing you think is, “I/they wouldn’t be wearing a stethoscope then”, it may make you question what, in the writing it accompanies, might also be a bit off-kilter and unreliable.

These healthcare professionals know they need to wear their stethoscopes at all times…!

You’ll never do this with a magnifying glass

In the world of stock images, menopausal women adopt a pained expression while holding a fan in one hand and putting the other to their brow. There’s only one pose for the incontinent, which is to bend forward slightly whilst clasping both hands to the groin, though the more daring might hold an ‘SOS’ sign in front of their pants. As for pain (especially heart attacks), there must be more to conveying this than placing a hand to one’s chest and grimacing. Those who can do it convincingly are presumably making careers out of acting rather than stock modelling. This is just the tip of the iceberg.

Nuns with fish?

It gets much, much stranger. I’ve seen an image of a woman apparently giving birth to a pineapple, which is potentially a good analogy for the often painful process of trying to illustrate our blogs. Then there are post-it notes – you do cover yourself in them if you want to remember something, don’t you? For some wonderful examples of inexplicable and unusable stock photos, see this Buzzfeed article, which gave us a good laugh in the office.

Images matter

Our need for images that are relatable, respectful, accurate and sometimes informative, to accompany our blogs and to illustrate our blogshots, is a serious one. Everything we put out on social media has to work for the Cochrane brand and certainly must do nothing to bring it into disrepute. Our brand guidance is to choose images that are ‘clear and bright’ and help to reinforce our organizational aims, encapsulated in Cochrane’s strapline: “trusted evidence, informed decisions, better health”. ‘Trusted’ is an important word here. The wrong image can be offputting, unhelpful and potentially misleading. Whilst we don’t expect people to use a stock image accompanying a blog or blogshot as they would an instruction manual, if we show a piece of equipment, it needs to be the right one, and a clinical situation needs to look credible.

We try hard to get this right, but if a mistake is made we’ll change it. We struggled to find a suitable image to go with a blog on asthma inhaler use in schools. We were challenged on our choice of one which showed a child using an inhaler without a spacer; whilst this probably reflects common practice, it falls short of best practice, so we changed it.

teacher using inhaler with child
We replaced an image of a child using an inhaler without a spacer with this one

Avoiding negative stereotypes 

Whilst aiming to be sensitive to the realities of living with a health condition, we do try to choose neutral or positive images where that seems reasonable. Oddly, stock images of people having a clinical consultations generally show them looking either despairing or euphoric, with little in between; not useful.

One of the first blogs I wrote was about childhood obesity, and I rejected the numerous available images of fat-child-sitting-alone for one which showed a happy picture of an overweight girl interacting with her parents. I was really struck by a comment left by a reader, who said that the use of such a positive image was welcome and made her feel comfortable sharing the blog with her son. But it doesn’t always go so well, because the whole business of images is subjective. Take hands, for example…

(No more) wrinkly hands

I confess. I like hands, and I like images of hands. Looking for a way to illustrate a bloghot (mini infographic) on a Cochrane review about palliative care interventions for people with end stage dementia, I chose an image of an older person’s hand being held by a younger person’s which, to me, spoke of the effort to comfort and care, where for other aspects of that situation I could find only bleak images. Someone questioned this on Twitter, adding “more to old people than wrinkly hands even when they’re dying?” It was only then that we saw the current backlash against this depiction of older people, which uses the hashtag #NoMoreWrinklyHands. However, the criticism behind it seems to be about “lazy, negative stereotyping of old people”, and we decided to let our careful choice of image here stand.

Stock image wrinkly hands
Stock images of wrinkly hands have caused some consternation

There was criticism of another organisation for using a hand washing image for a piece on OCD, again with the objection that there is more to this condition. But with a single image, even aside from the restrictions of image availability, brand requirements and so on, there’s a limit to what can be done. What’s important, I think, is to choose with care, be reflective when criticised and make changes if you decide there is good reason to.

Besides, the cliché dustbin is already full, with images of roadsigns, lightbulbs, arrows in targets, hands linked in the centre of a circle (hands again, this time for the team), and much, much more.

Bananas are not the only fruit. Illustrating sensitive topics

In the world of stock images, sexual problems are always the man’s fault and he will sit on the edge of the bed with his head in his hands, while a woman lies back in a fuzzy haze of disappointment; that’s when he’s not checking the contents of his pants with a magnifying glass, or holding a banana in front of them. In fact, bananas are definitely best left to comedians and those working in the food industry, which we had no difficulty in agreeing with here when thinking about how we could illustrate the blogs in our recent campaign on #theproblemwithsex. You can see what we used by taking a look at the blogs in our sexual health category.

Stock images: a Green Red Stitched Apple
I chose this stock image to accompany a blog on surgical approaches to vaginal prolapse repair – tricky to illustrate

Shout-out here to The Mental Elf where blogs on mental health topics are often illustrated not only sensitively but creatively, avoiding reaching for an obvious image in favour of something a bit more interesting.

Art capturing patient experience

There is a rich seam of art made by people who have created works in response to their experience of living with a condition. We have sometimes used these and love what this adds to the blogs. For example, take a look at the images we used for our series of blogs on Contemplating cancer.

A gap in the market?

We buy most of our images from a stock images library and put them in a central repository for use by others in Cochrane. Sometimes we are able to source and use images that are freely available, but mostly we’re stuck with the stock library. Whilst the awfulness of some of the available images give us a moment’s entertainment in the office, finding suitable photos can be a big problem. We want to ensure that we show diversity in the people we depict, accuracy in terms of clinical situations, and strive for respectfulness and authenticity. Surely there is a gap in the market here for library of health-related stock images.

The last word (for now)…

Sign off from Jack on his last day at Cochrane UK 

For the last 18 months, it has been my pleasure to be Communications and Engagement Officer at Cochrane UK. Thinking about the use of images across our digital presence has been a important part of my job, so on my last day, Sarah has asked me to share my thoughts. I suppose that when I began this role, I appreciated the need for images to respect the brand imagery of the organisation and to avoid insensitivity (indeed, that may have been one of my answers in my interview). However, what has grown on me is the need for real care when displaying a health condition or treatment. It is NOT “just an image”. People with health conditions need accurate information in all forms, including images, to help them make informed decisions. To do otherwise would be careless and disrespectful. This is why it has been my pleasure to work for an organisation that not only takes the care to illustrate topics carefully, but responds thoughtfully and with consideration to feedback.

The work that I am most proud of is our #TheProblemWithSex campaign. It was here that the parameters we set ultimately liberated us to think more creatively. We considered using a picture of a vagina for a blog on vaginismus  ,after all, we would not hesitate from showing an arm for a blog on shoulder surgery. Anatomy is anatomy. We were busting taboos! Yet, it would be foolish to ignore other factors, not least restrictions on imagery that is considered pornographic on social media. So, we used images that we felt illustrated the subject in a more conceptual way and allowed people to approach the blogs without the shock of imagery that many would find uncomfortable. We received positive feedback on the use of these images and, whilst I don’t always agree that ‘a picture is worth a thousand words”, I think that these images were worth the time and effort that we spent deliberating in order to meet our goals of trusted, respectful, accurate information.

Staircase looks like a vagina
The image we chose to feature in our blog Vaginal dilator therapy: vibrate, dilate, or wait?

Join in the conversation on Twitter with @SarahChapman30 @CochraneUK or leave a comment on the blog.

Sarah Chapman has nothing to disclose.







Pineapples and stethoscopes. The problem with stock images by Sarah Chapman

is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International

3 Comments on this post

  1. Thanks so much for this blog post. I remember writing in to complain about a breast and baby being covered during breastfeeding. I wonder whether at some point the branding guidelines could be reviewed to allow the use of artistic representation of people’s lived experiences with a particular medical condition? Cochrane Groups are encouraged to include people’s experiences throughout the process of selecting a topic for review, conduct and drafting of the review, editorial process, and dissemination. It seems counterproductive to exclude their artwork from illustrating the evidence behind their stories – especially when an image is in context of the whole piece which would be mindful of the brand guidelines. I think it would definitely be appropriate to use these artworks on a blog post which was able to touch on an individual’s experience – perhaps less so on a more academic piece (possibly it would depend on the content see above for discussion in relation to using images of vaginas), but in my opinion we should trust readers to be open-minded enough to accept how someone wants to share their lived experience. People don’t always have the words to convey their feelings.

    Emma Dennett / Reply
    • Thanks very much for raising this Emma. I agree and I think this is well worth putting forward to those making decisions about branding. When Evidently Cochrane was new, and before Cochrane rebranded, we sometimes illustrated blogs with art, including art created by people in response to their health experiences. I feel this really added something that can’t be achieved with stock images. Where art has come from health experiences, it’s another way to bring that into a blog of course, while images not so created can nonetheless offer alternative and perhaps more sensitive and thought-provoking ways to illustrate blogs on health topics. I wonder if you saw this early Evidently Cochrane blog about migraine art:
      Best wishes,

      Sarah Chapman / (in reply to Emma Dennett) Reply

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