Mental associations with COVID-19 and how they relate with self-reported protective behaviors: A national survey in the United States

To understand novel diseases, patients may draw comparisons to other diseases. We examined whether mentally associating specific diseases with COVID-19 was related to self-reported protective behaviors early in the pandemic. In March 2020, a national sample of 6534 U.S. adults listed diseases that came to mind when thinking of COVID-19. They self-reported protective behaviors, demographics, and COVID-19 risk perceptions. Participants associated COVID-19 with common infectious diseases like seasonal influenza (59%), common cold (11%), and pneumonia (10%), or emergent infectious diseases like pandemic influenza (28%), SARS/MERS (27%), and Ebola (14%). Seasonal influenza was most commonly mentioned, in all demographic groups. Participants mentioning seasonal influenza or common cold reported fewer protective behaviors. Those mentioning pneumonia or emergent infectious diseases reported more protective behaviors. Mentioning pneumonia, SARS/MERS, and Ebola was associated with the most protective behaviors, after accounting for other generated diseases, demographics, and risk perceptions (e.g., for avoiding crowds, OR = 1.52, 95% CI = 1.26, 1.83; OR = 1.28, 95% CI = 1.13, 1.46; OR = 1.30, 95% CI = 1.11, 1.52, respectively). Early in the pandemic, most participants mentally associated COVID-19 with seasonal flu, which may have undermined willingness to protect themselves. To motivate behavior change, COVID-19 risk communications may need to mention diseases that resonate with people while retaining accuracy. •To understand a new disease, patients may draw comparisons to known diseases.•We asked US participants which diseases came to mind when thinking of COVID-19.•Seasonal influenza was most commonly mentioned, across demographic groups.•Pneumonia and emergent diseases (SARS, pandemic influenza) were also listed.•Which diseases came to mind was associated with reported protective behaviors.