*3.1. Demographic Data*

Among the 340 municipalities, as of 30 November 2022, 7.05 million persons had completed a primary COVID-19 vaccine course. The median proportion of vaccination coverage among people aged at least six years in the municipalities was 42.3% (interquartile range, IQR, 31.8–53.8%) (Table 2). The median proportion of the female sex among municipalities was 51.3% (IQR 50.6–52.2%). The median proportion of the population aged 60 years or older among all municipalities was 7.8% (IQR 6.9–9.3%), and the median proportion of those identifying as Maya was 30.0% (IQR 2.9–91.4%). Four out of 151 majority Maya municipalities, San José Chacayá, Santa Catarina Barahona, Chimaltenango, and San Lorenzo, had at least 70% of their populations who had completed COVID-19 vaccination, and this relationship was inversely correlated (ρ = −0.299, *p* < 0.001) (Figure 1A). Guatemala, Mixco, Jocotenango, and San Lucas Sacatepéquez municipalities had the highest proportion of their populations (≥40%) who had received at least a primary school education. The median proportion of rural residence among all municipalities was 64.8% (IQR 37.1–82.7%), with an inverse correlation (ρ = −0.417, *p* < 0.001) with COVID-19 vaccination coverage (Figure 1B). The median proportion of people experiencing poverty among the municipalities was 60.8% (IQR 43.8–75.8%), with an inverse correlation with COVID-19 vaccination (ρ = −0.634, *p* < 0.001) (Figure 1C). Overall, the municipalities with the highest COVID-19 vaccination coverage were Guatemala, San José, and San José del Golfo. By November 2022, 23 municipalities had completed primary series vaccination in at least 70% of their populations (Figure 2). Additional summarizing demographic data among the municipalities are shown in Table 2.

#### *3.2. Factors Associated with COVID-19 Vaccination*

In the bivariate analysis of all COVID-19 vaccination data as of 30 November 2022, significant factors (α = 0.05) negatively associated with primary COVID-19 vaccination course coverage by municipality, adjusting for departmental level differences, included the proportion of the municipality identifying as Mayan (β = −0.15, 95% CI: −0.21–−0.10), the proportion of the municipality living in a rural residence (β = −0.19, 95% CI: −0.25–−0.13), the proportion of the municipality experiencing poverty (β = −0.54, 95% CI: −0.63–−0.46), the proportion of the municipality in the 0–17 years age group (β = −1.81, 95% CI: −2.16–−1.47), departmental-level under-five childhood mortality rate (β = −0.09, 95% CI: −0.46–0.27), the proportion of those in the department reporting difficulty accessing healthcare due to distance from a health facility (β = −0.82, 95% CI: −1.12–−0.53), and the department's Gini coefficient (β = −0.62, 95% CI: −1.20–−0.08) (Table 3).

Factors positively associated with primary COVID-19 vaccination series coverage by municipality, adjusting for departmental level differences, included the proportion of the municipality with at least a primary school education (β = 1.40, 95% CI: 1.18–1.62), the proportion of female sex in the municipality (β = 2.53, 95% CI: 1.02–4.03), proportion of the municipality in the 60 years and older age group (β = 4.54, 95% CI: 3.57–5.49), proportion of the municipality tested for SARS-CoV-2 infection (β = 0.52, 95% CI: 0.43–0.61), reported deaths due to COVID-19 in the municipality (β = 1.17, 95% CI: 0.94–1.41), and proportion of 12–23 months old children in the department who had received the third Pentavalent vaccine (β = 0.65, 95% CI: 0.20–1.11).

After adjusting for all covariates and departmental effects in the full model, the proportions of the municipal population who (1) had received at least a primary school education, (2) were experiencing poverty, (3) were below the age of 18 years, (4) were aged 60 years and above, and (5) tested for SARS-CoV-2 remained significantly associated with complete vaccination coverage (Table 3, Section "Full multivariable model"). In the simplified multivariable model (Table 3, Section "Simplified multivariable model"), when adjusting for covariates and departmental level differences, a 10% higher proportion of people experiencing poverty within a municipality was associated with 2.5% lower COVID-19 vaccination coverage (95% CI: −4.33–−0.70). Conversely, a 10% increase in

the proportion of the municipality having received at least a primary school education was associated with 7.4% higher COVID-19 vaccination coverage (95% CI: 3.83–10.75); a 10% increase in the proportion of the municipality aged <18 years was associated with 10.7% higher COVID-19 vaccination coverage (95% CI: 3.55–17.67); a 10% increase in the proportion of the municipality in the 60 years and older age group was associated with 29.4% higher COVID-19 vaccination coverage (95% CI: 17.00–41.21); and a 10% higher proportion of the municipality tested for SARS-CoV-2 infection was associated with a 2.5% higher COVID-19 vaccination coverage (95% CI: 1.37–3.55). Overall, the marginal R2 value was 0.496, and the conditional R2 value accounting for the covariates and departmentallevel differences was 0.594.

**Figure 1.** Guatemalan municipalities by percent of primary COVID-19 vaccination series coverage versus (**A**) percent of municipality population of Mayan identity, (**B**) percent of municipality population living in a rural area, and (**C**) percent of municipality population experiencing poverty. Labeled municipalities are those with >70% completed COVID-19 vaccination (green dashed line) and >50% of the Mayan population (**A**), rural residence (**B**), or people experiencing poverty (**C**) (gray dashed line).

**Figure 2.** Primary COVID-19 vaccination series coverage by municipality in Guatemala. Image adapted from Guatemala Ministry of Health and Social Assistance, 25 February 2021 to 30 November 2022 [11].

**Table 2.** Demographic characteristics among the 340 municipalities and 22 departments in Guatemala. Data source: Guatemala Population and Housing Census 2018, 2014–2015 Demographic and Health Survey, and Guatemala Ministry of Health and Social Assistance. The poverty variable is a model estimate from Figueroa Chávez et al. (2020) [33,35]. SARS-CoV-2 cases and vaccination data are from 13 February 2020 to 30 November 2022, except where indicated.


<sup>a</sup> Proportion derived by dividing by total population as provided by respective data source. <sup>b</sup> Ministry of Public Health and Social Assistance.
