**1. Introduction**

Guatemala has the largest population among Central American countries (over 17 million) and is bordered by Mexico, Belize, Honduras, and El Salvador [1]. While considered an upper-middle-income country due to a GDP of \$4603 per capita in 2020 [1], Guatemala has marked inequalities, with wealth held in a small sector of the population, low access to basic services for much of the population, and an overall lack of investment in the public sector [1–3].

Guatemala has the lowest COVID-19 vaccination coverage in Central America and is among the lowest compared with its regional neighbors in South America [4,5]. As of November 2022, there have been over one million SARS-CoV-2 cases and nearly 20,000 COVID-19-related deaths reported in Guatemala [6,7]. Within Guatemala, it was estimated that COVID-19-related mortality has been higher in people aged 60–69 years and in frontline healthcare workers [8]. As part of the National Vaccination Plan Against COVID-19, frontline healthcare workers were prioritized for vaccines when they initially became available in March 2021 [8,9]. In later phases, people aged 50 years and older and those

**Citation:** Choudhary, R.; Carter, E.; Monzon, J.; Stewart, A.; Slotnick, J.; Samayoa Jerez, L.L.; Rodriguez Araujo, D.S.; Zielinski-Gutierrez, E.; Suchdev, P.S. Sociodemographic Factors Associated with COVID-19 Vaccination among People in Guatemalan Municipalities. *Vaccines* **2023**, *11*, 745. https://doi.org/ 10.3390/vaccines11040745

Academic Editors: Ahmad Reza Hosseinpoor, M. Carolina Danovaro, Devaki Nambiar, Aaron Wallace and Hope Johnson

Received: 6 March 2023 Revised: 22 March 2023 Accepted: 25 March 2023 Published: 28 March 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

with underlying medical conditions were prioritized [8,9]. Vaccines became available free of charge to the general public in May 2021 [8,9]. Vaccines were obtained through donations, via the COVID-19 Vaccines Global Access (COVAX) mechanism for which Guatemala was a "self-pay" country, and one bilateral purchase of the Sputnik vaccine [9]. To date, there are four COVID-19 vaccines available to Guatemalans and all of them are two-dose primary series courses (Pfizer/BioNTech, Oxford/AstraZeneca, Moderna, and Sputnik V) [10]. As of 30 November 2022, 19,960,793 COVID-19 vaccines had been administered, with 49.4% of the total population having received at least one dose, and approximately seven million people, or 40.0% of the total population, having completed a primary COVID-19 vaccination series with two doses [4,6,7,10]. Of those who had completed a primary vaccination series, 42.8% had received Moderna, 23.0% received Oxford/AstraZeneca, 18.4% received Sputnik V, and 15.9% had received Pfizer/BioNTech vaccines [11]. In addition, about four million people, or 24.0% of the population, had received one or two booster doses by 30 November 2022 [12].

The inequity in the global distribution of COVID-19 vaccines with preferential access for countries with higher per capita incomes and gross domestic products has been welldocumented [13–15]. However, there are limited studies describing COVID-19 vaccination disparities within low- and middle-income countries, and many focus on vaccination intent. Studies that have explored sociodemographic factors associated with COVID-19 vaccination coverage have primarily focused on the United States. One survey conducted among U.S. adults found that participants with lower incomes, lower educational attainments, those without health insurance, who were non-Hispanic Black, and who lived outside of metropolitan areas had the lowest reported COVID-19 vaccination coverage and intent to get vaccinated [16]. Two other analyses showed that vaccination coverage was lower in rural compared with urban U.S. counties [17], and lower in counties with a higher percentage of people with incomes below the poverty threshold, experiencing unemployment, and not graduating from high school [18].

Several reasons have been posited for the low COVID-19 vaccination coverage in Guatemala. The country faces multiple challenges in its healthcare and public health system such as inadequate financing of the health sector, disparities in access to public health services in rural areas, and a shortage of healthcare workers [19,20]. COVID-19 vaccination coverage has been highest in the capital, Guatemala City, while rural areas with higher concentrations of Indigenous people have had lower vaccination coverage [5,21]. In the 2018 census, the Maya comprised 41.7% of the total population, and the Xinca were 1.8% of the total population [22]. The disproportionate burden of COVID-19 on Indigenous people and those of low socioeconomic status has been studied regionally, for instance, in Colombia [23]. A 2021 UNESCO report on COVID-19 vaccination in Latin America and the Caribbean noted that in communities with higher "unemployment or informal employment, or where ethnic groups live, there is a higher prevalence of COVID-19 and a higher risk of mortality" [24]. Moreover, there is evidence of vaccine hesitancy among people with lower levels of institutional trust, those living in rural areas, and those experiencing economic insecurity [25–27]. Early vaccination outreach in Guatemala was often conducted in Spanish using mainstream media instead of through local organizations, and using local Indigenous languages, according to a Pan American Health Organization report [5]. As part of the Ministry of Public Health and Social Assistance (MSPAS) *Strategy to Strengthen the COVID-19 Vaccination Plan in Rural Areas*, vaccination activities have more recently incorporated community leader guidance and local media campaigns [28].

Given the limited studies describing COVID-19 vaccination coverage disparities within Guatemala, we performed an ecological analysis to understand the association between sociodemographic factors and primary vaccination coverage among the 340 Guatemalan municipalities. Identifying factors associated with low vaccination could inform strategies to improve COVID-19 vaccine coverage and other public health interventions in Guatemala.
