Education as a mediator of ethnic disparities in adult COVID-19 vaccination in Peru

Background: COVID-19 vaccines have saved millions of lives, although access is still unequal and subject to several underlying factors. This study aimed to evaluate the mediating role of educational level on ethnic disparities in COVID-19 vaccination status in Peru. Methods: We performed a cross-sectional study based on Peru's 2022 National Household Survey. Vaccination status was defined as receiving ‘zero doses’ versus ‘one or more doses’. Education level was categorized as low education (none or primary) and high education (secondary and higher). A 4-way decomposition analysis using interventional analogues was performed to assess the mediating and moderating roles of educational attainment in the association between self-reported ethnicity (Indigenous vs Mestizos, and Afro-Peruvian vs Mestizos) and COVID-19 vaccination status. Results: A total of 51,505 adults were included. Mestizo was self-reported as the most common ethnicity (57.9%), followed by Indigenous (34.1%) and Afro-Peruvian (8.0%). Indigenous and Afro-Peruvians had an absolute risk of not receiving any COVID-19 vaccination that was 14 and 28 percentage points higher, respectively, in comparison to Mestizo ethnicity. About 30% of the observed disparity was mediated through education level in both ethnic contrasts. The contributions of reference and mediated interactions were negligible, indicating an absence of intersectionality in this disparity. Conclusion: The ethnic disparity in adult COVID-19 vaccination coverage between Afro-Peruvians and Mestizos is twice as large as the disparity between Indigenous people and Mestizos. Increasing education levels for minority Peruvians would substantially diminish ethnic disparities in vaccination coverage.