The Embedded Influence of Systemic Racism on Interpersonal Violence, Alcohol and Substance Misuse, and Reproductive Health Among American Indian and Alaska Native Communities: Great Plains Metropolitan Area, 2018-2024.

Abstract

<b>Objectives.</b> To use syndemic theory and system dynamics to describe how systemic racism shapes interrelationships among interpersonal violence, alcohol and substance misuse, and reproductive health among American Indian and Alaska Native communities. <b>Methods.</b> We conducted a community-based system dynamics study in a Great Plains metropolitan area. Using purposive and key informant sampling, we interviewed 110 participants (2018-2024) to develop causal loop diagrams. We aggregated 19 diagrams into a synthesized model, refined it through 5 additional group sessions (n = 28), and applied rigorously interpreted quotation analysis. <b>Results.</b> The final causal loop diagrams included 65 variables across 8 domains spanning health care, justice, child welfare, and social determinants. Collective trauma and discriminatory experiences emerged as central drivers. Reinforcing feedback loops linked systemic racism to increased trauma, substance misuse, interpersonal violence, and involvement with punitive systems. Balancing loops highlighted the potential of culturally sensitive services but were often offset by mistrust and barriers to care. <b>Conclusions.</b> Systemic racism operates through interconnected feedback loops that sustain co-occurring health inequities among American Indian and Alaska Native populations. <b>Public Health Implications.</b> Addressing inequities requires coordinated, culturally grounded, community-led strategies that target structural drivers and improve trust in systems. (<i>Am J Public Health</i>. Published online ahead of print July 2, 2026:e1-e9. https://doi.org/10.2105/AJPH.2026.308506).