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Holding the keys to health? A scoping
study of the population health impacts of
automated vehicles
Jennifer Dean
1*
, Alexander J. Wray
2
, Lucas Braun
3
, Jeffrey M. Casello
1,3
, Lindsay McCallum
4
and
Stephanie Gower
4,5
Abstract
Background: Automated Vehicles (AVs) are central to the new mobility paradigm that promises to transform
transportation systems and cities across the globe. To date, much of the research on AVs has focused on
technological advancements with little emphasis on how this emerging technology will impact population-level
health. This scoping study examines the potential health impacts of AVs based on the existing literature.
Methods: Using Arksey and O’Malley’s scoping protocol, we searched academic and ‘grey’literature to anticipate
the effects of AVs on human health.
Results: Our search captured 43 information sources that discussed a least one of the five thematic areas related to
health. The bulk of the evidence is related to road safety (n= 37), followed by a relatively equal distribution
between social equity (n= 24), environment (n= 22), lifestyle (n= 20), and built environment (n= 18) themes. There
is general agreement that AVs will improve road safety overall, thus reducing injuries and fatalities from human
errors in operating motorized vehicles. However, the relationships with air quality, physical activity, and stress,
among other health factors may be more complex. The broader health implications of AVs will be dependent on
how the technology is adopted in various transportation systems. Regulatory action will be a significant
determinant of how AVs could affect health, as well as how AVs influence social and environmental determinants
of health.
Conclusion: To support researchers and practitioners considering the health implications of AVs, we provide a
conceptual map of the direct and indirect linkages between AV use and health outcomes. It is important that
stakeholders, including public health agencies work to ensure that population health outcomes and equitable
distribution of health impacts are priority considerations as regulators develop their response to AVs. We
recommend that public health and transportation officials actively monitor trends in AV introduction and adoption,
regulators focus on protecting human health and safety in AV implementation, and researchers work to expand the
body of evidence surrounding AVs and population health.
Keywords: Automated vehicles, Autonomous vehicles, Driverless cars, Public health, Road safety, Health equity, Built
environment, Scoping review, Transportation planning, Mobility
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: jennifer.dean@uwaterloo.ca
1
School of Planning, University of Waterloo, 200 University Avenue West,
Waterloo, ON N2L 3G1, Canada
Full list of author information is available at the end of the article
Dean et al. BMC Public Health (2019) 19:1258
https://doi.org/10.1186/s12889-019-7580-9
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Background
Over the past five years, there has been substantive and
growing interest in how the new mobility paradigm of
intelligent vehicles will change the future of both trans-
portation systems and cities themselves. Central to these
discussions is the role that the impending arrival of au-
tomated vehicles (AVs) will play in urban accessibility
and connectivity as well as personal mobility [1–4].
Much of the work on AVs to date has focused on the
technological advancements to speed their arrival in
mainstream transportation [5] as well as debates around
ownership [6–8], connectivity [9,10] and data privacy
[11]. While AVs as the ‘future of transportation’have
generated an enormous amount of attention from
researchers and policy-makers, there is a paucity of
knowledge about how this emerging technology will im-
pact population-level health and wellbeing. Given the
potentially significant changes to the global mobility
paradigm, we undertook a scoping study of existing lit-
erature to explore the potential health impacts of AVs.
Automated Vehicles
Automated Vehicles (AVs) are a rapidly emerging tech-
nology expected to overtake humans as the primary op-
erators of motorized transport [12]. The Society of
Automotive Engineers [13] has defined six levels of auto-
mation that describe a balance between human and
computer inputs. Levels 0–2 include vehicle features
that support the human driver, while Levels 3–5 involve
automated driving features with limited human involve-
ment. Level 0 requires full human operation with vehicle
features providing warnings and momentary assistance
(e.g., blind spot warning). Level 1 includes minimal ve-
hicle support features that assist the driver in steering or
braking capacities (e.g., lane centring or adaptive cruise
control), while Level 2 includes vehicle features that sup-
port the driver in both steering and braking. Level 3 in-
volves automated features in some conditions (e.g., route
change to detour around traffic) but requires a human
driver take control of the vehicle when requested. Level
4 includes more automated features with the ability to
drive in some conditions and does not require a human
operator to take over (e.g., local driverless taxis). Level 5,
or full automation, a vehicle can drive everywhere in all
conditions (e.g. no pedals or steering wheel installed).
While the timeline for introducing AVs to market is un-
certain, widespread adoption is predicted to occur within
the next decade [4,14,15].
While AV technology is being applied to a wide variety
of transportation sectors including air, rail, and sea, it is
the road-based deployments that are expected to have
the most direct impact on urban transportation systems
and population health. This includes automation of both
passenger and freight vehicles. The transformational
capacity of AVs has been likened to the automobile at
the turn of the twentieth century [16], which resulted in
a host of social, environmental, economic, and health
consequences.
Health implications of transportation
The linkages between transportation and health are now
widely known and are the focus of a robust area of
research and policy-making. The United States Depart-
ment of Transportation (USDOT) recognizes five path-
ways through which transportation affects human
health: active transportation, road safety, air quality, con-
nectivity, and equity [17].
The choice between active and passive modes of trans-
portation is a key influencer of physical activity levels
[18]. The various masses and speeds of vehicles in a
transportation system expose participants to significant
safety hazards, particularly in a collision [19].
Carbon-intensive travel modes impact air and water
quality in ways that profoundly influence human health
directly (e.g., respiratory health) and indirectly (e.g., cli-
mate change) [20,21]. The design of transportation in-
frastructure and linkages between land use and urban
design elements can influence access to health promot-
ing or inhibiting aspects of the built environment (e.g.,
health care services, food outlets) [18,20,21]. Finally,
ubiquitous access to low-cost, reliable transportation is
recognized as a key determinant of social equity and
provides much needed access to other upstream deter-
minants of health (e.g., employment) [22].
As governments and agencies around the world strive
to improve road safety through programs such as Vision
Zero [23], ensure fair and affordable access to transpor-
tation through the Sustainable Development Goals [24],
and promote walkable communities for all ages through
the World Health Organization’s Age-Friendly Cities
program [25], the link between transportation and health
is a top political and practical issue. Addressing these
priorities requires further investigation into the range of
impacts of emerging transportation technologies. Yet, in
the recent boom of research on AVs, there is very little
literature examining the broader health impacts of this
emerging technology despite the reality that fully auto-
mated vehicles are already being tested in cities around
the globe.
To date, much of the social benefits rhetoric has fo-
cused on AVs potential to mitigate two health issues.
First, AVs will likely significantly improve road safety by
reducing the number of automobile crashes caused by
human error [1,26,27]. Further, AVs have been de-
scribed as potentially improving independent mobility
for populations who are unable to or can no longer drive
(e.g., older adults) [1–4]. While important, these two
issues do not include the broad range of potential
Dean et al. BMC Public Health (2019) 19:1258 Page 2 of 10
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impacts, both positive and negative, that AVs may have
on health [28].
The bulk of the current literature on societal impacts
of AVs is speculative, given the lack of empirical data on
their operations. However, even testing phases have had
health implications such as a widely publicized incident
in March 2018 when a person was struck and killed by
an Uber-owned AV in Arizona [29]. Moreover, emergent
research suggests that public readiness for AVs is low.
Researchers in Australia have begun to assess public
awareness of AVs and found in a survey of over 1600
residents that there were low levels of awareness of the
potential health benefits, with only 21% acknowledging a
potential improvement in road safety [30]. Even in the
short term, there is a clear need to assess the health im-
pacts of adopting AV technology.
In this paper, we synthesize the current expectations
of the impacts of AV technology, based on the known
linkages between transportation and health. We then
propose a conceptual map of and describe the most
likely health outcomes from various implementation sce-
narios. We conclude by identifying the critical indicators
that should be monitored by practitioners as AV
adoption progresses; providing a set of ideal constraints
on AV implementation to protect human health; and
suggesting areas for further research or professional
inquiry.
Methods
The existing body of knowledge on AVs is broad and
rapidly evolving. Accordingly, we adopt Arksey and
O’Malley’s[31] scoping review protocol to assess the
existing academic and grey literature for common
themes, key findings, and knowledge gaps. Scoping
reviews have certain advantages over traditional litera-
ture reviews, as the method allows for a systematic
search of a rapidly evolving evidence base [32]. The
method has been widely adopted in medicine and public
health; with it becoming more popular in the social and
natural sciences [32–34]. Wherever possible, we
followed the PRISMA standard [35] for reporting items
contained in the review (Fig. 1).
Our review is guided by the following question: what
implications could AVs have for human health, based on
the current understanding and state of knowledge about
AV technology? We proceed with describing the search
Fig. 1 PRISMA diagram for reporting search results
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strategy, screening criteria, and coding approach used to
synthesize the evidence.
Search strategy
The search strategy consists of exploring academic and
‘grey’literature repositories for evidence pertaining to
the health impacts of AVs. We investigated a broad
range of interdisciplinary databases, including: Canadian
Research Index, Embase, GeoScan, PsycINFO, PubMed,
Scopus, TRID, and Web of Science. The first search of
automated vehicles and related terms returned tens of
thousands of potential sources. The search strategy was
then scoped in by adding in terms related to health,
equity, road safety, mode choice, built form, environ-
ment, and synonyms to narrow the results to items relat-
ing to population health and transportation (Fig. 2). The
first search was conducted in November 2017, while an
update to the search was performed in December 2018.
Screening criteria
Articles captured in the search were screened for rele-
vance to the research question. Multiple raters reviewed
the titles, abstracts, and full-texts of each result in a pro-
gressive fashion to arrive at the final dataset for synthesis.
Articles were only included if they were published in Eng-
lish, addressed a specific determinant of health or well-
being, and offered a rigorous evidence-based approach to
their investigation. Duplicates of articles across databases
were removed at the title screening stage. Disagreements
about screening decisions were resolved by consensus.
Coding and synthesis
Included results were processed by multiple raters using
a piloted data extraction process. Coding items included
bibliographic information, health impacts, and findings
of each result. The health impacts were structured into
five themes for coding purposes: road safety, natural en-
vironment, social equity, lifestyle, and built environment,
which were closely aligned with the USDOT framework
for health impacts from transportation [17]. Within each
theme there were multiple subthemes that emerged
from the data as relevant to AVs and health. Disagree-
ments about coding decisions during this analysis were
resolved by consensus.
Results
The refined search terms returned over three hundred
potential sources relevant to the research question. The
scanning and screening process resulted in 43 items
that are included in the synthesis (Table 1). The bulk of
the evidence is related to road safety (n= 37), followed
by a relatively equal distribution between social equity
(n= 24), environment (n= 22), lifestyle (n=20), and
built environment (n= 18) themes. Each source was
coded into multiple a priori themes and emergent
subthemes, resulting in overlap between elements of
the synthesis.
Road safety
There are 37 items related to road safety, with 27 from
academic sources and 10 from grey sources. Most
Fig. 2 Search terms used to locate academic and grey literature
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evidence in this theme is related to collision avoidance
(n= 27), with less relating to transition period (n= 7),
safety testing the technology (n= 6), ethics (n= 5), hack-
ing (n= 3), and organ transplants (n= 1). AVs are pre-
dominantly viewed as a positive improvement to current
road safety conditions as they eliminate human error,
the most common reason for collisions [1,2,9,27,40].
However, improvements in road safety from autono-
mous vehicles would likely reduce the availability of hu-
man organs for transplant [2].
Social equity
There are 24 items related to social equity, with 16 from
academic sources and eight from grey sources. Accessible
mobility (n= 23) is of primary concern in this theme with
some discussion of employment impacts (n= 6), and afford-
able housing (n= 1). AVs are predicted to improve accessi-
bility for differently abled populations, reduce isolation, and
improve social connectivity [1,3,40]. However, AVs could
further perpetuate existing societal inequalities in the trans-
portation system depending on the ownership and access
models (i.e., shared vs personal ownership) [6,36]. For ex-
ample, if private ownership of AVs is the prevailing model,
high income populations will be more likely to benefit from
on-demand mobility while lower income populations may
face decreased access to transportation, longer commute
times or limited accessibility to desirable destinations by
relying on public transportation.
Natural environment
There are 22 items related to the natural environment,
with 17 from academic sources and five from grey
Table 1 Results organized by themes and subthemes
Road Safety (Theme)
Collision
Avoidance
(Subtheme)
Altarum Institute [36], Arief et al. [37],
Bahamonde-Birke et al. [38], Brown et al. [9],
Cohen et al. [39], Conference Board of Canada
[40], Crayton & Meier [1], Curl et al. [41], de Sio
[42], Duarte & Ratti [43], Fagnant & Kockelman
[14], Fleetwood [26], Freedman et al. [44], Harper
[45], Harrow et al. [46], Kelley et al. [3], Litman
[15], Luttrell [26], Marotte & Dixon [47], Menon et
al. [48], Milakis et al. [4], Milakis et al. [49], Millard-
Ball [50], Mladenovic et al. [7], Payre et al. [51],
Pettigrew [2], Pettigrew et al. [29], RAND [10],
Rodriguez et al. [52], Ryerson et al. [53], Sessa et
al. [8], Thomopoulos & Givoni [6], Ticoll [54],
Watkins [55], van Schalwyk & Mindell [28],
Yeomans [56],
Transition Period Altarum Institute [36], Bahamonde-Birke et al.
[38], Brown et al. [9], Cohen et al. [39], Fitt et al.
[41], Marotte & Dixon [47], Thomopoulos &
Givoni [6]
Safety Testing Altarum Institute [36], Arief et al. [37], Fleetwood
[26], Kelley et al. [3], RAND [10], Yeomans [56]
Ethics de Sio [42], Fleetwood [26], Harrow et al. [46],
Rodriguez et al. [52], Ryerson et al. [53]
Hacking Litman [15], Milakis et al. [4], Yeomans [56]
Organ Transplants van Schalwyk & Mindell [28]
Social Equity
Accessible Mobility Altarum Institute [36], Bahamonde-Birke et al.
[38], Brown et al. [9], Conference Board of
Canada [40], Crayton & Meier [1], Fagnant &
Kockelman [14], Fitt et al. [43], Harper et al. [43],
Kelley [3], Litman [15], Marotte & Dixon [47],
Milakis et al. [4], Milakis et al. [49], Mladenovic et
al. [7], Pettigrew [2], Pettigrew et al. [29], RAND
[10], Thomopoulos & Givoni [6], Ticoll [54], van
Schalkwyk & Mindell [28], Sessa et al. [8], Watkins
[55]
Employment Altarum Institute [36], Clements & Kockelman
[57], Conference Board of Canada [40], Marotte &
Dixon [47], Milakis et al. [4], Milakis et al. [49]
Affordable
Housing
Milakis et al. [4]
Natural Environment
Fuel Efficiency and
Emissions
Altarum Institute [36], Amberg [58], Bahamonde-
Birke et al. [38], Brown et al. [9], Cohen et al. [39],
Conference Board of Canada [40], Crayton &
Meier [1], Fagnant & Kockelman [14], Fitt et al.
[41], Altshuler at al. [59], Harrow et al. [46],
Marotte & Dixon [47], Merlin [60], Milakis et al. [4],
Pettigrew [2], Pettigrew et al. [29], RAND [10],
Sessa et al. [8], Tomopoulos & Givoni [6], van
Schalkwyk & Mindell [28], Wadud et al. [12]
Vehicle Kilometres
Travelled
Amberg [57], Brown et al. [9], CPHA [40], Cohena
et al. [38], Crayton & Meier [1], Fagnant &
Kockelman [14], Harrow et al. [46], Merlin [60],
Milakis et al. [4], Sessa et al. [8], Wadud et al. [12]
Life Cycle Menon et al. [48], Milakis et al. [4], Pettigrew [2]
Noise Milakis et al. [4], RAND [10]
Lifestyles
Mode Choice Bahamonde-Birke et al. [38], Crayton & Meier [1],
Table 1 Results organized by themes and subthemes
(Continued)
Road Safety (Theme)
Milakis et al. [4], Marotte & Dixon [47], Merlin [60],
Sessa et al. [8], Thomopoulos & Givoni [6], Ticoll
[54], van Schalkwyk & Mindell [27], Watkins [55],
Yap et al. [61]
Travel Enjoyment Altarum Institute [36], Bahamonde-Birke et al.
[38], Crayton & Meier [1], Curl et al. [41], Fagnant
& Kockelman [14], Harrow et al. [46], Litman [15],
Morris & Guerra [62], Pettigrew et al. [29],
Thomopoulos & Givoni [6]
Public Perception Harrow et al. [46], Menon et al. [48], Payre et al.
[51]
Built Environment
Land Use and
Transportation
Altarum Institute [36], Bahamonde-Birke et al.
[38], Brown et al. [9], Clements & Kockelman [57],
Crayton & Meier [1], Conference Board of Canada
[40], Duarte & Ratti [43], Fitt et al. [41], Fagnant &
Kockelman [14], Harrow et al. [46], Milakis et al.
[4], Milakis et al. [49], Mladenovic et al. [7], RAND
[10], Sessa et al. [8], Thomopoulos & Givoni [6],
Ticoll [54], Watkins [55]
Note: Items may be coded into multiple themes and subthemes
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sources. The evidence base is predominantly interested
in the fuel efficiency or emissions of AVs (n= 21), and
implications for vehicle kilometres travelled (n= 11).
There is also minor interest in the life cycle of AVs (n=3),
and noise impacts (n= 2). Authors are split on the implica-
tions of AVs, with most arguing they will render a more ef-
ficient and less carbon-intensive transportation system if
the majority of AVs are electrically powered [4,6,10].
Others argue that AVs will further exacerbate existing auto-
mobile dependency requiring more road infrastructure with
deleterious impacts to the natural environment [8,9,14,
47]. Again, the model of AV ownership and access, coupled
withthetypeoffuelsource,willdeterminetheactualenvir-
onmental impacts.
Lifestyle
There are 20 items related to lifestyles, with 14 from
academic sources and six from grey sources. Changes in
travel mode choice (n= 11) and the effects of travel by
AVs on overall travel enjoyment or stress (n= 10) are
interdependent areas of interest in this theme. There is
also limited research on public perceptions towards AV
technology with evidence suggesting a lack of awareness
of both their environmental and human health impacts
(n= 3). AVs are expected to rapidly improve the user ex-
perience with private transport by removing the stressful
element of driving the vehicle and limiting the amount
of time spent in congested traffic conditions [1,4,6,36,
62]. However, reliance on AVs could result in more sed-
entary behaviour as users opt to take AVs for trips that
traditionally involved some form of active travel or rely
on AVs for longer trips where they previously relied on
rail or air travel [6,8,40]. The limits placed on AV use,
and where they can operate will shape their influence on
lifestyle factors.
Built environment
There are 18 items related to the built environment,
with 12 from academic sources and 6 from grey sources.
All the evidence in this theme was related to the interac-
tions between transportation systems and land use pat-
terns (n= 18), and how use of AVs could affect the
demand for parking, urban design, density, and distribu-
tion of right-of-way space between modes [1,4,6–10,
14,40,57]. The modification of land use and transport
cycles in urbanized areas could have significant health
implications. For example, the traffic efficiency of AVs
could free up space in the right-of-way to allow for cyc-
ling infrastructure and wider sidewalks for pedestrians.
Further, a shared model of AVs would allow for reclaim-
ing parking lots as part of the public realm and present
opportunities for affordable housing or urban green
spaces [1].
Discussion
The existing literature suggests that AVs, like other
modes of transportation, have a clear and direct role in
shaping the social and environmental determinants of
health. There was almost universal agreement in the lit-
erature that automated driving will result in significantly
fewer road-related injuries and fatalities. However, this
reliance on technology rather than human operation of
road vehicles comes with additional risks, such as power
grid-failures and cyber-terrorism. Beyond road safety,
there is a lack of consensus on the impacts of AVs on
human health.
Much of the speculation and uncertainty is based on
how AVs will be introduced into existing urban trans-
port systems with the most important variables being
ownership models, fuel sources, government regulations,
and user experiences. For example, a fully shared and
electrically-powered fleet of ultra-lightweight AVs that is
fully integrated into an active transportation network
will promote travel behaviours, urban forms, and cli-
matic conditions that will contribute to improved health
outcomes. A future with large individually-owned AVs
powered by fossil fuels and operating with low occu-
pancy is likely to decrease physical activity, degrade the
climate, and exacerbate existing inequities, leading to
poor health outcomes. Realistically, between these two
extreme scenarios there exists a continuum of possible
outcomes. Given the breadth of scenarios, we propose a
‘conceptual map’that could be used to evaluate the
potential health outcomes related to an element of AV
implementation. We follow the discussion of this
conceptual framework with recommendations for trans-
portation planners, urban planners, public health practi-
tioners, regulators, and researchers.
The conceptual map of AV impacts on population health
Automated vehicles could have a range of direct and in-
direct health impacts. We structure these impacts as a
pathway model of cause-effect dependencies (Fig. 3).
These types of models are often used in the health and
transport fields. For example, the Health Impact
Pyramid [63] or Multi-Level Biological and Social Inte-
grative Construct [64] provide structured models of
nested intervention levels, and cause-and-effect path-
ways between an environmental factor and health out-
comes [63,64]. From a transportation perspective,
modelling of cause-effect relationships has been an inte-
gral part of estimating changes to modality, as well as
the health effects of transportation systems [65]. The
construction of an interdisciplinary theoretical model
that brings together disparate health and transportation
related evidence can provide a unifying framework for
all fields that are interested in AVs to engage in well-in-
formed dialogues. Therefore, the intent of this figure is
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to capture our findings in an easily interpretable model
of the cause-effect relationship between AVs and human
health outcomes.
We begin at the top of the ‘map’by outlining the the-
matic areas of change from the introduction of AVs
(Fig. 3). These themes provide a structured set of
impacts across the built and social environments that
are associated with health. We then describe the specific
change(s) that could occur, given the results of our
review, in these thematic areas from greater adoption of
AVs. We follow by providing the built, social or health
effect dependencies of the AV-induced cause, noting
interdependencies between the relationships. These links
then lead to a specific health outcome, and/or a change
in overall population morbidity and mortality from the
chain of environmental health impacts. Thus, the pur-
pose is to provide a navigational tool to explain the com-
plex, and sometimes contradictory, health outcomes of
AVs. For example, applying the map illustrates that our
review found evidence that AVs could reduce motor
vehicle collision. While this is a positive outcome in
terms of public health, there is a potential ‘cost’associ-
ated with this result; with fewer organs being made
available for people who need a transplant.
Both the concept map and the body of literature it was
developed from, predominantly focus on AVs in an
urban context. However, there are likely differential
health impacts related to road safety and equity for AVs
in rural environments to reduced access to emergency
services in the event of a collision. Overall, rurality is an
underexplored area of AV research.
Recommendations
There are complex relationships between AVs, social
and environmental determinants, and health outcomes.
Transportation, planning, and health practitioners
should focus on the long-term objective of achieving the
best possible health outcomes when considering the re-
sponse to AV adoption including maintaining a focus on
health equity. The impact of AVs on population health
can be moderated by monitoring trends, prioritizing
health in regulatory actions, incentivizing health and
safety in vehicle design, and closing knowledge gaps.
Monitor trends
Most of the articles from public health authors stress the
importance of actively monitoring AVs as they are intro-
duced into the transportation system [2,26,35]. These
authors advise that only by keeping up with the rapid
progression of this technology can practitioners partici-
pate in discussions of regulation so that safety is priori-
tized and plan initiatives that equitably and proactively
manage the impacts of AVs rather than provide a
delayed response to their effects. A key factor to monitor
will be safety performance in both simulated and live
traffic conditions. Otherwise, the arrival of AVs before
adequate testing is completed could pose a significant
threat to road user safety.
Prioritize health
The literature suggests AVs could have a net benefit for
human health and wellbeing. Researchers anticipate re-
ductions in road fatalities and injuries, and improvements
Fig. 3 Conceptual framework for the linkages between AVs and health outcomes
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in overall social connectivity [2,26,35,41]. However,
there remains significant uncertainty with respect to sev-
eral aspects of AV emergence, including the rate of adop-
tion, technological capabilities, and ownership models.
Without limits on use and discouragement of sole private
ownership, there is a significant chance of decreased utili-
tarian physical activity, and inequities in accessibility and
commute time for low-income populations. Thoughtful
planning and community design is needed to integrate
AVs into transportation networks in a way that supports
safe and healthy travel for all modes; complementary pol-
icies may be able to promote affordability and encourage
physical activity. Therefore, regulators and policymakers
should adopt a precautionary approach that promotes the
protection of public health and safety during the imple-
mentation of AVs in the transportation system. Our con-
ceptual framework could be the ideal tool for use in
scenario analyses to inform regulatory action.
Incentivize healthy and safe vehicle design
There are opportunities for AV manufacturers and de-
velopers to assist in the promotion of health by design-
ing and programming vehicles to benefit road safety,
equity, and natural environment. For instance, manufac-
turing vehicles that are electrically powered, and kept as
light as possible will reduce energy consumption, reduce
emission of harmful air pollutants, and benefit the nat-
ural environment. Further, assessing how to reconfigure
seating arrangements inside an AV will better protect
passengers (who do not need to interact with vehicle
controls or observe their surroundings) in the event of a
collision. Governments can also provide incentives for
manufacturers with the highest safety ratings and fea-
tures. From a programming perspective, AVs will need
to be capable of determining the best course of action
(e.g., whether to collide with an individual or inanimate
object) when a collision is inevitable, and manufacturers
can be transparent about how these decisions are made
and how they consider both road safety and equity. This
has complex and distinct implications related to equity
and road safety. Further, AVs may be programmed to
connect with infrastructure and/or other vehicles on the
road in order to increase road safety for all road users.
There are also potential opportunities for governments
to incentivize research and development on AV related
software programs that will help promote healthy and
safe design.
Close gaps
Most of literature, while relevant to health and well-
being, was not written by authors with health credentials
and affiliations. This finding stresses the importance of
further engagement by the population health community
in AV research. We suggest areas for further inquiry
include: (1) the interaction between AVs and other road
users such as cyclists, pedestrians and other micro-mo-
bility users, as well as integration with public transit sys-
tems; (2) the broader land-use impacts of AVs in dense
urban areas; (3) regulatory policies that promote popula-
tion health through advantageous AV ownership models,
fuel sources, and right of way; and, (4) identifying ways
to measure and monitor health and equity impacts of
AV adoption.
In 2018, global consulting firm KPMG began an an-
nual ranking of countries’readiness for autonomous ve-
hicles based on several indicators including policy and
legislative support for AV adoption [66]. Given the mul-
tiple linkages between AVs and population health im-
pacts found in this review, it is important that public
health stakeholders are included in policy-making deci-
sions on AVs in order to ensure consideration of health
impacts associated with the technology and facilitate
healthy and safe integration of AVs on our roads.
Conclusion
We have found that AVs are indeed a complex and
multi-faceted population health and wellbeing issue.
There are direct effects such as rates of road injury or
vehicle emissions, and less obvious effects such as
changes to urban form or commuting stress, which can
ultimately affect health and wellbeing. The list of im-
pacts found here is not exhaustive, as the link between
AVs and health is a subject that requires further investi-
gation. When discussing these potential impacts, it is
equally important to consider the uncertainty and range
of outcomes that exist. There are many factors that will
influence the future of AVs, including the ownership
model, the fuel source, and the corresponding regulation
by public and private entities. The impacts that are expe-
rienced, and the degree to which they are felt depends
entirely on which of these scenarios become reality.
However, regulators are not passive participants in this
paradigm shift. Action, or the lack thereof, will deter-
mine the role AVs assume in local, regional and global
transportation systems. Sinasic and Wray [67]
hypothesize that the degree of AV regulation will be
the prime factor determining the economic, social, en-
vironmental, and health impacts of AVs. It is therefore
crucial that all stakeholders, including public health
agencies work to ensure that population health out-
comes and equitable distribution of health impacts are
priority considerations as regulators develop their re-
sponse to AVs. In conclusion, we suggest that public
health and transportation officials actively monitor
trends in AV introduction and adoption, regulators
focus on protecting human health and safety in AV im-
plementation, and researchers work to expand the body
of evidence surrounding AVs and population health.
Dean et al. BMC Public Health (2019) 19:1258 Page 8 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Abbreviations
AV: Automated Vehicle; PRISMA: Preferred Reporting Items for Systematic
Reviews and Meta-Analyses; TRID: Transportation Research International
Documentation; USDOT: United States Department of Transportation
Acknowledgements
We would like to acknowledge Taryn Ridsdale, Health Research Specialist
with the Healthy Public Policy Directorate at Toronto Public Health, for her
review and input into the draft manuscript. We would also like to thank
Katherine Chan, School of Planning, University of Waterloo for her research
assistance on the study.
Authors’contributions
JD designed and supported data collection, analysis, interpretation and
drafted the manuscript. AW and LB collected and analyzed data and drafted
the manuscript. JC supported data analysis, interpretation, and made
substantial editorial revisions. LM and SG conceptualized the study,
interpreted the results and made substantial contributions to the manuscript.
All authors read and approved of the final manuscript.
Funding
This study was funded through Toronto Public Health (TPH) and the School
of Planning, University of Waterloo (UW). TPH staff conceptualized the study,
aided in interpretation and writing of the manuscript. UW collected, analysed
and interpreted the data and led writing of the manuscript.
Availability of data and materials
All data generated or analysed during this study are included in this
published article.
Ethics approval and consent to participate
The need for ethics approval was waived.
Consent for publication
Not Applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
School of Planning, University of Waterloo, 200 University Avenue West,
Waterloo, ON N2L 3G1, Canada.
2
Human Environments Analysis Lab,
Department of Geography, Western University, London, ON, Canada.
3
Department of Civil and Environmental Engineering, University of Waterloo,
200 University Ave, West, Waterloo, ON N2L 3G1, Canada.
4
Toronto Public
Health, 277 Victoria St., 7th Floor, Toronto, ON M5B 1W2, Canada.
5
Dalla Lana
School of Public Health, University of Toronto, 155 College St, Toronto, ON
M5T 3M7, Canada.
Received: 14 May 2019 Accepted: 30 August 2019
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