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Background: Personal health records (PHRs) or patient portals have been on the healthcare policy agenda for many countries as a promising mechanism to support patient-centred healthcare by making medical records accessible to patients and those assisting patients in health self-management. Studies on clinical outcome have been inconsistent. To help us to understand why, we propose to look at measures that precede clinical outcome, specifically patient engagement and activation. Patient activation describes the knowledge, skills and confidence a person has in managing their own health and healthcare., Objective: To systematically review the current evidence on the impact of PHRs on patient activation., Methods: A literature search was conducted for randomised controlled trials and quasi-experimental studies published up to January 2024 across EMBASE, PsycINFO, CINAHL and PubMed. Publications were included in the study if they examined any association between PHR use and activation., Results: The search initially produced 3062 papers for review, of which 88 full-text articles were screened for eligibility. Two reviewers assessed 22 of these articles, and 8 papers were identified as meeting the selection criteria. Among these, seven studies found no statistically significant differences in activation. However, one study reported a significantly greater effect than the others. Data from seven randomised controlled trials and quasi-experimental studies examining the effects of PHRs on patient activation and similar measures were extracted for meta-analysis. Overall, the use of PHRs was associated with a 0.41 standardised mean difference increase in activation (95% confidence interval 0.31-0.51). There was a high degree of heterogeneity ( I ² = 98%), with one study showing a much larger effect size compared to the rest., Conclusion: Most studies showed little impact on activation, but one study found a large effect. This study notably offered PHRs combined with health coaching and training in the use of the system to their intervention group, which may indicate an important requirement for how to get the best out of a PHR system., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2025.)