**4. Discussion**

Healthcare systems worldwide face new health and organizational challenges as a result of two distinct phenomena: an aging population with an increased prevalence of chronic diseases and the need for healthcare systems to migrate outside of hospitals to promote proactive medicine and community support [37–39]. Chronic patients are, in fact, challenged with both an increase in their overall health needs and the necessity to guarantee continuity of care [40,41]. Primary care settings can help achieve these objectives by granting patients access to healthcare services and facilitating continuity of care [42].

According to the results of our overview of systematic reviews, community-wide eHealth interventions can indeed have a positive impact on self-care in patients with chronic diseases [29,31–35]. The eHealth approach also allows a higher degree of continuity of care than traditional methods delivered in community settings and/or at home and makes it possible to provide interventions founded on personalized care [31,32,35,43]. This is especially true in light of the recent COVID-19 pandemic [16], which highlighted, even more, the need to maintain close contact with chronic patients [44,45] to offer as much continuity of care as possible, despite a widespread reduction in the availability of access to healthcare services [16]. In fact, the eHealth interventions included in this overview appeared to be effective at improving self-care in chronic patients in six of the eight systematic reviews retrieved [29,31–35]. Self-care interventions in chronic patients

were found to be effective when consistently monitored and maintained with the support of health services [46].

Thus, eHealth helps chronic patients in self-care by:


Our overview also showed that eHealth effectively enhances OROs and PROs in chronic patients. For example, telemonitoring interventions improve the quality of life for all chronic diseases and reduce hospitalization and mortality in patients with CVD [29,31–33,52,53]. Another interesting observation that emerged from this overview was that, although reminders are widely used to improve adherence to their medication regime in patients with chronic diseases, this improvement declined in the long term. Thus, patients using eHealth interventions for more than six months tended to return to "bad habits" once the novelty of telemedicine had worn off [29,35,54]. In fact, the duration of the intervention and engagement with it are also important factors that influence its effectiveness [55,56]. This evidence, in line with the literature, highlights the importance of the role of healthcare workers in encouraging patient adherence to eHealth programs [57,58].

Regarding the role of healthcare workers, this summary emphasizes the fact that eHealth interventions are most effective at improving self-care when they are led by multidisciplinary teams, especially when such teams work in primary care [30,32,34–36,59–62]. This is probably because specialized multidisciplinary teams can address both health and social health issues, ensuring that care is personalized and based on the perceived needs of the patient [63].

In conclusion, this overview carries some implications for practice, proving that eHealth is effective in increasing self-care in chronic patients with T2DM, CVD, and COPD; however, one must first be able to designate the most appropriate type of eHealth intervention based on the outcome to be achieved (e.g., implementing telemonitoring to increase self-monitoring of blood pressure). The results of this synthesis could help health care providers choose the most effective, outcomes-based eHealth interventions. In addition, this overview that included most of the major chronic diseases provided an overview of the effectiveness of eHealth on improving self-care, considering two aspects: (i) most population with chronic disease lives with multimorbidity, and designing an eHealth intervention on the basis of pathology could be a limitation (ii) eHealth interventions in increasing self-care should not be limited to disease, as self-care is a fundamental ability of patients with NCDs to live with their new life condition.

Finally, this overview of evidence brings to light two implications for the research: first, we observed that few systematic reviews in the literature use validated tools to assess the effectiveness of eHealth interventions in improving self-care. This might be because many of the self-care tools currently available have been developed for specific diseases and thus have limited applicability to other conditions, and also because transferring the data to the appropriate electronic platform can be a complex process [64]. Unfortunately, these limitations make it impossible to systematically evaluate those results that are not supported by standardized, validated instruments. Therefore, the quality of evidence

would be markedly improved by the use of such standardized instruments across the scientific community to systematically evaluate self-care in all populations.

Secondly, none of the systematic reviews in our survey assessed the eHealth literacy of the patients involved, despite its importance for effective use of the interventions. The literature shows that people with high levels of eHealth literacy are empowered and enabled to fully participate in health decisions informed by eHealth resources and technologies [65]. Where eHealth literacy is at a low level, e.g., in elderly or rural populations [66], the ability to participate in eHealth interventions that aim to improve self-care is known to be reduced. If eHealth literacy levels are not assessed or if only technologically competent participants are selected, the results of any eHealth study or program are likely to be affected.

Finally, it should be noted as a limitation that this systematic review included only articles published in the last decade and up to July 2020. However, this choice allowed us to synthesize the most recent evidence by including systematic reviews with RCTs in chronic patient populations that were not affected by organizational changes resulting from the COVID-19 pandemic and are therefore more representative of care delivered in non-emergency settings.
