Relationship between resilience, self-esteem, and burnout in Medical students during the Covid-19 pandemic

Abstract: Introduction: In Brazil, the lack of studies evaluating self-esteem in medical students is evident. In the academic field, it is known that individuals with high self-esteem and resilience are more likely to be successful. In previous studies, resilience was negatively associated with anxiety and Burnout Syndrome (BS). The BS has become a public health problem due to its increased incidence, especially among medical professionals during the coronavirus disease (COVID-19) pandemic, making it essential to expand and develop this issue. Objectives: To evaluate the level of self-esteem in medical students and its association with the degree of resilience and burnout during the pandemic. Method: A cross-sectional cohort study was conducted with medical students from the first to the eighth semesters at Centro Universitário Christus in Fortaleza - CE, Brazil. The students answered three surveys: in the beginning of the semester, at the midterms and during finals. We applied the Maslach Burnout Inventory, Wagnild and Young’s resilience scale, the Rosenberg Self-Esteem scale and a sociodemographic questionnaire. Results: Students with higher levels of emotional exhaustion showed less professional efficiency (P < 0.001). Disbelief and professional efficiency are inversely related (P < 0.001). There was no significant variation in the prevalence of burnout throughout the semester (P = 0.593). However, this prevalence has been high since the first period of the study. Additionally, the higher the resilience, the higher the self-esteem (P < 0.001). Conclusion: Medical students show elevated levels of BS. There was no statistically significant variation in burnout, resilience, and self-esteem throughout the semester. Therefore, further studies are necessary to analyze these variables.


INTRODUCTION
Self-esteem is defined as the feeling of appreciation and consideration that people have for themselves 1 .According to SIGELMAN, 2017, self-esteem starts as the high or low evaluation, in a general context, of someone's value as a human being regarding all aspects, both positive and negative.This evaluation is based on a self-assessment that constitutes a concept of oneself.It is known that individuals with high selfesteem make decisions and engage in actions that benefit others in various areas of life, such as the academic environment, social relationships, and even their daily food choices.They also avoid putting themselves in situations where their physical and psychological health is sacrificed due to external factors They also avoid putting themselves in situations where their physical and psychological health is sacrificed due to external factors 3 .
A study by SCHMITT (2005) in which the Rosenberg Self-Esteem Scale (RSES) was applied to 16,998 people showed that self-esteem operates in a similar way across different cultures.It significantly correlates with low levels of neuroticism, which is a tendency to experience negative emotions over the long term, and high levels of extraversion and positive self-perception.Despite its importance, there is a lack of studies in the health area that comprehensively evaluate self-esteem.It is therefore clear that individuals with high self-esteem are more likely to be successful in various endeavors.
According to JIRDEHI M. et al., self-esteem is positively correlated with academic achievement.The study by ZEIGLER-HILL et al. showed an important relationship between the unstable self-esteem and poor academic performance among students 5 .
In view of the social distancing abruptly imposed on society 6 , the coronavirus pandemic had immeasurable impacts on the academic sphere, requiring changes in teaching methods and on the students' mental health.Such modifications in the academic scenario characterized the Emergency Remote Learning 7 .
The COVID-19 pandemic has had a profound effect on the academic world, with the sudden implementation of social distancing measures leading to a shift towards emergency remote learning 6 .This change in the educational environment has resulted in modifications to teaching methods and impacts on students' mental health status 7 .
Resilience is an important factor for medical students to navigate the stressors of a changing learning environment, including family relationships, work environments, and living conditions 8 .Medical students experience a higher level of suffering than the general population 9 .Therefore, it is important to identify mechanisms and support measures to address stressful situations and prevent the development of worse situations of psychological suffering 10,11 .Previous research has found a negative association between resilience and depression, anxiety, stress, and burnout syndrome 12 , but the relationship with self-esteem has not been fully explored.
The purpose of this study is to evaluate medical students' level of self-esteem and its association with resilience, self-esteem, and burnout during the COVID-19 pandemic.
Burnout Syndrome (BS), also known as professional exhaustion syndrome, is a type of psychological exhaustion caused by chronic work stress that is often observed among physicians and medical students.It consists of three main factors: depersonalization, low sense of accomplishment and psychological exhaustion 13 .The syndrome is the result of unsuccessful interactions between professional effort, goals, and performance 14 .In the healthcare area, BS has become increasingly prevalent 15 .
Therefore, it is crucial to identify the signs of BS and take steps to address potential issues to improve the quality of life of healthcare professionals and students.Furthermore, previous studies have linked BS with resilience during the training and specialization of medical students, making it essential to further study and understand this topic 16 .

Population study and design
The Christus University Center is a private higher education institution approved by the Ministry of Education (MEC), which uses traditional and active teaching methodologies to prepare students to become knowledgeable and capable doctors.It employs objective structured clinical examination (OSCE) activities, Problem-Based Learning (PBL), and traditional classes to help students acquire the skills and desire to promote health, prevent diseases, and treat patients.
To evaluate the effectiveness of this approach, we conducted a cross-sectional cohort study with 399 medical students attending the first to the eighth semesters at Centro Universitário Christus in Fortaleza, CE, Brazil.The students were tested three times: in the beginning, at mid-term, and at the end of the semester.We used Maslach Burnout Inventory, Wagnild and Young's resilience Scale, and the Rosenberg Selfesteem Scale.The students also completed a sociodemographic questionnaire.(See attachments)

Data collection
Data was collected using online questionnaires via Google Forms, consisting of the scales and the sociodemographic questionnaire.The students were sent the questionnaire links via SMS.The first phase of data collection was carried out in August 2020, the second in November 2020, and the third in January 2021.In each phase, the students completed two questionnaires: the first comprised the sociodemographic questionnaire, Rosenberg's scale, Wagnild, and Young's Scale, and the second consisted of the Maslach inventory.

Inclusion criteria
The inclusion criteria comprised all students enrolled in the Unichristus Medical School, attending the first to the eighth semesters and agreed to participate in the study by signing an informed consent form.

Exclusion criteria
Students who dropped out of participation during the study.

Scales
The Maslach Burnout Inventory is used to analyze burnout, and the MBI-SS (Maslach Burnout Inventory-Student Survey) is employed to evaluate burnout symptoms in students.It consists of a 15-item scale that measures emotional exhaustion, cynicism, and professional efficacy with scores ranging from 0 to 6, where 0 means the experience never occurs and 6 means it occurs daily 17 .
Wagnild and Young's Resilience Scale is used to assess resilience and it comprises 25 items divided into  indicating high resilience 18 .The Rosenberg Self-Esteem Scale is used to classify selfesteem as low, medium, or high based on 10 questions, five of which are related to positive self-image and five to negative self-image 19 .

Statistical analysis
Data from the completed surveys was encoded and analyzed using the software Statistical Package for the Social Sciences (SPSS) version 20.0 in Windows (p&lt;0.05).
The scores of the scales were correlated using Spearman's rank correlation tests and, after categorization, the reference categories were associated with all items of the questionnaire using Pearson's chi-squared test or Fisher's exact test.

RESULTS
The sociodemographic questionnaires, Maslach -MBI -SS scale (Maslach Burnout Inventory -Student Survey), Wagnild and Young's Resilience Scale and Rosenberg's Self-Esteem Scale are shown in Tables 1 and 2.  1 and 2.
Regarding the presence of Burnout Syndrome symptoms, we found that 84.6% of the participants exhibited such symptoms.Additionally, 40.6% of the students showed signs of low resilience, while only 15.5% demonstrated signs of high resilience.As for the students' self-esteem, 95.7% of the participants showed signs of healthy and strong selfesteem.There was no significant change in the prevalence of Burnout Syndrome symptoms throughout the semester (P = 0.593).It is noteworthy that this prevalence was already at elevated levels in the first phase of the study.The resilience pattern remained unchanged throughout the study period and showed no statistically significant variation in the sample (P = 0.132).
The results indicate a significant correlation (P = 0.002) between sleep deprivation and resilience, with longer sleep deprivation leading to lower levels of resilience.Additionally, there is a significant relationship (P = 0.013) between sleep deprivation and self-esteem, with increased sleep deprivation leading to a decline in self-esteem.However, a significant correlation (P < 0.001) was also found between resilience and self-esteem, with higher resilience levels resulting in higher self-esteem levels.
Regarding Burnout Syndrome, the assessment using the Maslach Burnout Inventory-Student Survey (MBI-SS) consists of three domains: emotional exhaustion, cynicism, and professional efficacy.In the study population, a significant relationship (P <0.001) was found between emotional exhaustion and cynicism, with higher levels of emotional exhaustion leading to increased levels of cynicism.Additionally, a significant inverse relationship (P < 0.001) was found between emotional exhaustion and professional efficacy, with higher levels of emotional exhaustion leading to decreased professional efficacy.Furthermore, a significant inverse relationship (P < 0.001) was observed between cynicism and professional efficacy.

Sociodemographic Data X Resilience
According to Table 3, participants aged up to 25 years showed low levels of resilience, while those aged over 25 years demonstrated medium levels of resilience.This suggests that older individuals have higher levels of resilience.Additionally, female participants demonstrated medium levels of resilience, while males showed high levels of resilience.s Students with a degree displayed high levels of resilience, while undergraduate students showed low levels of resilience.Participants without suggestive symptoms of ADHD demonstrated medium levels of resilience, while those with signs of ADHD displayed high levels of resilience.

Sociodemographic data X Self-esteem
Individuals aged up to 25 years showed average levels, while those over 25 years displayed high levels of self-esteem.
Married and divorced individuals demonstrated high levels of self-esteem, while single participants showed medium levels and those in a consensual marriage showed low levels.Participants with previous graduation degrees displayed high levels of selfesteem, while those without previous degrees showed medium levels.Furthermore, participants with borderline personality disorder showed low levels of self-esteem.

Sociodemographic data X Burnout
According to Tables 4 and 5, female individuals have more burnout than males and individuals with psychiatric disorders develop burnout more often than people without these disorders.

DISCUSSION
The   had prominent levels of depersonalization, and 34.2% had low personal efficacy 22 .
Furthermore, the study found a considerable increase in emotional exhaustion levels, from 39.5% in the first year of the course to 84.2% in the sixth year (P < 0.001), as well as a similar increase in depersonalization levels, with 23.3% in the first year and 49.1% in the sixth year (P = 0.008).This suggests that the stressors faced by medical students increase as they progress through their studies.
According to the Rosenberg Self-Esteem Scale, this study shows that 45.8% of medical students have healthy selfesteem, while 49.9% demonstrate a level of self-esteem that corresponds to a strong and healthy person 19 .Additionally, this study found a correlation between higher self-esteem scores and fewer hours of sleep, which is not in agreement with previous research by Mistarebih (2023) which found that fewer hours of sleep were associated with daytime sleepiness, impaired memory and decision-making, resulting in low academic performance 23 .
Another correlation found in this study was that higher resilience levels are associated with higher levels of self-esteem.
YU et al. (2020) concluded that the psychological well-being of medical students is positively associated with resilience and negatively associated with academic burnout.This study provides further evidence of the negative association between academic burnout and psychological well-being and highlights the importance of interventions that promote resilience among medical students 24 .

Resilience
The results of our study support previous research, such as the study by HOUPY in 2017, which found that the resilience of medical students is lower than that of the general population.Additionally, our study confirms that students who feel comfortable discussing Burnout and stress with their peers have higher resilience levels.Our findings indicate that over 80% of the students have low to medium resilience levels, emphasizing the need for a supportive environment that promotes open discussions about stress to build resilience 25 .
Although our study did not find a statistically significant variation in resilience levels among students throughout the academic period, we did observe that nearly half of the participants had a low level of resilience, with only 15.5% having a high level and 43.9% having a medium level.This highlights the alarmingly low resilience levels among medical students and the importance of interventions that promote it.
The findings of our study are in line with previous research that has reinforced the significant impact of resilience level on the well-being of medical students throughout their training and professional lives as stated by YUNG KAY et al. in 2019 26 .Furthermore, KIZIELA in 2019 highlights the various stressors that medical students face, and the need for adequate resilience to adapt healthily during times of stress.
Our study is the first to evaluate variations in resilience levels in medical students throughout the undergraduate course and emphasizes the need for further research in this field 27 .

Burnout X Emotional Exhaustion, Disbelief, Professional Efficacy, and Depression
The correlation between Burnout syndrome symptoms and depression symptoms is significant among medical students.Our study revealed a direct relationship between the prevalence of emotional exhaustion and disbelief 28 .Conversely, there is an indirect proportionality between professional efficacy and emotional exhaustion.Research has shown that promoting extracurricular activities can help improve low professional and academic efficacy, ultimately reducing stress levels and promoting well-being 29 .

CONCLUSION
In conclusion, this study has shown that medical students have elevated levels of Burnout Syndrome symptoms, which is consistent with previous literature.It is therefore essential to provide support mechanisms to help medical students cope with physical and mental stress during their training, as the clinical practice of medicine is known to be a challenging and demanding field.
Furthermore, this study is significant as it is the only one to currently evaluate the variables of self-esteem, resilience, and burnout during the COVID-19 pandemic, a period characterized by significant social and structural changes.
The results revealed that variations in these variables were not statistically significant, indicating the need for further research to better understand the determinant factors for the training of medical students.By doing so, it will ultimately contribute to the improvement of healthcare for the general population.
In summary, this study highlights the importance of addressing the issue of Burnout Syndrome among medical students, and the need for additional research to better understand this phenomenon.
two variables: personal competence and acceptance of self and life.Scores range from 25 to 175, with scores up to 125 indicating low resilience, scores between 125 and 145 indicating medium resilience, and scores above 145

A
total of 399 students participated in three phases of the first questionnaire, which included the Resilience and Self-Esteem Scales.The sample comprised 293 participants (73.4%) who were up to 25 years old and 106 participants (26.6%) who were over 25 years old.A total of 264 students participated in the three phases of the second questionnaire application, which included assessments of Burnout Syndrome and depression, with 200 (75.8%)being up to 25 years old and 64 (24.2%) being over 25 years old.The other sociodemographic characteristics of the study population are described in Tables
*p<0.05, chi-square and Fisher's exact tests; data shown as absolute and percentage frequencies.

Table 3 .
Correlation between Resilience and sociodemographic data, Self-esteem and sociodemographic data.
COVID-19 pandemic has had a significant impact on global health, including mental health.According to a study byZuljevic et al. (2021), the pandemic has led to an increase showing these symptoms.This is in line with other studies that have reported high rates of Burnout Syndrome among medical students, such as a study in Lebanon that found BS in 75% of medical students(Fares, 2016), but it is higher than other studies such as a study in Spain that showed 14.8% of *p<0.05,chi-square and Fisher's exact tests; data shown as absolute and percentage frequencies.

Table 4 .
Correlation between Burnout/ emotional exhaustion and disbelief and sociodemographic data.

Table 5 .
Correlation between Burnout/professional effectiveness and Burnout and sociodemographic data.