Self-esteem is one’s sense of self-worth, acceptance, and confidence that individuals feel toward themselves. ¹ Mentally and physically active people are the foundation of a healthy society and serve the community. Doctors and medical students in particular must have a healthy mental state. A doctor suffering from anxiety, dissatisfaction, and low self-esteem will not be able to fulfil his/her duty properly, ² and a medical student with low self-esteem will never grow to become a healthy, efficient doctor.

Having balanced self-esteem is highly important for healthcare professionals, including medical students. ³ Medical students undergo major stress in the form of academic workload, ⁴ family expectations, peer pressure, financial issues ^{5 , 6} and excessive working hours. ^{5 - 7} Studies show that a large proportion of medical students are unhappy and have low self-esteem, ⁸ and that students with low self-esteem are likely to suffer from anxiety and mental breakdowns, doubt themselves and feel a sense of inadequacy. ⁹ These students tend to appear less competent among their peers ¹⁰ which contributes to depression and unhappiness. Self-development and well-being is also negatively affected by inadequate self-esteem. ⁸

Self-esteem influences a student's performance, as well as their physical and psychological health and therefore is important to be maintained. A person who has high self-esteem can cope more effectively with stress and anxiety-inducing events in life without any negativity or impact on their mental health. ¹¹ It helps one to foster confidence, appear competent among their colleagues, tackle challenges with optimism and take on criticism without it affecting their self-image. ⁸

In Nepal, studies evaluating the self-esteem of medical students are lacking, but existing literature studying nursing students found that nearly 78% of the students had low self-esteem. ¹² This study uses Rosenberg Self Esteem Scale (RSES). It is a widely and commonly used scale for measuring self-esteem. ^{12 , 13} It classifies self-esteem as high, normal and low self esteem based on the scores obtained. ¹³

Assessing medical students’ self-esteem and designing necessary interventions for students with inadequate self-esteem can help us produce confident and optimistic doctors. Since confidence is regarded as a subjective marker of competence, ¹⁴ we can expect to produce highly competent doctors from the timely intervention. Having this competency in student life will help them acquire good knowledge and later, as a doctor, enable them to effectively manage patients. This study aims to report the status of self-esteem among medical students at a college in Kathmandu.

180 responses were received from 190 study participants (94.73% response rate). Out of the 180 participants, 123 (68.3%) were male and 57 (31.7%) were female. Majority of the respondents were from clinical years (third, fourth and fifth year) making up 63.5%, whereas only 36.1% respondents were from Pre-Clinical years (first and second year). The average age of the students was 22.17 ± 1.78 years. The mean self-esteem score of the respondents was 19.19 ± 4.18 (15.01 to 23.37 at 95% CI) which lies in the normal range of RSES score.

Among 180 participants, 18.9% (13.19 to 24.61 at 95% CI) were found to have low self-esteem. 74.4% (68.02% to 80.78% at 95% CI) students had normal self-esteem and 6.7% (3.05% to 10.35% at 95% CI) students had high self-esteem.

Female participants were found to have suffered lower self-esteem than males. The mean self-esteem score of males was 19.63 ± 4.29 and that of females was 18.26 ± 3.81. There is an association between sex and median values of RSES scores (i.e., whether students had higher or lower self-esteem than the median value). Significant difference in self-esteem was found between males and females at 5% level of significance (χ ² = 4.33, p = 0.037). Not enough evidence was found to suggest a significant difference in RSES scores between and among any other variables. Out of 65 pre-clinical year students, 11 (16.92%) and out of 115 clinical year students 23 (20%) were found to have low self-esteem. Third year medical students had the highest percentage of low self-esteem i.e., 12 (30.77%) as shown in Table 1.

It was found that 20% (14.16% to 25.84% at 95% CI) of the students who had attended private school for their primary level of schooling had low self-esteem whereas its prevalence among government school students was reported to be 10% (5.62% to 14.38% at 95% CI). Further details of the findings have been presented in Table 1.

Self-esteem refers to an individual’s overall sense of value or worth. ¹⁹ Various factors including age, ²¹ sex, ^{22 , 23} socio-economic status, ^{23 , 24} level of study, ²⁵ academic stress ¹² and family environment ²⁶ influence self-esteem. A reasonably high degree of self-esteem is considered an attribute of good mental health, ²⁷ and students with high self-esteem are found to have better academic achievements compared to those with low self-esteem. ²⁸ So, in order to improve the academic performance of medical students, healthy self-esteem is imperative. Moreover, healthcare professionals with high self-esteem show higher tendency to influence and induce positive well-being not only in patients but also in the healthcare team. ²⁹ Empathy is an essential element of the physician-patient relationship and is also an essential quality for medical students. ³⁰ A medical student with low self-esteem is likely to grow less empathetic since self-esteem and empathy are positively correlated. ³⁰ Low self-esteem has also been allied with unhappiness, ³¹ suicidal ideation, ³² isolation and avoidance of social settings ³³ and psychological disorders. ³⁴

Numerous studies have been conducted on self-esteem among the general population but there have been limited studies conducted among medical students. According to studies carried out by Syed, et al. and Nair, et al. among medical students, the prevalence of low self-esteem was found to be 18% ¹⁵ and 19.4% ³⁵ respectively. According to our study, the prevalence of low self-esteem among the medical students of NAIHS-COM was found to be 18.9% which was similar to the above mentioned studies. This prevalence of low self-esteem may be due to high academic stress, ¹² low perceived family support ¹² and learning environment. ²⁴ Since not many studies have been conducted on self-esteem among medical students in Nepal, other contributing factors are yet to be explored. 74.4% of the students had normal levels of self-esteem. Having high but realistic self-esteem is important for sound mental health. But considering the potential for subjective bias in this study, it cannot be implied that the high scores (>25) attained by the respondents are an accurate reflection of their actual self-esteem status, and not a subjective, narcissistic trait. Narcissistic people are self-centered people who do not care much about others. The prevalence of high self-esteem was reported to be 6.7% in our study. Studies among Arab participants suggest that self-esteem positively and significantly linked with attitude towards life, mental health, and general satisfaction. ^{36 - 41} People with high self-esteem are expected to persist in the face of challenges than those with low self-esteem. ⁴² But it is also suggested that people with high self-esteem are more likely to be conceited, arrogant and sometimes narcissistic. ⁴³

The mean RSES score of males was found to be significantly higher at 19.63 ± 4.29, whereas females had a score of 18.26 ± 3.8. Studies conducted among Malaysian and Indian students showed no significant difference between males and females. ^{44 , 45} A study done among four Arab counties showed Kuwaiti men had a significantly higher mean score than their female peers. ⁴⁰ A study conducted in Loni, India also showed higher prevalence of low self-esteem in males than females, ¹⁵ whereas our study indicated that low self-esteem was more prevalent among females.

In our study, significant differences between self-esteem were not found among clinical and pre-clinical year students. However, third year medical students had the highest prevalence of low self-esteem. This could be due to lack of adaptation to academic burden while transitioning from pre-clinical phase to clinical phase. A study conducted in India by Syed et al had a dissimilar finding that the cohort of first year males had the highest prevalence of low self-esteem. ¹⁵ In a study conducted by Naz, et al, the highest prevalence of low self-esteem was found in fourth year medical students. ⁴⁶ As the third year medical students had the highest prevalence of low self-esteem, proper orientation and pre-exposure sessions should be conducted before entering the clinical phase. Psychological counselling should be frequently provided to all medical students, focusing more on the students with low self-esteem. Medical students should also be encouraged to participate in extracurricular activities which may help in boosting their self-esteem. This is because involvement in extracurricular activities can help students achieve personal identity development and a sense of self-worth ⁴⁷ which will in turn, add to their self-esteem.

A Nigerian study showed that self-esteem is positively and significantly correlated with the primary school attended. ²⁴ The self-esteem of medical students who attended private schools was significantly higher than those of public school students. ^{24 , 48} In our study, we tried to figure out whether there was any difference in self-esteem between students who had attended government schools for primary level of schooling and those who had attended private schools. Although we found that a proportionately higher number of students who had acquired primary levels of education through private schools had low self-esteem, the difference was not significant. We propose that this could be because the majority of the students (88.9%) were from private schools and a comparatively higher percentage of low self-esteem was seen among them. But the statistical significance of this difference was not obtained which could have been due to the very low number of students from government schools for the comparison.

We were also interested to know if the permanent address of students created an impact on their self-esteem since not all parts of Nepal are equally developed and students from some areas may be deprived of opportunities. But we did not find any significant difference in the self-esteem of students from different provinces.

Self-esteem can be classified as explicit and implicit self-esteem. ⁴⁹ Explicit self-esteem is presented in the reflective and deliberative evaluations that one makes about oneself, while implicit self-esteem results from responses to self-relevant stimuli and is the function of automatic process. ⁵⁰ It is found that people with high explicit self-esteem and low implicit self-esteem showed higher levels of narcissism ⁴⁹ and the self-esteem level measured with RSES is usually the explicit one. ⁵¹ So, a self-esteem score of more than 25 cannot always be guaranteed to be healthy since high self-esteem can be relatively secure or defensive. ⁴⁹ Our study showed that 6.7% students had high self-esteem. The normal range of self-esteem falls within the 16-25 score range which 74.4% of the students come under.

Healthy self-esteem in healthcare professionals is a personal quality which, when combined with professionalism and accountability, can greatly reinforce patient satisfaction. ⁵² This is the reason why strengthening medical students’ self-esteem warrants special consideration from the beginning of their medical studies as early intervention could yield better results.

This study found that the majority of medical students had normal self-esteem. Several factors including age, gender, schooling, and year of study could have an impact upon self-esteem. Further studies on self-esteem should be conducted on larger populations to determine the contributing factors of low self-esteem in medical students. In our study, low self-esteem was most prevalent in third year students which may be due to the transition from pre-clinical to clinical study. Proper counseling and clinical exposure in pre-clinical years may help students to manage this transition more easily. Considering the conducted study and the related studies, we can conclude that self-esteem along with medical knowledge and skills play a great role in shaping future doctors. Hence, it is recommended that essential measures such as clinical exposure in pre-clinical years and proper counseling should be used to enhance the levels of self-esteem and mental health among medical students.

No competing interests were disclosed.

The author(s) declared that no grants were involved in supporting this work.