Breast cancer is the most prevalent type of cancer among women in both developed and developing countries and remains the leading cause of cancer-related mortality.1,2 The International Agency for Research on Cancer (IARCH) GLOBOCAN 2022 data showed that breast cancer is the most common female cancer worldwide with a rate of 23.8% and the mortality rate associated with this cancer is 15.4%.3 In Türkiye, with similar rates, breast cancer is reported to be the most common cancer among women (23.5%) and a type of cancer that threatens women’s lives with a mortality rate of 15.6%.3 These rates emphasize the critical need for well-established early screening programs in countries, as early detection is known to significantly improve survival rates.4

Mammography is considered the gold-standard for primary screening, as it increases survival rates by enabling the early diagnosis of breast cancer.4,5 While the World Health Organization (WHO) recommends mammography screening every 2 years for women aged 50 to 69 in organized community-based programs6; in Türkiye, all women aged 40 and above are recommended to undergo mammogram every 2 years.2 Although the importance of mammography in early diagnosis is known globally, the participation rate of women in mammography screening programs in Türkiye remains disappointingly low.6 While breast cancer screening rates are 77% in the United States (USA) and 61% in the United Kingdom; the mammography screening rate in Türkiye is significantly lower, at 24.9%.7 Additionally, this rate varies considerably among women with a family history of breast cancer, ranging from 16.7% to 35.7%.7 This disparity underscores the urgent need for targeted initiatives aimed at increasing early diagnosis efforts to reduce breast cancer-related mortality in Türkiye.

Several factors affect women’s participation in mammography screening.8,9 In particular, self-efficacy and fear of cancer have been identified as key determinants of mammography screening behaviors.9, 10, 11, 12 Self-efficacy, rooted in Social Cognitive Theory, is defined as an individual’s belief in their own abilities to achieve specific performance outcomes. Within this framework, self-efficacy is based on two fundamental types of expectations: self-efficacy beliefs and outcome expectations, both of which affect individual behavior.13 In the context of mammography, self-efficacy refers to women’s belief in their ability to successfully complete the steps required for mammography screening.8,11

Fear is recognized as both a motivating and inhibiting factor in health-related behaviors14 and is influenced by individual differences.15 Within the framework of the Extended Parallel Process Model, fear is defined as an emotional response triggered by the perception of a threat.15,16 According to this model when an individual perceives a high level of threat alongside high effectiveness—comprising perceived self-efficacy and response effectiveness—they are more likely to engage in positive health behaviors.14, 15, 16 Conversely when perceived threat is high but effectiveness is low, fear intensifies and may lead to avoidance behaviors.14, 15, 16 Research investigating the relationship between fear of cancer and breast cancer screening behaviors has produced conflicting findings. While some research suggests that fear serves as a motivator for mammography screening,17, 18, 19 other studies indicate that it acts as a deterrent.20,21 This contradiction has been attributed to variations in fear levels,19,22 as well as differences in health beliefs, attitudes toward health and disease, and socio-cultural factors.12,18,23,24 Additionally, the Health Belief Model, which is widely used in terms of breast cancer early screening behaviors, suggests that individuals’ health behaviors are shaped by their beliefs, values, and attitudes.25 Given that attitudes toward health and disease vary across cultures, each with its own belief systems and perceptions,26,27 understanding the impact of attitudes toward cancer on breast cancer screening behaviors is essential for developing culturally sensitive health promotion programs that align with individuals’ health beliefs and ultimately enhance participation in routine screening programs.

While there are several studies in the literature examining the factors that influence women’s mammography screening behaviors,7,18,22,28,29 no research has specifically explored the direct and/or indirect relationships among variables such as fear of breast cancer, attitudes toward cancer, and mammography self-efficacy. Understanding these relationships may allow us to understand the differences in women’s mammography behaviors, to use fear of breast cancer as a motivating force, and to design interventions to increase mammography self-efficacy. In this context, this study aimed to investigate the relationship between the attitudes toward cancer and the fear of breast cancer of women aged 40 to 69, as well as the mediating role of mammography self-efficacy in this relationship.